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Guardian Advocacy Forms (Thirteenth Judicial Circuit Court Hillsborough County)

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Guardian
Advocacy
Forms
Table
of
Contents
A. Application for Appointment as Guardian/Co-Guardian Advocate(s)
B. Application for Determination
of
Civil Indigent Status (Clerk's Form)
C. Waiver and Consent to Appointment
of
Guardian/Co-Guardian Advocate(s)
D. Petition for Appointment
of
Guardian/Co-Guardian Advocate(s)
E. Report
of
Attending Physician
F.
Oath
of
Guardian/Co-Guardian Advocate, Designation
of
Resident Agent
and Acceptance
G. Notice
of
Confidential Filing Information
H. Notice
of
Petition to Appoint Guardian Advocate/Co-Guardian Advocate(s) Under
393.12, Florida Statutes.
I. Notice
of
Hearing Before General Magistrate
J. Order Appointing Guardian Advocate (Modify to Co-Guardian Advocate
if
applicable)
K.
Letters
of
Guardian/Co-Guardian Advocacte
L. Initial Plan
M. Annual Plan
Miscellaneous Forms
N. Application for Appointment as Standby Guardian Advocate
0 . Standby Guardian Advocate's Joinder in Petition
P. Notice
of
Filing
Helpful Links
Q.
Guide to Filing Reports:
http://www.f1
ju
dl3.o
rg/Portals/O/Fon
ns
/pdfs/ejc/GuidetoFilingReports.pdf
FORMA
IN
THE
CIRCUIT
COURT
OF
THE
THIRTEENTH
JUDICIAL
CIRCUIT
FOR
HILLSBOROUGH
COUNTY,
FLORIDA
Probate, Guardianship, Mental Health and Trust Division
IN
RE:
GUARDIAN
ADVOCACY
OF
CASE
NO.:
A Person with a Developmental Disability,
DIVISION: A
______________________________
./
APPLICATION
FOR
APPOINTMENT AS GUARDIAN/CO-GUARDIAN
ADVOCATE
Pursuant
to
Sections 744.3 125
of
the Florida Guardianship Law,
the
undersigned
submits
this
App
lication for
Appointment
as Guardian/Co-Guardian
Advocate
of
_______________
_
(the
person
with a
development
disability) and
submits
the following information
(whenever
the
space
provided
is insufficient, attach additional pages):
1.
Name:
2. Social Security
Number:
3.
Date and Place
of
Birth:
4. Residence address:
5.
Mailing
address:
6.
Email address:
7. U.S. Citizen? Yes
No
8.
Emp
l
oyer's
name
and
address:
position:
--------
Applicant
's
--------
--------------
- -
--------
9. Marital status and
name
of
spouse,
if
any:
------------
------
----
---
10.
Home
telephone number:
--
---
---------------
-
Work
telephone number: -
--
------
--
----
-
-----
11. Leng
th
of
residence in county wherein application is filed:
__
______
_ _
12.
If
currently
se
rving
as a guardian for
any
other
ward,
li
st nam
es
of
each ward, court file
number(s), circuit court(s)
in
which
the case(s) is/are
pending
and
whether
applicant is acting as
the limited
or
plenar
y guardian
of
the
per
son
or
property
or
both:
___
______
___
_
13.
If
you are a professional guardian, please indicate month, day, and year in which you
were appointed on your third case:
14. Does applicant have any physical disabilities? Yes
__
No
__
.
If
yes, please
describe and state whether such disability my affect applicant's ability,
in
any degree, to serve as
guardian:
------------------
--------
------------------------
----------
---
15
. 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:
If
"y
es" was answered to any
of
the above, please state date, time, location
of
treatment
and name
of
physician
or
professional involved:
-----------------------------------
16.
Has applicant ever been judicially determined to have committed abuse, abandonment, or
neglect against a child as defined by the Florida Statutes? Yes No
17. Has applicant ever been the subject
of
a confirmed report
of
abuse, neglect, or exploitation
which has been uncontested or upheld pursuant to the provisions
of
Sections 415.104 and
415.1075, Florida Statutes? Yes No
18.
Has applicant ever been charged with fraud, misrepresentation or perjury
in
a judicial
or
administrative proceeding? Yes
No
If
yes, please give date and complete details:
19
. Has applicant ever been charged with, arrested for,
or
convicted
of
a felony,
even
if the
record
of
such arrest
or
conviction has been expunged, unless the expunction was ordered pursuant
to Florida Statutes Section 943.0583? Yes
__
No
__
If
yes, please furnish details including
date, type
of
offense, location and final dis
po
sition:
20. Has applicant ever been charged with, arrested for, or convicted
of
any other crimes?
Yes No
If
yes, please furnish details, including date, type
of
offense, location, and
final disposition:
21. Has applicant ever held a position, which required bonding? Yes
__
No
_ _ If
yes, please describe position, date, amount
of
bond and name
of
surety:
22. Has applicant, in the past, ever served as guardian
of
a person
or
of
a person's property?
Yes
__
describe below, including reason for termination No
__
If
yes, please
of
fiduciary
position:
---------------
-----
--
----------
23. Has applicant ever been held in contempt
of
court or removed as guardian?
Yes
__
No
__
If
yes, please describe below:
24. Has applicant ever filed for bankruptcy? Yes
No
If yes, please state date
and location
of
court:
25. Has the applicant ever been found guilty, plead nolo contendere or guilty
of
an
offense
prohibited by Florida Statutes 435.04 or similar statute
of
another jurisdiction? Yes No
If
yes, please give details,
to
include date, type
of
offense, location, and final disposition:
26. What is applicant's relationship to the alleged the person with a developmental disability?
27.
