Fillable Annual Guardianship Plan (Pinellas County Clerk of the Circuit Court and Comptroller)

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Annual Guardianship Plan (Pinellas County Clerk of the Circuit Court and Comptroller)

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BROWSE PINELLAS COUNTY CLERK OF THE CIRCUIT COURT AND COMPTROLLER FORMS

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Page 1 of 13
Annual Guardianship Plan
(Pursuant to F.S. 744.367, the Report with Original Signatures is due within 90 days
after the last day of the anniversary month that the letters of guardianship were
signed.)
In the Circuit Court, Sixth Judicial Circuit, Florida
County:
IN RE: GUARDIANSHIP OF:
Social Security Number:
Case Number:
For the period:
through
Guardianship Inception Date:
Guardian Name(s):
Attorney Name:
This Report, with original signatures, is due within 90 days after the last day of the anniversary month that the
letters of guardianship were signed.
The Ward is living:
In a private residence leased or owned by them (house, condo, apartment).
In a private residence not leased or owned by them (such as family member).
In a facility (Skilled Nursing, Assisted Living, etc)
A
ddress and Phone Number where Ward is currently residing:
Address:
City, State, ZIP:
Phone:
Mailing Address for Ward (if different from above):
Mailing Address:
City, State, ZIP:
The guardian(s) submit(s) and propose(s) the following plan. Filed separately is the Annual Physician’s
Report. Together, these are the Annual Report of the Guardians(s) of the Person.
Annual Medical Report: A report of a physician who examined the Ward no more than 90 days before
the beginning of the applicable reporting period is to be filed separately, but at the same time as this
plan. The report must contain an evaluation of the Ward’s condition and a statement of the current level
of capacity of the Ward.
Note 1: The rights on the physician’s report should match the Order Determining Incapacity and/or
Order Appointing Guardian (signed when Letters were issued) or the guardian must either file a petition
to remove or restore rights as appropriate, or provide an explanation for why no change should be
made.
For Official Use Only:
Pinellas
Ward Name:
Case Number:
Page 2 of 13
Note 2: Per Administrative Order 2019-005, you must file an updated Disaster Plan when you file the
annual plan if the ward has changed residence or a new guardian has been appointed.
1. The places the ward has lived (resided) during the prior 12 months
Facility’s name or owner of the private residence’s name (first line)
Street Address (second line)
City, State and Zip Code (third line)
Phone Number (fourth line)
Type of Facility
Approximate
Dates Of
Residence
1
From
To
2
From
To
3
From
To
4
From
To
5
From
To
6
From
To
7
From
To
8
From
To
9
From
To
10
From
To
Ward Name:
Case Number:
Page 3 of 13
2. If the ward’s address has changed since the last plan filed (check all that apply):
N/A, the ward has not moved since the last plan was filed.
The move was within this county and a change of address was provided to the court.
The move was within this Circuit (Pinellas to Pasco or Pasco to Pinellas) and Notice was
provided to the court within 15 days of the move. The notice stated the compelling reasons
for, and expected duration of, the move.
The move was not within this Circuit (Pasco/Pinellas) and prior court approval was obtained.
The move was not within this Circuit (Pasco/Pinellas) and a petition to change venue is or has
been filed with this plan. plan.
3. For the best welfare of the ward in a setting best suited for his/her needs, the undersigned
guardian plans as follows:
A
The guardian states the place and kind of residential setting best suited for the needs of the ward is:
Assisted Living (ALF)
Group Home
Intermediate
Private Residence
Skilled Nursing
Specialized
State Hospital
Other (Please Explain Below)
.
Explanation:
B.
The guardian will ensure that the above is the best residential setting for the Ward by:
Periodically Assessing Needs
The Ward retains the right to decide
No change, unless required by medical condition
C.
Provision for medical care services for the ward:
(Check all applicable boxes and provide explanation below)
Routine examination by primary care physician
Routine examination by dentist
Routine examination by Ophthalmologist
Routine examination by Specialist – area of specialty
Physical Therapy
Speech Therapy
Occupational Therapy
The ward retains the right to make their own decision
None (Please Explain Below)
Other (Please Explain Below)
Explanation:
Ward Name:
Case Number:
Page 4 of 13
D.
