Application For Appointment Of Guardian

IN THE CIRCUIT COURT OF THE SIXTH JUDICIAL CIRCUIT OF THE STATE OF FLORIDA, IN AND FOR COUNTY PROBATE DIVISION UCN: REFERENCE NO: IN RE: GUARDIANSHIP OF ______________________________/ APPLICATION FOR APPOINTMENT OF GUARDIAN Pursuant to Florida Statutes §744.3125, the Undersigned submits this Application for Appointment as Guardian and submits the following information (whenever the space provided is insufficient for your answer, please attach additional pages): 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. Name: Social Security Number: (may be filed under seal) Date and Place of Birth: Residence address: Mailing address: U.S. Citizen? Employer's name and address: Marital status and name of spouse, if any: Home telephone number: Work telephone number: Cell telephone number: Fax number: Email address (if applicable) If currently serving as guardian for any other ward, list names of each ward, case number(s), circuit court and whether each guardian is plenary or limited: 15. Does applicant have any physical disabilities? . If "yes", please describe and state whether such disability may affect applicant's ability, in any degree, to serve as guardian: Has applicant ever been treated for the following: a. Mental condition? _____ YES _____ NO b. Alcohol? _____ YES _____ NO c. Drugs? _____ YES _____ NO d. Other? _____ YES _____ NO Nature of condition: 16. American LegalNet, Inc. www.FormsWorkFlow.com If "yes" was answered to any of the above, please state date, time, location of treatment and name of Physician or professional involved: 17. Has applicant ever been charged with fraud, misrepresentation or perjury in a judicial or administrative proceeding? If "yes", please give date and complete details: Has applicant ever been charged with, arrested for or convicted of a felony? If "yes", please furnish details including the date, type of offense, location and final disposition: Has applicant ever held a position which required bonding? If "yes", please describe position, date, amount of bond and name of surety: Has applicant, in the past, ever served as guardian of a person or of a person's property? If "yes", please describe below, including reason for termination of fiduciary position: Has applicant ever been held in contempt of court or removed as guardian? If "yes", please describe below: Has applicant ever flied for bankruptcy? If "yes", please state date and location of court: What is applicant's relationship to the alleged incapacitated person? At the present time, is applicant or applicant's business, corporation or other business entity providing professional, personal or business services to the incapacitated person? If "yes", please furnish details: At the present time, is applicant employed by a business, corporation or other business entity which is providing professional, personal or business services to the incapacitated person? If "yes", please furnish details: Is applicant a health care provider for the alleged incapacitated person? "yes", please furnish details: Educational history of applicant: High School: College: Other: If 18. 19. 20. 21. 21. 22. 23. 24. 25. 26. American LegalNet, Inc. www.FormsWorkFlow.com 27. 28. 29. Has applicant ever been discharged from employment? explain: If "yes", please If Has applicant ever been a member of the armed forces of the U.S.? "yes", what branch, dates of service and military serial number: Does applicant possess any special educational qualifications (financial, business or otherwise?) that uniquely qualifies applicant to be appointed as guardian? If "yes" please describe: Has applicant received instruction and training which covered the legal duties and responsibilities of a guardian, the rights of an incapacitated person, the availability of local resources to aid a ward, and the preparation of habilitation plans and annual guardianship reports, including financial accounting for the ward's property? If so, indicate when and where training was received: 30. Under penalties of perjury, I declare that I have read the foregoing, and the facts alleged are true, to the best of my knowledge and belief. Executed this day of , 2007. __________________________________ SWORN TO AND SUBSCRIBED before this ___ day of __________________, 2007 __________________________________ NOTARY PUBLIC My commission expires: American LegalNet, Inc. www.FormsWorkFlow.com