Is
applicant, or applicant
's
business, corporation or other business entity a creditor of, or
providing substantial professional, personal, or business services
to
the person with a
developmental disability? Yes
__
No
__
If
yes, please furnish details:
28. Is applicant employed by a person, agency, government, corporation or other business
entity, which
is
providing professional, personal or business services to the person with a
developmental disability?
Yes
__
No
__
If
yes, please furnish details:
29.
Is
applicant a health care provider for the person with a developmental disability?
Yes No
---
30. Educational history
of
applicant:
Name and address Degree
High
school:--------------------------
College:
---------------------------
Other:
31. List applicant's employment experience for the past ten
(1
0) years beginning with the
most recent date:
Na
me and address
Date(s)
Reason for leaving
32. Has applicant ever been discharged from employment: Yes
No
If
yes,
please explain:
33.
Has applicant ever been a member
of
the armed forces
of
the U.S.? Yes
No
If
yes, what branch, dates and military se
ri
al number:
34. PERSONAL REFERENCES. Please give the names, addresses and telephone numbers
of
three (3) responsible persons who have been close
ly
associated with applicant and who have
known applicant for five (5) years or mor
e,
not including relatives
or
spouse:
Na
me and address Telephone numb
er
35. Does applicant possess any special educational qualifications (financial, business or
otherwise) that uniquely qualifies applicant to be appointed as guardian? Yes No
__
_
If
yes, please describe below:
-----------------------
-
36. Has applicant received instruction and training, which covered the legal duties and
responsibilities
of
a guardian, the rights
of
a ward, 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? Yes
__
No
__
If
so, indicate when and where training
was received:
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.
Signed
on
___________
,
20_
Signature _
____
__
____
__
_
Name
____
___
__
_____
_
Address
_______
____
___
_
Phone
______________
_
E-mail address
__
_
________
_
(Petitioner)
FORM B
(Please obtain the Clerk's Application for Determination of Civil Indigent Status)
Directly from the Office
of
the Clerk
of
Court)
FORMC
IN
THE
CIRCUIT
COURT
OF
THE
THIRTEENTH
JUDICIAL
CIRCUIT
FOR
HILLSBOROUGH
COUNTY,
FLORIDA
Probate,
Guardianship,
Mental
Health
and
Trust
Division
IN
RE:
GUARDIAN
ADVOCACY
OF
CASE
NO.:
______________________________
A
Person
with
a
Developmental
Disability,
DIVISION:
A
./
WAIVER
AND
CONSENT
TO
APPOINTMENT
OF
GUARDIAN
ADVOCATE
The undersigned, _
__
________
, whose complete name and address are:
an
d who has an interest in the above Guardian Advocacy as the (brother/sister/parent/child)
_
_________
_
of
the person with a developmental disability/Ward,
acknowledges recei
pt
of
a copy
of
the Petition for Appointment
of
Guardian/Co-Guardian
Advocate(s) and hereby waives hearing and notice
of
hearing thereon, and consents to the
set
tl
ement and entry
of
an
order granting the relief requested in the Petition without notice
or
hearing.
Signed this
___
of
_day
_____
__
, 20
__
_
Na
me
-
------
-----------
Address
------------------
Phone
--
-----
------------
E-mail address
-------
------
---
FORMD
IN
THE
CIRCUIT
COURT
OF THE
THIRTEENTH
JUDICIAL
CIRCUIT
FOR
HILLSBOROUGH
COUNTY,
FLORIDA
Probate, Guardianship, Mental Health and Trust Division
IN
RE: GUARDIAN
ADVOCACY
OF
CASE
NO.:
A Person with a Developmental Disability, DIVISION: A
__
__
______
__________
__________
!
PETITION FOR
APPOINTMENT
OF GUARDIAN/CO-
GUARDIAN
ADVOCA
TE(S)
Petitioner(s),
--------------------------
-----------------
--
-'
allege:
1.
Petitioner
's
residence is
----------
--------------------------
and mailing address
is
2.
(If
Co-Guardian Advocacy
is
sought, list
2nd
Petitioner here.
If
none, write "none")
Petitioner
-------------------------------
's
residence is
--------------------------------------
and mailing address
is
3.
Petitioner's date
of
birth
is
____________
and is an adult, age
___
_
Petitioner
's
relationship
to----------------------
-'
the person with a
developmental disability (hereinafter the "Ward")
is
____________
_
4.
(If
Co
-Guardian Advocate, list
2nd
Petitioner here.
If
none, write "none")
Petitioner's date
of
birth
is
and
is
an
adult, age . Petitioner's
relationship
to
the Ward is _
______________
5.
-----------------------is
a person with a
developmental disability, who was born on age.
The Ward's primary
_______
, and who
is
__
years
of
language
is
and the Ward
's
Social Security
number
is
. (Requires filing
of
Notice
of
Confidential Information
Within Court Filing pursuant
to
FRJA 2.420(d)(2)). The Ward
re
sides in Hillsborough County,
Florida, and his/her residential address
is
and
his/her mailing address
is:-
--------------------------
---
6.
The Ward's next
ofkin
is/are: (include names and addresses
of
any non-
petitioning parent and any adult
siblings:-----------------------------
7.
The Petitioner(s) believe that the Ward is
in
need
of
a Guardian Advocate due to his/her
developmental disability which manifested itself prior
to
the age
of
eighteen (
18
),
specifically
(choose one or all that apply): ( ) intellectual
di
sability; ( ) cerebral palsy; ( ) autism;
( ) Spina Bifida; ( ) Prader-Willi syndrome; ( ) Down syndrome; ( ) Phelan-McDermid
syndrome. As a result, the Ward essentially functions at the grade le
ve
l
of
___
and all
medical probability indicates that this condition will not change.
8.