Provision for mental health services for the ward:
(Check all applicable boxes and provide explanation below)
Routine examination by Psychiatrist/Psychologist
Ward retains the right to make own decisions
Ongoing Treatment Outpatient
Ongoing Treatment Inpatient
None (Please Explain Below)
Other (Please Explain Below)
Explanation:
E.
Provision for the personal care of the ward, such as bathing, grooming and feeding:
(Check all applicable boxes and provide explanation below)
Care Facility
Nurses and Aides
Family and Friends
Ward does without assistance
None; ward can provide own personal care
Other(Please Explain Below)
Explanation:
F.
Provision for socialization and/or recreational activities for the ward:
(Check all applicable boxes and provide explanation below)
Care Facility
Nurses and Aides
Family and Friends
The ward retains the right to make their own decision
None (Please Explain Below)
Other (Please Explain Below)
Explanation:
G.
Description of health and accident insurance and any other private or governmental benefits to which
the Ward is receiving to meet any part of the costs of medical, mental health or related services
provided to the Ward.
(Check all applicable boxes and provide explanation below)
Eligible Applied
For
Social Security
Social Security Disability Income (SSDI)
Health Maintenance Organization (HMO)
Ward Name:
Case Number:
Page 5 of 13
Supplemental Security Income (SSI)
Optional State Supplement
Institutional Care Program
Supplemental Insurance
(Continued Next Page)
Pension
Medicare
Medicaid
VA
Trusts
None (Please Explain Below)
Other (Please Explain Below)
Explanation:
4. Professional Medical Treatment performed on the Ward during the prior 12 months
Data Entry Format:
1
st
Line input: Provider’s first name, last name, and middle initial
2
nd
Line input: Street Address
3
rd
Line input: City, State and Zip Code
4
th
Line input: Phone Number
Type of Provider
Number of
Visits
1
2
3
4
5
6
7
Ward Name:
Case Number:
Page 6 of 13
8
9
10
5. Social Skills, Abilities and Activities of the Ward
A.
Describe the social skills (abilities) of the Ward (i.e.: the Ward can communicate well; the Ward
communicates with gestures; the Ward cannot communicate at all; etc…). In addition, please describe
any changes from the previous plan period.
Explanation:
B.
Describe the activities undertaken in an effort to increase the capacity of the Ward in the prior plan
period (i.e.: encouragement; physical or mental therapy, rehabilitative services; etc…) In addition,
please explain whether or not these activities were effective.
Explanation:
6. Is the Ward now capable of having some or all of the following rights restored?
Place a checkmark where applicable
Yes No Not Removed
Needs
to be Restored
A. Right to marry:
B. Right to Vote:
C. Right to personally apply for government benefits:
D. Right to have a driver’s license:
E. Right to travel:
F. Right to seek or retain employment:
G. Right to contract:
Ward Name:
Case Number:
Page 7 of 13
H. Right to sue and be sued
I.
Right to manage property or to make any gift of
disposition:
J. Right to determine residence:
K. Right to consent to medical treatment:
L.
Right to make decisions about social environment
or other aspects of social life:
7. If you answered “Yes” to any right in question 5, and the doctor has indicated on the
physician’s report that a right may be restored, you must file a petition to restore the right. If
you do not agree with the physician’s report, please provide an explanation.
