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Fla. Prob. R. 5.904

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Rule 5.904 Forms for Initial and Annual Guardianship Plans

Part V: Forms

Rule Text

(a) Initial Guardianship Plan for Minor.

In the Circuit Court of the

__________________ Judicial

Circuit,

in and for ____________________

County, Florida

Probate Division

Case No. _____________________

In Re: Guardianship of

________________________

Minor Ward

________________________

INITIAL GUARDIANSHIP PLAN FOR MINOR

.....(Guardian’s name)....., the guardian of the person of .....(ward’s name)....., submits the following annual plan for the period beginning on .....(beginning date)..... and ending on .....(ending date)....., for the benefit of the ward.

1. The ward’s address at the time of filing this plan is: _______________

______________________________

2. The medical, dental, mental, or personal care services for the welfare of the ward that will be provided during the upcoming year are:

Provider	Type of Service to be Provided

3. The social and personal services to be provided for the welfare of the ward during the upcoming year are: ______________________________

______________________________

4. The place and kind of residential setting best suited for the needs of the ward is: ______________________________

______________________________

5. The physical and/or mental examinations necessary to determine the ward’s medical, dental, and mental health treatment needs are: ____________

______________________________

6. Education of the ward:

Name and address of the school the ward will attend: ___________________

______________________________

Grade level of ward: ______________________________

Description of classes the ward will attend: _____________________________

7. Consulting with ward (Check 1):

( ) a. The ward is under age 14;

( ) b. The guardian attests that the guardian has consulted with the ward (if ward is 14 years of age or older) and, to the extent reasonable, honored the ward’s wishes consistent with the rights retained by the ward under the plan, and to the maximum extent reasonable, the plan is in accordance with the wishes of the ward.

8. This initial plan does not restrict the physical liberty of the ward more than is reasonably necessary to protect the ward 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.

(Please use additional sheets if necessary.)

Under penalties of perjury, I declare that I have completed and read the foregoing, and the facts set forth are true, to the best of my knowledge and belief.

Signed on .....(date)......

[A certificate of service is required if ward is 14 years of age or older.]

[I certify that the foregoing document has been furnished to .....(name, address used for service, mailing address, and e-mail address)..... by (e-mail) (delivery) (mail) (fax) on .....(date)…...]

______________________________

Guardian’s Signature

Guardian’s Printed Name: __________

______________________________

Guardian’s Address: _______________

______________________________

Guardian’s Phone Number: _________

Guardian’s E-mail Address: ________

If the guardian is represented by counsel, the attorney must comply with Florida Rule of General Practice and Judicial Administration 2.515.

(b) Annual Guardianship Plan for Minor.

In the Circuit Court of the

__________________ Judicial

Circuit,

in and for ____________________

County, Florida

Probate Division

Case No. _____________________

In Re: Guardianship of

________________________

Minor Ward

________________________

ANNUAL GUARDIANSHIP PLAN FOR MINOR

1. The ward’s address at the time of filing this plan is: _______________

______ . During the prior 12 months, the ward resided at (include dates, names, addresses, and length of stay at each location):

Date	Name	Address	Length of stay

2. List any professional treatment (medical or dental) given to the ward during the prior 12 months:

Date	Provider	Treatment provided

3. A report from the physician who examined the ward no more than 180 days before the beginning of the applicable reporting period that contains an evaluation of the ward’s physical and mental conditions has been filed with this plan. [See subdivision (e) of this rule for a format for a physician’s report.]

4. The plan for providing medical or dental services in the coming year:

______________________________

5. A summary of the ward’s school progress report:

______________________________

6. A description of the ward’s social development, including how well the ward communicates and maintains interpersonal relationships:

______________________________

7. The social needs of the ward are:

______________________________

8. Consulting with ward (Check 1):

( ) a. The ward is under age 14;

(Please use additional sheets if necessary.)

Under penalties of perjury, I declare that I have completed and read the foregoing, and the facts set forth are true, to the best of my knowledge and belief.

Signed on .....(date)......

[A certificate of service is required if ward is 14 years of age or older.]

[I certify that the foregoing document has been furnished to .....(name, address used for service, mailing address, and e-mail address)..... by .....(e- mail) (delivery) (mail) (fax)..... on .....(date)…...]

______________________________

Guardian’s Signature

Guardian’s Printed Name: __________

______________________________

Guardian’s Address: _______________

______________________________

Guardian’s Phone Number: _________

Guardian’s E-mail Address: ________

In the Circuit Court of the

__________________ Judicial

Circuit,

in and for ____________________

County, Florida

Probate Division

Case No. _____________________

In Re: Guardianship of

________________________

Respondent’s Name

Person with Developmental Disability

________________________

INITIAL GUARDIANSHIP PLAN (Initial Report of Guardian/Guardian Advocate)

.....(Guardian’s name)....., the guardian of the person/guardian advocate of .....(ward’s name)....., the ward, submits the following initial plan:

During the period beginning .....(beginning date)....., and ending on .....(ending date)....., the guardian proposes the following plan for the benefit of the ward.