The Petitioner(s) believe(s) a Guardian Advocate is necessary because the Ward
lacks the decision-making ability to make informed decisions about the Ward
's
own per
so
n,
specifically the following rights: (check all which appl
y)
L_)
to personally apply for and manage government benefits
L_)
to contract
L_)
to sue and defend lawsuits
L_)
to manage property
or
make any gift
or
disposition
of
property
L_)
to determine his/her residency
L_)
to consent to medical and mental health treatment
L_)
to make decisions about his/her social environment/social aspects
of
his/her life
L_)
to marry
L_)
to vote
L_)
to travel without assistance or supervision
L_)
to have a driver's license
L_)
to seek
or
retain employment
9.
Petitioner(s) is/are willing and able to act as Guardian Advocate for the Ward, and
should be appointed as Guardian Advocate because Petitioner(s) is/are the Ward's
_______
(insert relationship to Ward), is willing to serve
in
that capacity, and is best
qualified to act on the Ward
's
behalf.
10.
The Petitioner(s) further state(s) that the Ward is unable to understand the concept
of
legal representation and cannot afford an attorney for representation at this proceeding.
11.
In accordance with Probate Rule 5.649(a)(7), Petitioner(s) has/have knowledge,
information or belief that the Ward (has) (has
not)-
CHOOSE ONE - created an advanced
directive
or
a durable power
of
attorney.
12.
The Petitioner(s) further state(s) that the Ward is indigent, having no assets and no
income other than public assistance and requests that the Court waive all costs incurred
commencing this case and direct the Clerk
of
the Circuit Court to void all charges related to
same.
13.
The Petitioner(s) request(s) this Court set a hearing to inquire into the capacity
of
the Ward, and should the Court determine it is appropriate to do so, enter an Order appointing
-
--
-----
---
----
-------(
Insert Guardian/Co-Guardian's
name(s)) as Guardian Advocate(s) for (the Ward).
14
. Petitioner(s) file(s) with this Court his/her/their Application(s) for Appointment as
Guardian Advocate which provides the Social Security Number
of
the proposed Guardian
Advocate(s), so that a criminal records check can be conducted by the Court, pursuant to the
applicable Administrative Order
of
the Court. Further, Petitioner(s) also submits his/her/their
credit report(s) to the Court for review prior to the hearing, pursuant to the applicable
Administrative
Order
of
the Court.
15
. The Petitioner(s) further request(s) that this Court allow the Guardian Advocate(s)
to file a Simplified Annual Plan without the necessity
of
a physician's statement, after
the
filing
of
and the Court
's
approval
of
a full Initial Plan and the First Annual Plan.
Under penalties
of
perjury, 1/We 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
_________
, 20
__
Signature
__
_
__
_
___
__
_ _ _
Name
-
-------------
--
Address
------------
- -
-mail
---------------
Phone
--
E address
-----------
-
(Petitioner)
(If
co-Guardians, both sign)
Signature
_______
_______
_
Name
------
-----------
Address
---------------
Phone
-----------------
E-mail address
-------------
(Co-Petitioner)
CERTIFICATE
OF
SERVICE
I, , do hereby certify that a true and correct copy
of
the attached Petition to Appoint Guardian/Co-Guardian Advocate, has been furnished by (type
of
mail) , on this
__
day
of
, 20
___
to the
following persons, at the address specified:
Address
---------------
Phone
-----------------
E-mail address
---
-
--
-----
--
(Petitioner)
FormE
IN
THE
CIRCUIT
COURT
OF
THE
THIRTEENTH
JUDICIAL
CIRCUIT
IN
AND
FOR
HILLSBOROUGH
COUNTY,
FLORIDA
PROBATE
GUARDIANSHIP
DIVISION
INRE
:
GUARDIAN
ADVOCACY
OF
CASE
NO. -
CP-
DIVISION:
Developmentally Disabled.
------------------------~
'
REPORT
OF
ATTENDING
PHYSICIAN
PHYSICIAN'S NAME:
INCLUDING SPECIALTY: PHYSICIAN'S PRACTICE,
FOR: { patient:}
------------------
------------------
---------
(DATE:)
________
_
This will verify that {patient}
__________________________________
__
__
has been a patient
of
mine since (date)
____________________________
__
and that my diagnosis and the associated disabilities, are as follows {describe diagnosis and
disabilities:)
-------------------------------------------------
With the extent
of
these medical problems, I feel th
at------
----------------
---
is unable to handle personal matters regarding finances and physical well-being and that a
guardian advocate should be appointed to act on { his
I her } behalf.
PHYSICIAN'S SIGNATURE
DATE:
________________
_
FORMF
IN THE CIRCUIT COURT OF THE THIRTEENTH JUDICIAL CIRCUIT
FOR HILLSBOROUGH COUNTY, FLORIDA
Probate, Guardianship, Mental Health and Trust Division
IN RE: GUARDIAN ADVOCACY OF CASE NO.:
A Person with a Developmental Disability, DIVISION: A
-----------------------------'
OATH OF GUARDIAN/(CO)GUARDIAN ADVOCATE, DESIGNATION OF
RESIDENT AGENT
& ACCEPTANCE
(Each Guardian Advocate mu
st
sig
n an Oath)
STATE OF FLORIDA
COUNTY OF HILLSBOROUGH
I,
------------
(Affiant), state under oath that:
l. I will faithfully perform the duties
of
Guardian/Co-Guardian Advocate
of
the Person
of
-------------------------------
(the Ward), according
to
law and accept
the Designation as Resident Agent.
2.
My place
of
residence
is
--
----
--------------
----
----------
--------
-----a
nd
po
st office
address
is------
------------------------------
----
-----
Signature.
__
_____
____________
__
_
Name.
____________
__
___________
__
Address.
________________________
_
Phone
_________
__
__
_
E-mail address
______
__
___
_
(Affiant-
Resident Agent)
Sworn to and subscribed before me on
__
__
(month)
__
(day), 20
__
, by
Affiant, who is personally known to me or who produced as
identification.