Explanation:
8. Rate the following Activities of Daily Living (ADL’s)
A. Eating Choose an item.
B. Prepare Meals: Choose an item.
C. Heavy Chores (e.g., vacuuming) Choose an item.
D. Light Housekeeping Choose an item.
E. Managing Money: Choose an item.
F. Dressing Choose an item.
G. Transportation Ability Choose an item.
H. Walking/Mobility: Choose an item.
I. Toileting Choose an item.
J. Climbing Stairs: Choose an item.
K. Transferring (from wheelchair to char/bed): Choose an item.
L. Doing Laundry: Choose an item.
M. Shopping Choose an item.
N. Bathing: Choose an item.
O. Grooming Choose an item.
P. Administration of medication Choose an item.
The rest of this page intentionally left blank
Choose an item
Choose an item
Choose an item
Choose an item
Choose an item
Choose an item
Choose an item
Choose an item
Choose an item
Choose an item
Choose an item
Choose an item
Choose an item
Choose an item
Choose an item
Choose an item
Ward Name:
Case Number:
Page 8 of 13
9. Disabilities:
A.
Mental disabilities: (Check all applicable boxes and provide explanation below)
Dementia
Autism Spectrum Disorders
Closed Head Injury
Developmental Disabilities
Schizophrenia or related disorders
Depression
Intellectual Disability
Induced by substance abuse
Alzheimer’s type of Dementia
Ward has no mental disabilities
Other: (Please Explain Below)
Explanation:
B.
The physical disabilities of the Ward are:
(Check all applicable boxes and provide explanation below)
Mobility
Blindness
Deafness
Diabetic
Parkinson’s disease
Severe arthritis
Ward has no physical disabilities
Other (Please Explain Below)
Explanation:
C.
The assistive devices used by the Ward are (devices currently being used by the ward):
(Check all applicable boxes and provide explanation below)
Dentures
Hearing Aid
Wheelchair
Walker/Cane
Crutches
Prosthetics
Glasses
None
Other (Please Explain Below)
Ward Name:
Case Number:
Page 9 of 13
Explanation:
D.
The assistive devices needed by the Ward are( devices needed but ward does not yet have them):
(Check all applicable boxes and provide explanation below)
Dentures
Hearing Aid
Wheelchair
Walker/Cane
Crutches
Prosthetics
Glasses
None
Other (Please Explain Below)
Explanation:
10. There are NO pre-existing orders Not To Resuscitate (a/k/a “DNR”) or any other advance directive
and I have taken the following steps to verify there are none: (check all that apply)
Search of ward’s prior and current residence
Inventory of ward’s safe deposit box
Interviewed family and friends
Requested documents from the ward’s medical providers
Requested documents from the ward’s attorney
The ward executed the following advanced directives:
Order Not to Resuscitate, F.S. 401.45(3) ( a/k/a “DNR”)
Advanced Directive for Healthcare (including but not limited to: healthcare
surrogate, living will or anatomical gift)
Durable Power of Attorney, F.S., Chapter 709
Other:______________________________________________________
For ANY advanced directive listed above:
Title of the order or directive: __________________________________________
Date executed/signed: ________________________________________________
Name of Person who signed: ___________________________________________
Name of Designated Agent(s) or Surrogate(s):_____________________________
Name of any Alternate Agent(s) or Surrogate(s): ___________________________
Relationship of Agent(s) or Surrogate(s) to the Ward:_______________________
Contact information for any Agent(s) or Surrogate(s): _______________________
__________________________________________________________________
Has a Court suspended or revoked the Order/Directive: 0 Yes 0No
Ward Name:
Case Number:
Page 10 of 13
Date of Order: _______________ entered _________________ (County/State)
Title of the order or directive: __________________________________________
Date executed/signed: ________________________________________________
Name of Person who signed: ___________________________________________
Name of Designated Agent(s) or Surrogate(s):_____________________________
Name of any Alternate Agent(s) or Surrogate(s): ___________________________
Relationship of Agent(s) or Surrogate(s) to the Ward:_______________________
Contact information for any Agent(s) or Surrogate(s): _______________________
__________________________________________________________________
Has a Court suspended or revoked the Order/Directive: 0 Yes 0No
Date of Order: _______________ entered _________________ (County/State)
11. Each guardian must declare any remuneration from any source for services rendered to or on
behalf of the ward. Remuneration means any payment or other benefit made directly or indirectly,
overtly or covertly, or in cash or in kind to the guardian. F.S. 744.367 (3)(a).
(You are not limited to spaces on this form. Attach additional sheets, as needed.)
