Declaration Of Proposed Guardian (Certified) {8} | Pdf Fpdf Doc Docx | Washington

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Declaration Of Proposed Guardian (Certified) {8} | Pdf Fpdf Doc Docx | Washington

Declaration Of Proposed Guardian (Certified) {8}

This is a Washington form that can be used for Guardianship within Local County, King, Superior Court.

Alternate TextLast updated: 9/8/2006

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IN THE SUPERIOR COURT OF WASHINGTON FOR THE COUNTY OF KING In the Guardianship of: ) Case No.: ) ______________________________ ) DECLARATION OF PROPOSED ) GUARDIAN (Certified) ) ) (DCLR) 1. Personal Information. Name of Proposed Guardian: ______________________________ Certified Professional Guardian #: ______________________________ Mailing Address of Proposed Guardian: ______________________________ Street Address (if different): ______________________________ City/State/Zip: ______________________________ Telephone Number: __________________ Fax Number: __________________ Email Address: __________________________________________________________ 2. Certified Status. The proposed Guardian is a certified professional Guardian in the State of Washington. Attached as Exhibit A to this Declaration is a summary listing the educational programs (pertaining to Guardianships or fiduciary matters) which the proposed Guardian and its employees have attended during the past twelve (12) months. 3. Business Form. The form in which the proposed Guardian does business is: [ ] sole proprietor [ ] partnership [ ] trust company [ ] corporation [ ] non-profit corporation Declaration of Proposed Guardian (Certified)-Page 1 2001 Guardianship Forms <<<<<<<<<********>>>>>>>>>>>>> 24. Identification of Principals of Proposed Guardian. List the name of each member of the board of directors, officer, and owner of the business of the proposed Guardian and their title: ______________________________________________________________. 5. Individual Certified Guardians. List each certified Guardian in the employ of the Guardian who may have responsibilities in this case and the individual certified Guardian who will have supervising responsibility in this case. ____________________________. 6. Relationship to Allegedly Incapacitated Person. The proposed Guardian has the following relationship with the Incapacitated Person _____________________________. 7. Guardians Organizational Structure. (a) Date the proposed Guardian began doing business: _______________________. (b) Allocation of job responsibilities: ______________________________. (Brochures or other printed materials may be attached as an Exhibit in response to this question.) 8. Criminal Background Checks. Does the proposed Guardian conduct criminal background checks pursuant to RCW 43.43.832 on all employees or volunteers who will or may have unsupervised access to the Incapacitated Person? [ ] Yes [ ] No 9. Criminal and Disciplinary History. Provide the following information for the proposed Guardian and for each of its principals and employees who are certified professional Guardians. However, do NOT include employees who are neither principals nor certified Guardians: (a) Circumstances leading to removal as a Guardian or as a fiduciary for breach of fiduciary duty or for any other reason: ______________________________. (b) Criminal proceedings for a felony or misdemeanor involving moral turpitude, which resulted in a finding or plea of guilty (attach an explanation as an exhibit explaining why this individual is employed by the proposed Guardian): _______________________________________________________________________. (c) Civil proceedings in which there was a finding of dishonesty, misappropriation of funds, breach of fiduciary duty, or mistreatment of any person (identify any civil proceedings where there was a settlement, even if such settlement was without specific findings by the Court): _______________________________________. Declaration of Proposed Guardian (Certified)-Page 2 2001 Guardianship Forms <<<<<<<<<********>>>>>>>>>>>>> 3 (d) Reported disciplinary proceedings by a disciplinary body or licensing agency that resulted in a finding of misconduct (including proceedings by a professional organization such as a state bar association, a medical disciplinary review board, etc.): _______________________________________________________________________. 10. Bond/Insurance. The nature and extent of the proposed Guardians insurance coverage available to provide protection in the event of financial loss or personal harm caused by the negligent or intentional conduct of the proposed Guardian, its employees or agents (list the companies with which insurance or bond is obtained, the policy limit and deductibles) is: __________________________________________________________. 11. Compensation and Reimbursement. The proposed Guardians compensation schedule is as follows (include the different hourly rates for various services): _______________________________________________________________________. 12. Experience. The proposed Guardians experience with similar Guardianships (for example, similar amount of assets, the family circumstances of the Incapacitated Person, the proximity of the proposed Guardian to the residence of the Alleged Incapacitated Person, and any relevant information) is: _____________________________________. 13. Case Load. The Guardian is currently the Court appointed Guardian for __________ of total individuals in this County and __________ individuals in other Counties. I certify (or declare) under penalty of perjury under the laws of the State of Washington that to the best of my knowledge the statements above are true and correct. Signature of Certified Professional Printed Name of Certified Professional Guardian, Guardian WSBA/CPG# Address Telephone/Fax Number City, State, Zip Code Email Address Declaration of Proposed Guardian (Certified)-Page 3 2001 Guardianship Forms

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