Notary Public State
of
Florida
My
Commission Expires:
FORMG
IN
THE CIRCUIT
COURT
OF
THE
THIRTEENTH
JUDICIAL
CIRCUIT
FOR
HILLSBOROUGH
COUNTY,
FLORIDA
Probate, Guardianship, Mental Health and
Trust
Division
IN RE: GUARDIAN
ADVOCACY
OF
CASE NO.:
A Person with a Developmental Disability,
DIVISION: A
-------------------------------'
NOTICE OF CONFIDENTIAL INFORMATION
WITHIN
COURT
FILING
Pursuant to Florida Rules
of
Judicial Administration 2.420(d)(2), the filer
of
a court record at the
time
of
filing shall indicate whether any confidential information is included within the document
being filed; identify the confidentiality provision that applies to the identified information; and
identify the precise location
of
the confidential information within the document being filed.
Title/Type
of
Document(s):
( ) Petition for Appointment
of
Guardian/Co-Guardian Advocates
of
Person,
Page(s) , Paragraph(s) _
__
_
( ) Application
of
for Appointment as Guardian Advocate,
Page(s).
___
___
, Paragraph(s).
___
_
( ) Application
of
for Appointment as Co-Guardian
Advocate, Page(s) , Paragraph(s) ; (
ifthere
is co-Guardian)
( ) Confidential Psychological Report, Entire report.
( ) Credit report(s)
of
.
________
____________
________
________
______________
__
(if
more
than
one
Guardian, list both names), Entire Report.
( ) Copy
of
Death Certificate
of
deceased parent
of
Ward, Entire report.
Indicate the applicable confidentiality provision(s) below from Rule 2.420(d)
(l
)(B), by
specifying the location within the document on the space provided:
--
Signature
------
--
------------
----
-
Name
----
--
--
------------
-------
Address
------
----
--------
---------
Phone
------
--------
----
--
--
------
E-mail address
--
------------------
---
(Filer)
Note: The clerk
of
court shall review filings identified as containing confidential information to
determine whether the information is facially subject to confidentiality under the identified
provision. The clerk shall notify the filer in writing within 5 days
if
the clerk determines that the
information is
NOT
subject to confidentiality, and the records shall not be held as confidential for
more than l 0 days, unless a motion is filed pursuant to subdivision(d)(3)
of
Rule 2.420.
FORMH
IN
THE
CIRCUIT
COURT
OF
THE
THIRTEENTH
JUDICIAL
CIRCUIT
FOR
HILLSBOROUGH
COUNTY,
FLORIDA
Probate,
Guardianship,
Mental
Health
and
Trust
Division
IN RE: GUARDIAN ADVOCACY
OF
CASE NO.:
A Person
with
a Developmental Disability, DIVISION: A
______________________________
!
NOTICE
OF
PETITION
TO
APPOINT
GUARDIAN ADVOCATE
UNDER 393.12,
FLORIDA
STATUTES
THIS
NOTICE
MUST BE READ
TO
THE
PERSON
WITH
DEVELOPMENTAL
DISABILITY(IES)
(In the language
of
the Person
and
in English)
TO:
[SUBJECT'S
NAME]
[Address for Service]
[NEXT
OF
KIN'S
NAME(S)]
[Address(es) for Service]
1.
YOU
ARE
HEREBY
NOTIFIED
that a Petition has been filed seeking to appoint
a Guardian Advocate for the person (and goverrunent benefits,
if
applicable)
of
__________
____
. A copy
of
the Petition to Appoint Guardian Advocate, pursuant to 393.12(2)
Fla. Stat., is either attached to this notice
or
has already been provided to you. There will be a
hearing
on
the Petition to
Appoint Guardian
Ad
vocate
before
____
__
___________
, in Courtroom/Hearing Room
___
of
the Hillsborough
County Edgecomb Cowihouse, Tampa, Hillsborough County, Florida, on the
___
day
of
___
_____
,
20_,
at
_:_
a.m./p.m.
2.
The reason for this hearing is to inquire into
________________
's
capacity
to exercise the rights enumerated in the petition and to determine whether a guardian advocate should
be appointed over
's
person
or
government benefits
or
both.
3.
For
the person with a developmental disability ONLY: You have the right to an
attorney, and one has been appointed to represent you. The name, address and telephone number
of
the attorney are as follows:
Name
Address
Phone
Email
You also have the right to substitute your own attorney for the attorney appointed by the court.
CERTIFICATE OF SERVICE
I HERE
BY
CERTIFY, under penalties
of
perjur
y,
that a copy
of
t
he
foregoing Notice was read to
the alleged developmentally disabled person on ,
20_
, and that a
copy
of
the Petition for Appointment
of
Guardian Advocate was furnished to the alleged
developmentally disabled person on
__
_
Signature.
________
___
_ _
Name
__________
__
__
_
Address.
_________
____
_
Phone
___________
__
___
E-mail addr
ess------------
(Petitioner)
If
you
are
a person with a disability who needs any accommodation in
order
to participate
in this proceeding, you
are
entitled,
at
no cost to you, to
the
provision
of
certain assistance.
Please contact ADA
Coordinator,
Hillsborough
County
Courthouse, 800
E.
Twiggs St.,
Room 604,
Tampa,
FL
33602
at
(813) 272-7040,
at
least 7 days before
your
scheduled
court
appearance,
or
immediately upon receiving this notification
if
the time before the scheduled
appearance
is
less
than
7 days; if you
are
hearing
or
voice impaired, call
711
Form
I
IN
THE
CIRCUIT
COURT
OF
THE
THIRTEENTH
JUDICIAL
CIRCUIT
IN AND
FOR
HILLSBOROUGH
COUNTY,
STATE
OF
FLORIDA
PROBATE, GUARDIANSHIP, MENTAL
HEALTH
AND TRUST DIVISION
IN RE:
THE
GUARDIAN ADVOCACY
OF
CASE NO. -CP-
DIVISION:
'
Developmentally disabled person.