I, _____________________
_______ declare that I have received NO remuneration from
any source for services rendered to or on behalf of the ward.
I declare that I have received the monies of $__________
_ from
__________________________ (name of person/company) for services rendered on behalf
of the ward.
All requests for reimbursement or fees have been submitted to the cour
t for review and
approval.
The rest of this page intentionally left blank.
Ward Name:
Case Number:
Page 11 of 13
CERTIFICATION AND SIGNATURE OF GUARDIAN(S)
(Check all that apply)
If the Ward’s ability to exercise rights has changed since the Order Determining Capacity and/or Order
Appointing Guardian, the guardian must either file a petition to remove or restore rights as appropriate, or
provide an explanation as to why no change should be made.
The Ward was declared totally incapacitated and has not been given a copy of this plan.
The Ward is a minor and has not been given a copy of this plan.
The guardian has consulted with the Ward, to the extent reasonable, has honored the Ward’s wishes,
and to the maximum extent possible the plan is in accordance with the Ward’s wishes or consistent
with the rights retained by the Ward.
The plan does not restrict the physical liberty of the Ward except as necessary to protect the Ward
and other from serious physical injury, illness, or disease.
The plan provides for the Ward’s medical care and mental health treatment.
The physician’s statement of an examination of the Ward no more than 90 days before the beginning
of the plan period is attached.
In exercising his or her powers, the guardian shall recognize any rights retained by the ward [FS
744.363(6)].
UNDER PENALTIES OF PERJURY, I declare that I have read and examined the foregoing plan, and the facts
alleged are true, to the best of my knowledge and belief.
Guardian Signature
Guardian Name Printed
Guardian SSN/EIN
Guardian Mailing Street Address
Guardian Phone Number
Guardian Mailing City/State/Zip
Guardian Email Address
Residence (individual) or Office (corporate)
Street Address
Date Signed
Residence (individual) or Office (corporate)
City/State/Zip
Guardian Relationship to Ward:
Co-Guardian Signature
Co-Guardian Name Printed
Ward Name:
Case Number:
Page 12 of 13
Co-Guardian SSN/EIN
Co-Guardian Mailing Street Address
Co-Guardian Phone Number
Co-Guardian Mailing City/State/Zip
Guardian Email Address
Residence (individual) or Office (corporate)
Street Address
Date Signed
Residence (individual) or Office (corporate)
City/State/Zip
Co-Guardian Relationship to Ward
Co-Guardian Signature
Co-Guardian Name
Co-Guardian SSN/EIN
Co-Guardian Mailing Street Address
Co-Guardian Phone Number
Co-Guardian Mailing City/State/Zip
Guardian Email Address
Residence (individual) or Office (corporate)
Street Address
Date Signed
Residence (individual) or Office (corporate)
City/State/Zip
Co-Guardian Relationship to Ward
All guardians of person must sign and provide the most current mailing address, telephone number, social security
number, email address and either the residence address (of an individual guardian) or an office address (of a
corporate or public guardian). Only reports with Original signatures will be audited by the Clerk of the Court.
The rest of this page intentionally left blank
Ward Name:
Case Number:
Page 13 of 13
C
ERTIFICATION AND SIGNATURE OF GUARDIAN’S ATTORNEY
The undersigned hereby notifies the Court of the filing of the annual guardianship plan for the period
through .
T
he undersigned hereby notifies the Court of the annual guardianship plan of the guardian of the person. This
annual guardianship plan is the representation of the guardian. I have not audited the accompanying annual plan.
The undersigned attorney represents that he/she has examined the contents of the annual guardianship plan and
that it conforms to the requirements of the Florida Guardianship Law and the standards for the plans in
Select
County County.
Attorney Signature
Date Signed
Attorney Name
Attorney Bar Number
Attorney Address
Attorney Phone Number
Attorney City/State/Zip
The rest of this page intentionally left blank.
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Annual Guardianship Plan (Pinellas County Clerk of the Circuit Court and Comptroller)

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Completed 10 February 2021

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