GUARDIANSHIP INFORMATION SHEET

I.NOMINEE/PETITIONER
Name of Nominee: ______
Address:______
Telephone Number: ______
Date of Birth/Age: ______
Relationship to Alleged Incapacitated Person: ______

II.ALLEGED INCAPACITATED PARTY (AIP)

Name of AIP: ______Age of AIP: ______
Date of Birth of AIP: ______ AIP’s Social Security No.: ______
Current Residence Address: ______, ______
County of Residence: ______
If AIP is/was Married, Name of Spouse: ______
If Spouse Deceased, Date of Death: ______
Is AIP a U.S. Veteran? ______ If so, AIP’S Veteran ID #: ______

III.CUSTODIAN/CARE PROVIDER

AIP’s Custodian/Care Facility: ______
Custodian/Care Facility Address: ______
______
Custodian/Care Facility Phone Number: ______
Length of Time:______

IV.PHYSICIAN/MEDICAL PROVIDER

AIP’s Physician/Medical Provider: ______
Physician/Provider’s Address: ______
______
Physician/Provider’s Telephone number: ______
Length of Time Treated AIP: ______
V.ALTERNATE ARRANGEMENTS: WILL/POWERS OF ATTORNEY
Does AIP have a Will: Yes No
If yes, date of Will: ______
Executor of Will: ______
Relationship to AIP: ______
Address of Executor:______
______
Telephone of Executor: Home: ______
Work: ______/ Durable Power of Attorney: Yes No
If so, Effective Date: ______
Person named Attorney in Fact: ______
Relationship to AIP: ______
Address of AIF:______
______
Telephone of AIF: Home: ______
Work: ______
VI.EXISTING OR PENDING GUARDIANSHIPS
There [ ] is [ ] is not an existing or pending Guardianship action for the person and/or the estate of the Alleged Incapacitated Person. If there is an existing or pending Guardianship, set forth the following:
A.State Where Guardianship/Limited Guardianship Established: ______
B.Name of Guardian/Limited Guardian: ______
C.Date of Appointment: ______

D.Type of Guardianship: ______

VII.RELATIVES OF AIP
The name and addresses, and the nature of the relationship of the persons most closely related by blood or marriage to the Alleged Incapacitated Person: (list additional on separate sheet)
A.Name: ______
Address:______
______
Relationship: ______
Name: ______
Address:______
______
Relationship: ______
B.Name: ______
Address:______
______
Relationship: ______

VIII.INCOME OF AIP

A.Social Security Benefits:$______/month
B.Veterans Benefits$______/month
C.Washington State Assistance$______/month
D.Other:______$______/month
Total Approximate Income:$______/month

IX.ASSETS OF AIP (list additional on separate sheet)

A.Real Property: Address:______County/State:______
Fair Market Value: $______Mortgage: Yes No Loan #______
B.Securities/Investments $______Broker: ______
C.Mortgages/Notes: $______Debtor: ______
D.Bank Accounts: $______Bank: ______
E.Furniture/Household Goods: $______
F.Other Personal Property: $______Type:______
Total Approximate Value of Assets: $______

X.DEBTS OF AIP (list additional on separate sheet)

A.Credit Accounts: ______Monthly Payment:______
B.Mortgages: ______Monthly Payment:______
C.Notes Payable: ______Monthly Payment:______
D.Loans: ______Monthly Payment:______
E.Other: ______Monthly Payment:______
Total Debts: $______Total Monthly Payments:$______

XI.ESTIMATED MONTHLY EXPENSES (list additional on separate sheet)

  1. Rent/Room/Board: ______
  2. Clothing: ______
  3. Food: ______
  4. Medical/Dental: ______
  5. Insurance Premiums: ______
  6. Monthly Utilities: ______

G.Other: ______

Total Estimated Monthly Living Expenses: $______

Other Information Not Provided Above:______

______

XII.Miscellaneous Information REQUIRED

Please provide the following:

Copy of Last Will and Testament

Original Power of Attorney

Copy of Vehicle Titles

Copy of Deeds, Contracts, Notes, etc.

Copy of Stock Certificates and Bonds

Copy of current Brokerage Account Statements

Copy of current Bank Account Statements

Copy of current Insurance Policy Premium Statements

Copy of last tax return

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