_________________________________ !
NOTICE
OF
HEARING
BEFORE
GENERAL MAGISTRATE
To: All interested parties and the court appointed attorney for the
AlP
:
YOU
WILL
PLEASE
TAKE
NOTICE
there will be a hearing on the Petition to Appoint
Guardian Advocate on before General
Magistrate on.
________
______________
_
in Courtroom
of
the George Edgecomb Courthouse, 800 East Twiggs Street, Tampa, FL
33602.
TIME
RESERVED: 15 minutes
PLEASE
BE
GOVERNED ACCORDINGLY.
NOTICE:
In
the event
that
English/Spanish interpretative assistance
is
required
for this
hearing, you must immediately contact the Office
of
Court
Interpreters
at
(813) 272-5947.
No
other
interpretative assistance will be accepted by the court.
In accordance with the Americans with Disabilities Act
of
1990, persons needing a special
accommodation to participate in this proceeding should contact the
ADA
Coordinator for proceedings
in court or out
of
court proceedings no later than seven (7) days before the proceeding. Telephone
813-272-7040 for assistance.
If
hearing impaired, telephone (TAD) 1-800-955-8770 for proceedings
in court or Florida Relay Service 1-800-955-8771 for out
of
court proceedings.
YOU ARE HEREBY ADVISED THAT IN THIS CIRCUIT:
Electronic recording is provided by the court. A party may provide a court reporter at
Page I o
f2
that party's expense.
I HEREBY CERTIFY that a true and correct copy
of
the above and foregoing has been furnished
to the above addressees, by U.S. Mail, or indicated e-mail address, this
Petitioner
Address:,
______________
_
Page 2
of2
FormJ
IN
THE
CIRCUIT
COURT
OF
THE
THIRTEENTH
JUDICIAL
CIRCUIT
IN
AND
FOR
HILLSBOROUGH
COUNTY,
STATE
OF
FLORIDA
PROBATE,
GUARDIANSHIP,
TRUST
AND
MENTAL
HEALTH
DIVISION
IN
RE:
THE
GUARDIAN
ADVOCACY
OF
CASE
NO:
-
CP-
A Developmentally Disabled
Persoa
DIVISION: A
--------------------------------~/
ORDER
APPOINTING
GUARDIAN
ADVOCATE
(developmentally disabled, person
and
property)
I.
The nature of the incapacity
of
(the Ward) is
developmental disability in the
form
of
intellectual disability, the scope of the Ward's disability being such
that the Ward functions at the level
of
a young child, a condition that,
in
all medical probability, will not
change.
2.
The Ward lacks the capacity to make informed decisions regarding any aspect
of
care or
treatment,
is
unable to meet any essential requirements for his own physical health and safety and cannot
exercise on his own behalf, any
of
the following rights: to contract; to sue and
def
e
nd
lawsuit
s;
to apply
for government and other public benefits; to manage property or make any gift or disposition
of
the same;
to determine residence; to consent to medical, surgical and mental health treatment; and to consent to
marriage.
3. The Ward's specific legal disabilities are
intellectual disability and other related health
conditions resulting
in
an
operational level commensurate with that
of
a young child.
4. It
is
necessary for a Guardian Advocate to be appointed for the Ward, the Guardian
Advocate having the power and duty to exercise on behalf
of
the Ward the fo
ll
owing rights:
a.
To
contract; and
b.
To
sue and defend lawsuits; and
c. To apply for government and other public benefits; and
d.
To manage property or make any gift or disposition
of
the same; and
e. To determine residence; and
f.
To
consent to medical, surgical and mental health treatment; and
g.
To
consent to marriage.
It
is,
therefore,
ADJUDGED
as follows:
-----
----
----
---
----
--is
qualified to serve, and is hereby
appointed as Guardian Advocate
of
the person and property
of
, a
developmentally disabled person, with the power and duty to exercise on behalf
of
those rights described
in
paragraphs 4a through 4g above.
DONE
and
ORDERED
in
Chambers at Tampa, Florida,
this-
----
--------
--
-------
CIRCUIT
COURT
JUDGE
Copies to:
Page
I
of
I
FORM K
IN
THE
CIRCUIT COURT
OF
THE
THIRTEENTH JUDICIAL
CIRCUIT
FOR
HILLSBOROUGH COUNTY, FLORIDA
Probate, Guardianship, Mental Health and Trust Division
IN RE: GUARDIAN ADVOCACY
OF
CASE
NO.:
DIVISION: A
____
______________________
Ward.
./
LETTERS
OF
GUARDIAN/CO-GUARDIAN ADVOCATE(S)
OF
THE
PERSON
TO ALL WHOM IT MAY CONCERN:
WHEREAS, has/have been appointed
Guardian/Co-Guardian Advocate(s)
of
the Person
of
--------------------------------'a
person with a developmental disability who
lacks the decision-making capacity to do SOME/ALL
of
the tasks necessary to take care
of
his
person; and
WHEREAS, the Guardian/Co-Guardian Advocate(s) has taken and filed the prescribed
oath and performed all other acts prerequisite to the issua
nc
e
of
Letters
of
Guardian/Co-Guardian
Advocate( s)
of
the Person;
NOW, THEREFORE,
I,
the undersigned circuit judge, declare that
_________
__
_____
is duly qualified under the laws
of
the State
of
Florida to
act as Guardian/Co-Guardian Advocate(s)
of
the Person
of
with full power to exercise the following
powers and duties on behalf
of
the person with a developmental disabilit
y:
(__)
to determine his/her residency
(__)
to consent to medical and mental health treatment
(__)
to make decisions about his/her social environment/social aspects
of
his/her life
(__)
to act as representative payee
of
government benefits
or
seek such benefits
(__)
Other:
-------------------
-----------------
Without first obtaining specific authority from the Court, as stated in section
744.3725, Florida Statutes, the Guardian/Co-Guardian Advocate(s) may not:
(a) commit the person with a developmental disability to a facility, institution, or licensed
service provider without formal placement proceedings, pursuant to Chapter 393, Florida Statute
s;
(b) consent to the participation
of
the person with a developmental disability in any
experimental biomedical
or
behavior procedure, exam, study, or research;
(c) consent to the performance
of
a sterilization or abortion procedure on the disabled
person;
(d) consent to termination
of
life support systems provided for the person with a
developmental disability
(e) initiate a petition for dissolution
of
marriage for the ward
(f) exercise any authority over any health care surrogate appointed by any valid advance
directive executed by the disabled person, pursuant to Chapter 765, Florida Statute
s,
except upon
further order
of
this Court.