1. The medical, mental, or personal care services for the welfare of the ward that will be provided during the upcoming year are:

Provider	Type of Service to be Provided

2. The social and personal services to be provided for the welfare of the ward during the upcoming year are: ______________________________

______________________________

3. The place and kind of residential setting best suited for the needs of the ward is: ______________________________

______________________________

4. Describe the 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: ____

______________________________

5. The physical and mental examinations necessary to determine the ward’s medical, and mental health treatment needs are: _______________________

______________________________

6. The guardian/guardian advocate hereby attests that the guardian/guardian advocate has consulted with the ward and, to the extent reasonable, honored the ward’s wishes consistent with the rights retained by the ward under the plan, and to the maximum extent reasonable, the plan is in accordance with the wishes of the ward.

7. This initial plan does not restrict the physical liberty of the ward more than is reasonably necessary to protect the ward 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.

(Please use additional sheets if necessary.)

8. The following is a list of preexisting orders not to resuscitate, health care surrogate decision, living will, or anatomical gift.

#	Title	Date	Suspended by Court (Yes or No)	Steps Taken to Locate any Preexisting Document
1.
2.
3.

(Please use additional sheets if necessary.)

Under penalties of perjury, I declare that I have completed and read the foregoing, and the facts set forth are true, to the best of my knowledge and belief.

Signed on .....(date)......

[A certificate of service is required unless ward has been declared totally incapacitated.]

______________________________

Guardian’s Signature

Guardian’s Printed Name: __________

______________________________

Guardian’s Address: _______________

______________________________

Guardian’s Phone Number: _________

Guardian’s E-mail Address: ________

(d) Annual Guardianship Plan for Adult.

In the Circuit Court of the

__________________ Judicial

Circuit,

in and for ____________________

County, Florida

Probate Division

Case No. _____________________

In Re: Guardianship of

________________________

Respondent’s Name

Person with Developmental Disability

________________________

ANNUAL GUARDIANSHIP PLAN OF GUARDIAN/ GUARDIAN ADVOCATE OF THE PERSON

.....(Guardian’s name)....., the guardian of the person/guardian advocate of .....(ward’s name)....., the ward, submits the following annual plan for the period beginning .....(beginning date)..... ending .....(ending date)......

1. The ward’s address at the time of filing this plan is: _______________

______________________________

2. During the prior 12 months, the ward resided or was maintained at (include dates, names, addresses, and length of stay at each location):

Date	Name	Address	Length of stay

3. The residential setting best suited for the current needs of the ward is (Check 1):

( ) a. group home;

( ) b. assisted living;

( ) c. nursing home;

( ) d. live with parents;

( ) e. at ward’s private residence; or

( ) f. other: ______________________________

4. 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: __________________

______________________________

5. The following is a list of any medical treatment given to the ward during the preceding year:

Date	Provider	Treatment provided

6. Attached is a report of a physician who examined the ward no more than 90 days before the beginning of the reporting period, including that physician’s evaluation of the ward’s condition and a statement of the current level of capacity of the ward.

7. The plan for provision of medical, dental, mental health, and rehabilitative services (for example, occupational therapy, physical therapy, speech therapy, applied behavioral analysis) in the coming year is:

Date	Provider	Service provided

8. The following information is submitted concerning the social condition of the ward:

a. The ward is currently using the following social and personal services (include name, services rendered, and address of each provider), including any groups in which the ward is participating:

Date	Provider	Service provided

b. The following is a statement of the social skills of the ward, including how well the ward maintains interpersonal relationships with others:

______________________________

c. The following is a description of the social needs of the ward, if any: ______________________________

______________________________

9. The following is a summary of activities during the preceding year designed to increase the capacity of the ward, including involvement in groups or group activities: ______________________________

______________________________

10. Is the ward now capable of having some or all of the ward’s rights restored?

( ) If yes, identify the rights that should be restored: ___________

______________________________

11. Do you plan to seek the restoration of any rights to the ward?

( ) If yes, identify the rights that you are seeking to be restored:

______________________________

12. This plan _______ has or ___________ has not been reviewed with the ward.

(Please use additional sheets where necessary.)

13. The following is a list of preexisting orders not to resuscitate, health care surrogate designation, living will, or anatomical gift:

#	Title	Date	Suspended by Court? (Yes or No)	Steps Taken to Locate any Preexisting Document
1.
2.
3.

(Please use additional sheets if necessary.)

Under penalties of perjury, I declare that I have completed and read the foregoing, and the facts set forth are true, to the best of my knowledge and belief.

