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IN THE CIRCUIT COURT OF THE SIXTH JUDICIAL CIRCUIT
IN AND FOR PINELLAS COUNTY, FLORIDA
PROBATE DIVISION
Case Number #: ______________________________
IN RE: The Guardianship of ________________________________________
ANNUAL AFFIDAVIT
COMES NOW, _________________________________________, as Guardian Advocate(s) or
Guardian(s) for the above named Ward and files this Affidavit and states as follows:
1. I am/we are appointed Guardian Advocate(s) or Guardian(s) by Order of this Court.
2. The ward resides at___________________________________________________________
_____________________________________________________________________________
3. The income of the ward consists of: ______________________________________________
______________________________________________________________________________
4. I/we affirm all income received monthly on the ward are used for the care and maintenance of
the ward.
5. I/We declare that I/we have received NO payment from any source for goods or services
rendered to or on behalf of the ward. Payment includes any monies or other benefit made
directly or indirectly, overtly or covertly, in cash or in kind. For additional information, see
Florida Statute 744.367(3)(a).
6. All requests for reimbursement or fees, if any, have been submitted to the court for review and
approval.
7. There are NO pre-existing orders or advanced directives such as: a Not To Resuscitate
(“DNR”), healthcare surrogate designation, living will, anatomical gift or durable power
of attorney).
OR
The following advanced directives were executed since the establishment of the
guardianship or the Guardian obtained a copy of a Not to Resuscitate (“DNR”) form,
healthcare surrogate designation, living will, anatomical gift or durable power of
attorney or other advanced directive:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
(Please describe above and attach a copy of the document to this form)