(the person with developmental
disability) shall retain all legal rights except those which are specifically granted to the
Guardian/Co-Guardian Advocate(s) pursuant to court order.
DONE AND ORDERED in chambers at
____
______
, Hillsborough
County, Florida
on
___
____________
_
Circuit Court Judge
FORM L
IN THE CIRCUIT COURT OF THE THIRTEENTH JUDICIAL CIRCUIT
FOR HILLSBOROUGH COUNTY, FLORIDA
Probate, Guardianship, Mental Health and Trust Division
IN RE: GUARDIAN ADVOCACY OF CASE NO.:
Ward, DIVISION: A
______________________________
./
INITIAL GUARDIANSHIP PLAN (GUARDIANSHIP REPORT)
OF GUARDIAN OF THE PERSON
----------------------------------------
----
' the Guardian (s)
of
the person
of
______________
____________
_ , (the Ward), submits the following plan
as the Initial Guardianship Plan
ofthis
guardian:
1.
During the period beginning
____________
____
, 20
__
and ending
_________________
, 20
__
, the Guardian(s) propose(s) the following plan for the benefit
of
the ward, which is based upon the Order Appointing a Guardian/Co-Guardian Advocate(s):
a. Medical, mental
or
personal care services to be provided for the welfare
of
the Ward (Which doctor(s) does the ward visit regularly? What kind
of
assistance does the
ward
require
for
activities
of
daily living? Does the
ward
require any mental health care?) :
b.
Social and personal services to be provided for the welfare
of
the Ward (The
Guardian must detail all services provided to
or
for
the ward, including any services
provided by friend
s,
family,
paid
caregivers
or
facility staff.) :
c.
Place and kind
of
residential setting best suited for the needs
of
the Ward
(Please list the ward's address, name and type
of
facility,
if
applicable, and describe why
this
is
the best, least restrictive, living arrangement
for
the ward):
d.
Description
of
health and accident insurance and any other private or
governmental benefits to which the Ward may be entitled to meet any part
of
the costs
of
medical, mental health or related services provided to the Ward (list all types
of
income/benefits received by or for the ward,
for
example, Social Security, pensions,
Medicare, Medicaid, etc.)
e.
Physical and mental examinations necessary to determine the Ward's
medical and mental health treatment needs, including names
of
those who wi
ll
provide
examinations and approximate dates for examinations
(What care providers does the
guardian intend to have the ward see
in
the coming reporting period):
2.
The Guardian(s) hereby attest(s) that the Guardian(s) has/have consulted with the
Ward and, to the extent reasonable, honored the Ward
's
wishes consistent with the
ri
ghts retained
by the Ward under the plan, and to the maximum extent reasonable, the plan is in accordance with
the wishes
of
the Ward.
3.
This Initial Guardianship Plan does n
ot
restrict the physical liberty
of
the Ward
more than is reasonably necessary to protect the Ward or others from serious physical injury,
illness or disease and provides the Ward with medical care and mental health treatment for the
Ward's
physical and mental health.
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.
Signed on the
__
day
of
, 20 .
Signature:
__
_
____
_____
_ _
Name
----
_
-
----
-----
-
Address
---
--
-
------
--------
Phone
----
--------------
----
E-mail address
--------
---
-
------
(Guardian Advocate)
Signature:
_________
_____
__
___
_
Name
-----------
- -
---
--
--
Address
--------
----
-
----
Phone
------
----
------
----
-
E-mail address
------
----------
(Co-Guardian Advocate)
CERTIFICATE OF SERVICE
I,
, do hereby certify that a true and correct copy
of
the attached Initial Guardianship Plan
of
the Guardian/Co-Guardian Advocate
of
the Person,
has been furnished by (type
of
mail) , on this day
of
____________
,
20_
to the following persons, at the address specified:
___
_ _
Signature
(If
Co-Guardians, only one needs
to sign Certificate
of
Service)
FORMM
IN THE CIRCUIT COURT OF THE THIRTEENTH JUDICIAL CIRCUIT
FOR HILLSBOROUGH COUNTY, FLORIDA
Probate, Guardianship, Mental Health and Trust Division
IN RE: GUARDIAN ADVOCACY OF
CASE NO.:
DIVISION: A
Ward.
------------------------~'
ANNUAL GUARDIANSHIP PLAN (GUARDIANSHIP REPORT)
OF GUARDIAN/CO-GUARDIAN OF PERSON (adult)
the Guardian/Co-
Guardian
of
the person
of
_______
__
______
(the ward), submits the
following plan as the Annual Guardianship Plan
of
this guardian/co-guardian:
The Annual Guardianship Plan for the period beginning
___
_
__
__
,
20_,
and ending , 20
__
, shall be as follows:
1.
The ward's address
at
the time
of
filing this plan is:
2.