Signed on .....(date)......

[A certificate of service is required unless ward has been declared totally incapacitated.]

______________________________

Guardian’s Signature

Guardian’s Printed Name: __________

______________________________

Guardian’s Address: _______________

______________________________

Guardian’s Phone Number: _________

Guardian’s E-mail Address: ________

If the guardian is represented by counsel, the attorney must comply with Florida Rule of General Practice and Judicial Administration 2.515 (every document of a party represented by an attorney must be signed by at least 1 attorney of record).

(e) Physician’s Report.

In the Circuit Court of the

__________________ Judicial

Circuit,

in and for ____________________

County, Florida

Probate Division

Case No. _____________________

In Re: Guardianship of

________________________

Respondent’s Name

Person with Developmental Disability

________________________

PHYSICIAN’S REPORT (Required by section 744.3675, Florida Statutes)

1. Name of Physician: ______________________________

Address: ______________________________

______________________________

2. Name of ward: ______________________________

3. Date of examination: ______________________________

4. Purpose of examination: ______________________________

a. Regular checkup: ______________________________

b. Treatment for: ______________________________

5. Evaluation of ward’s condition: (Specify mental and physical condition at time of examination) ______________________________

______________________________

6. Description of ward’s capacity to live independently: ______________

______________________________

7. The ward ____ does ____ does not continue to need assistance of a guardian.

8. Is the ward capable of being restored to capacity at this time?

_____ Yes ______ No

Are there any rights that can be restored at this time? Check any rights that can be restored:

( ) a. to marry;

( ) b. to vote;

( ) c. to personally apply for government benefits;

( ) d. to have a driver license;

( ) e. to travel;

( ) f. to seek or retain employment;

( ) g. to contract;

( ) h. to sue and defend lawsuits;

( ) i. to apply for government benefits;

( ) j. to manage property or to make any gift or disposition of property;

( ) k. to determine the ward’s residence;

( ) l. to consent to medical and mental health treatment; or

( ) m. to make decisions about the ward’s social environment or other social aspects of the ward’s life.

9. Date of this report: ______________________________

10. Signature of physician completing this report: _____________________

APPENDIX A

INSTRUCTIONS TO GUARDIANS AND GUARDIAN ADVOCATES FOR FILING ANNUAL PLANS

1. Fill in the name of the county in which the case is filed on the second blank line at the top where it reads “IN AND FOR ________________ COUNTY.”

2. Print the name of the ward on the line just below the “In Re: Guardianship of” caption.

3. Put the case number in the space marked “CASE NO.” in the upper right-hand corner (same as court file number).

4. On the first blank line after the title of the document (Annual Plan), print the guardian’s name.

5. On the next blank line, print the ward’s name.

6. Write in the dates for the period of time of the plan. This period should end on the last day of the month of the month you were appointed and begin a full year before that. If you do not know your plan period, please see the chart below. Please call the clerk’s office or the appropriate court staff in the county in which you are filing, if you cannot determine the plan period after reviewing the chart.

7. Type or print answers to all of the questions on the plan. If the question does not apply to your ward’s circumstances, write in the phrase “not applicable.” Fill in all the blanks. If your ward has a habilitation plan (produced by the social worker or the Florida Department of Children and Families) and it has changed, please provide a copy of the habilitation plan as an attachment to the annual plan. If the habilitation plan has not changed then do not file a copy.

8. In paragraph 9, if your ward participates in groups, include that information in this paragraph.

9. Sign your name, and print your name, address, e-mail address, and phone number where indicated. If there are co-guardian advocates, both must sign the plan.

10. Make a copy of the plan for your records in the event there is a problem and work from it for next year’s plan. Make a copy of any attachments to the plan, as well.

11. Mail or hand deliver the original plan to the Clerk of Court of the county in which the case is filed. You MUST also send a copy of the plan to your attorney, if you have an attorney, so that the attorney will know that you have filed the plan and will have a copy of the plan in case there is a problem.

APPENDIX B

ANNUAL ACCOUNTING AND PLAN DATES (IF FISCAL YEAR REPORT PERIOD)

Month Letters Signed	Report Begin Date	Report End Date	Report Due Date
January	February 1	January 31	May 1
February	March 1	February 28	June 1
March	April 1	March 31	July 1
April	May 1	April 30	August 1
May	June 1	May 31	September 1
June	July 1	June 30	October 1
July	August 1	July 31	November 1
August	September 1	August 31	December 1
September	October 1	September 30	January 1
October	November 1	October 31	February 1
November	December 1	November 30	March 1
December	January 1	December 31	April 1

Rule 5.904 Forms for Initial and Annual Guardianship Plans

Rule Text

Plain-English Summary (for reference only — not a substitute for the rule text above)

Committee Notes

Disclaimer