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IN THE CIRCUIT COURT FOR _____________ COUNTY, FLORIDA

PROBATE, GUARDIANSHIP AND MENTAL HEALTH DIVISION

IN RE: GUARDIANSHIP OF

Case No.

Division

FLORIDA APPLICATION FOR APPOINTMENT AS GUARDIAN

Pursuant to Section 744.3125 of the Florida Guardianship Law, the undersigned submits

this Application for Appointment as Guardian of ____________________________ (the Ward)

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. Employer’s name and address: _____________________________________________

_____________________________________________________________________________

9. Marital status and name of spouse, if any: ____________________________________

_____________________________________________________________________________

10. Home telephone number: ________________________________

Work telephone number: __________________________________________________

11. Length of residence in county wherein application is filed: ________________________

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 a Professional Guardian, please indicate month, day, and year in which you were

appointed on your third case:

_____________________________________________________________________________

Page 1 of 5

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 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? Yes _____

No _____ If yes, please furnish details including date, type of offense, location and final disposition:

___________________________________________________________________

_____________________________________________________________________________

20. Has applicant ever held a position which required bonding? Yes _____ No _____ If yes,

please describe position, date, amount of bond and name of surety: ___________________

Page 2 of 5

_____________________________________________________________________________

21. Has applicant, in the past, ever served as guardian of a person or of a person’s property?

Yes _____ No _____ If yes, please describe below, including reason for termination of fiduciary

position: _____________________________________________________________________

22. Has applicant ever been held in contempt of court or removed as guardian? Yes _____

No _____ If yes, please describe below: ____________________________________________

_____________________________________________________________________________

23. Has applicant ever filed for bankruptcy? Yes _____ No _____ If yes, please state date

and location of court: ____________________________________________________________

_____________________________________________________________________________

24. What is applicant’s relationship to the alleged incapacitated person? __ _________

25. Is applicant, or applicant’s business, corporation or other business entity a creditor of, or

providing professional, personal or business services to the incapacitated person? Yes _____

No _____ If yes, please furnish details: _____________________________________________

_____________________________________________________________________________

26. Is applicant employed by a business, corporation or other business entity which is providing

professional, personal or business services to the incapacitated person?

Yes _____ No _____ If yes, please furnish details: ____________________________________

_____________________________________________________________________________

27. Is applicant a health care provider for the alleged incapacitated person? Yes _________

No ______

28. Educational history of applicant:

Name and address Degree Date

High school: ____________________________________________________________

College: _______________________________________________________________

Other: _________________________________________________________________

29. List applicant’s employment experience for the past ten (10) years beginning with the most

recent date:

Name and address Date Reason for leaving

_____________________________________________________________________________

Page 3 of 5

_____________________________________________________________________________

30. Has applicant ever been discharged from employment: Yes _____ No _____ If yes,

please explain: ________________________________________________________________

_____________________________________________________________________________

31. 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: __________________________________

_____________________________________________________________________________

32. PERSONAL REFERENCES. Please give the names, addresses and telephone numbers

of three (3) responsible persons who have been closely associated with applicant and who have

known applicant for five (5) years or more, not including relatives or spouse:

Name and address Telephone number

_____________________________________________________________________________

33. 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: _____________________________________________________

_____________________________________________________________________________

34. 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? Yes _____ No _____ If so, indicate when

and where training was received: ______________________________________

_____________________________________________________________________________

Page 4 of 5

Page 5 of 5

I certify that on _______________________________, a copy of this Application for

Appointment as Guardian was served upon the following persons at the addresses shown, by first

class United States Mail:

Unde

r 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.

S

igned on _________________________, 20___

________________________________

Guardian Signature

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