During the preceding year, the ward was maintained at (include dates, names,
addresses and length
of
stay at each place; include date ward began residing at this address and
date left
{if
applicable}; name{s}
of
caregiver/relative with whom the ward resides
and
the
physical address
of
the location. Also include a statement as
to
why this
is
the best living
arrangement/or the ward):
3. Plans for ensuring that the ward is in the best residential setting to meet the ward's
needs during the coming year are as follows
(What will the guardian
do
to ensure the ward
is
in
the most appropriate living arrangement. For example, will the guardian attend care plan
meetings, visit with the ward, confer with caregivers/medical professionals, etc.):
4. The following is a resume
of
any medical treatment given to the ward during the
pr
eceding year (the guardian must detail all medical
and
mental health providers the
ward
visited
and
the reasons
for
these visits during the past year):
5. Attached is a report
of
a physician who examined the ward no more than ninety
(90) days before the beginning of the report period containing that physician
's
evaluation of the
ward's
condition, a statement
of
the current level
of
capacity
of
the ward and a statement of
whether a guardian is still necessar
y.
The report must be signed by a licensed physician, preferably
the ward' s primary care physician, psychiatrist, or a neurologist.
Forms signed
by
an
ARNP
will
not be accepted, absent a change in the current law.
6. The plan for providing medical, mental health and rehabilitative serv
ic
es
in the
coming year is as follows
(w
hat doctors
or
other medical/mental health providers does the
guardian expect the
ward
to visit in the upcoming year):
7. The following
inf
ormation is submitted concerning the social condition
of
the ward:
a.) The social and personal services currently used by the ward are as
fo
llows (The
guard
ian must detail all services provided to,
or
for, the ward, including any services
provided
by
friends, family,
paid
caregivers or facility
staff
In addition, the guardian must
explain how the ward spends his/her day
.):
b.) The following is a statement
of
the social skills
of
the ward, including
how
well the
ward communicates and maintains interpersonal relationships
(Does the ward
communicate verbally? How does he/she communicate his/her wants
or
needs?):
c.) The social needs
of
the ward (What does/would the ward require to obtain/maintain
social happiness
and
interaction?):
8.
The following is a summary
of
activities during the preceding year designed to
enhance the capacity
of
the ward (What has the guardian done to maintain or increase the ward's
quality
of
life?):
9.
Is the ward now capable
ofhaving
some or all
ofthe
ward's rights restored?
If
so,
identify the rights that should be restored.
(!'he guardian's statement should agree with the
physician's statement.
If
it
does not, an explanation should be provided.)
I
0.
Do you plan to seek the restoration
of
any rights to the ward?
II.
This plan has/has not(circle one) been reviewed with the ward.
Under penalties of perjury, 1/we declare that 1/we have read the foregoing and the facts alleged are
true, to the best
of
my knowledge and belief.
Signed on.
___________
, 20_
Signature:
_____
_______
_ _
Name
--------
------
--
Address
_____
_ _ _
_____
_
Phone
-
---------------
E-mail address
--
-----
--
----
Guardian Advocate
Signature:.
___
___
__
_
_____
_
Name
-----
--
---------
Address
----
-
----
- -
--
-
Phone
_______
_
__
_
___
___
E-mail address
----
-
-------
Co-Guardian Advocate
Form N
IN
THE
CIRCUIT
COURT
OF
THE
THIRTEENTH
JUDICIAL
CIRCUIT
FOR
HILLSBOROUGH
COUNTY,
FLORIDA
Probate,
Guardianship,
Mental Health
and
Trust
Division
IN
RE:
GUARDIAN
ADVOCACY
OF
CASE
NO.:
A Person with a Developmental Disability,
DIVISION:
A
------------------------------'
APPLICATION
FOR
APPOINTMENT
AS
STANDBY
GUARDIAN
ADVOCATE
Pursuant to Sections 744.3125
ofthe
Florida Guardianship Law, the undersigned submits
this Application for Appointment as Standby Guardian/Co-Guardian Advocate
of
---------
(the person with a de
ve
lopment di
sa
bility) and submits the following
information (whenever the space provided is insufficient, attach additional pages):
I.
Name:
2. Social Security Number:
3. Date and Place
of
Birth:
4. Residence address:
address: 5. Mailing
6.
Email address:
7. U.S. Citizen? Yes
No
8.
Emp
l
oyer's
name and address:
Applicant' s position:
9.
Marital status and name
of
spouse,
if
any:
10. Home telephone number:
---------------------------
filed:
Work telephone number:
-------------------
----
---
11
. Length
of
residence
in
county wherein application is
---------------
---
12.
If
currently serving
as
a guardian for any other ward, list names
of
each ward, court file
number(s), circuit court(s) in which the case(s) is/are pending and whether applicant is acting as
the limited or plenary guardian
of
the person or property or both:
---------------------
13.
If
you are a professional guardian, please indicate month, day, and year in which you
were appointed on your third case:
14. Does applicant have any physical disabilities?
Yes__
No
__
.
If
yes, please
describe and state whether such disability my affect applicant's ability, in any degree, to serve as
guardian:
15. 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:
If
"yes" was answered to any
of
the above, please state date, time, location
of
treatment
and name
of
physician or professional involved:
------------------
16. Has applicant ever been judicially determined to have committed abuse, abandonment,
or
neglect against a child as defined by the Florida Statutes? Yes No
17. Has applicant ever been the subject
of
a confirmed report
of
abuse, neglect,
or
exploitation
which has been uncontested
or
upheld pursuant to the provisions
of
Sections 415
.l
04 and
415.1075, Florida Statutes? Yes
No
18.
Has applicant ever been charged with fraud, misrepresentation
or
perjury in a judicial
or
administrative proceeding? Yes No
If
yes, give date and complete details: please
19. Has applicant ever been charged with, arrested for,
or
convicted
of
a felony,
even
if
the
record
of
such arrest or conviction has been expunged, unless the expunction was ordered pursuant
to Florida Statutes Section 943.0583? Yes
__
No
__
If
yes, please furnish details including
date, type
of
offense, location and final disposition:
20. Has applicant ever been charged with, arrested for, or convicted
of
any other crimes?
