Guardianship Intake Form Step 1 of 6 16% Select number of applicants(Required) Single Multiple Applicant(s)Applicant's Full Name(Required)State your name as would regularly sign your checks, etc. Applicant's Phone Number(Required)Applicant's Former Name(Required)Applicant's AddressApplicant's Social Security Number (Last three digits)(Required)Applicant's Driving License Number (Last three digits)(Required)State that issued applicant's driver’s licenseCo-Applicant's Full Name(Required)State your name as would regularly sign your checks, etc. Co-Applicant's Former Name(Required)Co-Applicant's AddressCo-Applicant's Social Security Number (Last three digits)(Required)Co-Applicant's Driving License Number (Last three digits)(Required)State that issued co-applicant's driver’s license Proposed WardThe proposed ward is the person that you wish to seek a guardianship for. Proposed Ward Name(Required)Proposed Ward AddressProposed Ward CountyProposed Ward Date of Birth MM slash DD slash YYYY Proposed Ward Age(Required)Proposed Ward Gender(Required) Male Female Proposed Ward's Social Security Number (Last three digits)Proposed Ward's Driving License Number (Last three digits)State that issued proposed ward's driver’s licenseApplicant’s Relationship to proposed wardHas the proposed ward lived with you for the past year?(Required) Yes No Name of the adult the proposed ward has lived with for more than six months of the previous yearAddress of the adult the proposed ward has lived with for more than six months of the previous yearCounty of the adult the proposed ward has lived with for more than six months of the previous yearDo you have a letter from a physician or other qualified person who has evaluated the proposed ward and describes the conditions giving rise to a guardianship?(Required) Yes No Please upload a copy of letterMax. file size: 32 MB. Which of the following conditions apply to the proposed ward? Mental Illness Mental Deficiency Physical Illness or Disability Chronic Drug Use Chronic Intoxication Minor Other Please describe the condition of proposed wardGuardian InformationProposed Guardian Name(Required)Proposed Guardian Address(Required)Proposed Guardian Social Security Number (Last 3 digits)Proposed Guardian Driving License (Last 3 digits)Proposed Guardian Qualifications Rights Affected By GuardianshipLimit or terminate Ward’s right to vote(Required) Yes No Limit or terminate Ward’s right to obtain/operate a motor vehicle(Required) Yes No Limit or terminate Ward’s right to determine personal residence(Required) Yes No Please specify Other rights affectedGuardianship DetailsPlease briefly describe why you wish to seek a guardianship for the proposed ward at this timeAre you requesting an emergency guardianship?(Required) Yes No Describe the imminent danger to the ward requiring temporary guardianship?Please list the current income of the proposed wardProposed Ward AssetsPlease list the assets of the proposed ward: (Ex. Real property, bank accounts, IRAs, 401K, automobiles, etc.)Please select the number of assets owned by proposed ward(Required) 1 2 3 4 5 Asset 1 InformationType of Asset 1Estimated Value of Asset 1Details of Asset 1Asset 2 InformationType of Asset 2Estimated Value of Asset 2Details of Asset 2Asset 3 InformationType of Asset 3Estimated Value of Asset 3Details of Asset 3Asset 4 InformationType of Asset 4Estimated Value of Asset 4Details of Asset 4Asset 5 InformationType of Asset 5Estimated Value of Asset 5Details of Asset 5This field is hidden when viewing the formWard's total estate value Power of AttorneyDoes the proposed ward have a Power of Attorney?(Required) Yes No Name of person who currently holds a power of attorneyAddress of person who currently holds a power of attorneyThis field is hidden when viewing the formIs Power of Attorney executed?(Required) Yes No Date of Execution of Power of Attorney MM slash DD slash YYYY Please upload a copy of power of attorneyMax. file size: 32 MB. Adult Relative of Proposed WardWard's SpouseName of spouseIs spouse deceased? Yes No Address of spouseWard's ParentName of MotherIs mother deceased? Yes No Address where mother livesName of FatherIs father deceased? Yes No Address where father livesWard's ChildrenDoes the ward have any children? Yes No Select number of children ward have 1 2 3 Name of Child 1Is child 1 deceased? Yes No Date of Birth of child 1 MM slash DD slash YYYY Address where child 1 livesName of Child 2Is child 2 deceased? Yes No Date of Birth of child 2 MM slash DD slash YYYY Address where child 2 livesName of Child 3Is child 3 deceased? Yes No Date of Birth of child 3 MM slash DD slash YYYY Address where child 3 livesWard's SiblingsDoes the ward have any siblings? Yes No Select number of siblings ward have 1 2 3 Name of Sibling 1Is sibling 1 deceased? Yes No Date of Birth of sibling 1 MM slash DD slash YYYY Address where sibling 1 livesName of Sibling 2Is sibling 2 deceased? Yes No Date of Birth of sibling 2 MM slash DD slash YYYY Address where sibling 2 livesName of Sibling 3Is sibling 3 deceased? Yes No Date of Birth of sibling 3 MM slash DD slash YYYY Address where sibling 3 livesWard's Adult RelativesDoes the ward have any adult relatives? Yes No Select number of adult relative ward have 1 2 3 Name of adult relative 1Address of adult relative 1Name of adult relative 2Address of adult relative 2Name of adult relative 3Address of adult relative 3 Previous GuardianshipHave guardianship proceedings been opened in any other state?(Required) Yes No Are those proceedings still open? Yes No Information about other GuardianshipGuardian NameGuardian AddressGuardian Phone NumberCourt Proceedings Open InCase NumberHow Proceedings ClosedWhen Case Closed MM slash DD slash YYYY Please upload copies of any documents that you have regarding these proceedings Drop files here or Select files Max. file size: 32 MB. Referrals and RepresentationFrom what sources did you hear about Carr & Cole, PLLC?Who is your primary attorney?(Required) Chavon Carr Geré Cole