Yes No
If
yes, please furnish details, including date and
final disposition:
, type
of
offense, location,
21.
Has applicant ever held a position, which required bonding? Yes
__
No
__
If
yes, please describe position, date, amount
ofbond
and name
of
surety:
22. Has applicant, in the past, ever served as guardian
of
a person
or
of
a person
's
property?
Yes below, including reason for termination
of
No
__
If
yes, please describe fiduciary
position:
------
-------
-------------------
23. Has applicant ever been held in contempt
of
court or removed as guardian?
Yes
__
No
__
If
yes, please describe below:
24.
Has applicant ever filed for bankruptcy?
Yes
__
No If yes, please state date
and location
of
court:
25. Has the applicant ever been found guilty, plead nolo contendere
or
guilty
of
an offense
prohibited by Florida Statutes 435.04 or similar statute
of
another jurisdiction? Yes No
If
yes, please give details, to include date and final disposition: , type
of
offense, location,
26. What is applicant's relationship to the person with a developmental disability?
27. Is applicant,
or
applicant's business, corporation or other business entity a creditor
of
, or
providing substantial professional, personal, or business services to the person with a
developmental disability? Yes
__
No
__
If
yes, please furnish detail
s:
28. Is applicant employed by a person, agency, government, corporation or other business
entity, which is providing professional, personal or business services to the person with a
developmental disability?
Yes
__
No _ _
If
yes, please furnish detail
s:
29. Is applicant a health care provider for the person with a developmental disability?
Yes
No
---
30. Educational history
of
applicant:
Name and address Degree
Highschool:
__________________
________________
__________________
__
College:
Other:
31
. List
applicant's
employment
experience for the
past
ten
(1
0) years beginning
with
the
most
recent date:
Name
and address Date(s)
Reason for leaving
32.
Has
applicant
ever
been
discharged from employment: Yes
No
If
yes,
please explain:
33.
Has
applicant ever been a
member
of
the armed forces
of
the U.S.? Yes
No
If
yes,
what
branch, dates and military serial number:
34
.
PERSONAL
REFERENCES.
Please give the
name
s, addresses and teleph
one
numbers
of
three (3) responsible persons who have been closely associated with applicant and
who
have
known
app
licant for five (5) years
or
more,
not
including relatives
or
s
pou
se:
Name
and
address
Telephone
number
35.
Does
applicant possess
any
special educational qualifications (financial, business
or
otherwise) that uniquely qualifies applicant to be appointed as guardian? Yes
No
__
_
If
yes, please describe below:
----
--
-----
--
-----
--
----
36. Has applicant received instruction and training, which covered the legal duties and
responsibilities
of
a guardian, the rights
of
a ward, 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 propet1y? Yes
__
No
__
If
so, indicate when and where training
was received:
Under penalties
of
perjury, I declare that I have read the foregoing, and the facts alleged are true,
to the be
st
of
my knowledge and belief.
Signed on _ _
____
_
__
___
,
20_
Signature. _
_____
____
_
__
_
Name
_____
___
______
___
Address.
___
_________
_ _
Phone
_____
__
_
______
_
__
E-mail address ___
_____
____
_
(Proposed Standby Guardian Advocate)
FORMO
IN
THE
CIRCUIT
COURT
OF
THE
THIRTEENTH
JUDICIAL
CIRCUIT
FOR
HILLSBOROUGH
COUNTY,
FLORIDA
Probate,
Guardianship,
Mental Health
and
Trust
Division
IN
RE: GUARDIAN ADVOCACY
OF
CASE NO.:
A Person with a Developmental Disability,
DIVISION: A
-------------------------------'
STANDBY GUARDIAN ADVOCATE'S
JOINDER
IN
PETITION
The undersigned,
--------------------------
, who
is
the
--
-------------
(relation to)
ofthe
Ward,
joins
in the Petition for Appointment
of
Guardian Advocate
of
the
Person and Appointment
of
Standby Guardian Advocate; the undersigned is sui juris (over
18
years
of
age) and is otherwise qualified under the laws
of
the State
of
Florida to act in such
capacity and waives the requirement
of
a notice
of
hearing with respect to entry
of
an Order
Appointing Standby Guardian Advocate; and the undersigned is willing to serve as Standby
Guardian Advocate.
EXECUTED this
___________
day
_______
of
_ _ , 20
Signature
____________
____
_
Name
_____________
___
Address
--------------------
Phone
--------------
--
E-mail address
-----------------
(Proposed Standby Guardian Advocate)
FORM P
IN
THE
CIRCUIT
COURT
OF
THE
THIRTEENTH
JUDICIAL
CIRCUIT
FOR
HILLSBOROUGH
COUNTY, FLORIDA
Probate,
Guardianship,
Mental Health
and
Trust
Division
IN
RE:
GUARDIAN ADVOCACY
OF
CASE
NO.:
A Person with Developmental Disability,
DIVISION: A
-----------------------------1
NOTICE
OF
FILING
PLEASE TAKE NOTICE that the Proposed Guardian/Co-Guardian Advocate,
______
_
______
_
______
, hereby gives notice
of
filing the following
documents:
Title/Type ofDocument(s): (choose which ones apply)
( ) Death certificate
of
Ward's parent
( ) Confidential Psychological Report/Doctor Report/IEP
( ) Other
(describe)
:.
___________
__
_____________
_
Signature
_______
_
___
_
Na
me
---
-----------------
--
----
Address
__
__
_
________
_
Phone
-----------
--
-------
E-mail address
-------
------
-----
-
(Guardian/Co-Guardian Advocate)
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Guardian Advocacy Forms (Thirteenth Judicial Circuit Court Hillsborough County)

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Completed 17 August 2021

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