Proposed Ward Information

Thank you in advance for filling out the form! If you have any questions about the form, please call us; otherwise, please complete as much of it as possible. Once you complete the form, send it to us at iva@difranzalaw.com.

DIFRANZA LAW, P.A. GUARDIAN ADVOCACY INTAKE FORM

INFORMATION ON THE PERSON NEEDING A GUARDIAN ADVOCATE (THE PROPOSED WARD)

Name

Complete Address (Home or Facility/Community)

Age & Date of Birth

DATE YOU BEGAN CARING FOR THIS INDIVIDUAL (Since Birth or Since a Date)

What is the nature/diagnosis of the developmental disability? Date or approximate date of diagnosis of disease/disability

Do you have documentation with official diagnosis of developmental disability? (IEP, Physician’s report/statement/letter) Please provide documentation.

Name & phone number of contact person to meet with person needing guardian advocate Any special instructions?

Is the person receiving SSI and/or Medicaid?

Will a special needs trust be needed?

Does the person have an ABLE account?

PRIMARY DOCTOR NAME, Address & Phone number

Has the person executed any health care directive, power of attorney, do not resuscitate order or living will? If so, please name which documents and provide a copy of each.

The proposed ward lacks the following decision-making ability to do decision-making tasks necessary to care for his or her person or property (check all that apply): (if the person does not lack any of these abilities – please state whether the person has the understanding to sign a power of attorney and health care designation in the Other section below)

The proposed ward lacks the ability …

To dress or feed himself or herself
to make informed decisions about his/her care and treatment services
to judge the consequences of decisions/actions regarding person or property, such as management of property or money or making changes
to safely live alone
to understand decisions about friendships and other social aspects
to make informed decisions or understand or judge the consequences of contracts and lawsuits
regarding activities related to independent living including:
decisions about the preparation of meals, decisions about shopping for groceries or personal items
decisions about feeding and dressing him/herself

Other:

The proposed ward lacks the ability 2

The proposed ward only receives Social Security income.
The proposed ward receives SSI and works part-time, of which reduces the amount of the SSI ward.
The proposed ward does not receive any government benefits at this time; however once he or she turns 18, proposed guardian advocates will be applying for benefits, such as SSI (supplemental security income from social security) and will be the representative payee.
Because of the proposed ward’s disability and condition, he or she is unable to become employed.
The proposed is employable; however, the proposed ward will always require one-to-one supervision.

NEXT OF KIN (NoK) TO THE PROPOSED WARD:

DEFINITION: Typically, the NoK to the proposed ward in guardian advocacy are the parents. However, if the proposed ward has children, the NoK will be the children.
If there are no children or parents, then NoK will be the grandparents.

If only one parent is applying, we must have information on the other parent. Florida Law requires that notice be provided to the next of kin. *

NAME

RELATIONSHIP

AGE

PHONE

ADDRESS

EMAIL

* Please let us know, if applicable:

If the next of kin will consent to the guardian advocacy
If there may be an issue with notifying the next of kin
If the other parent is deceased, and the date of death

* Please let us know, if applicable:

If the next of kin will consent to the guardian advocacy
If there may be an issue with notifying the next of kin
If the other parent is deceased, and the date of death

*

INCOME/SOURCE OF INCOME AND ASSETS OF THE PROPOSED WARD
Is his/her income less than $25,520? If yes, complete this section. If no, strike through this section

INCOME

ASSETS

Social Security benefits

Cash

Social Security Representative Payee Name

Checking account(s)

Unemployment compensation

Name(s) on the checking account

Union payments

Bank or credit union name for the checking account

Retirement/pensions

Savings account

Trusts

Name(s) on the savings account

Veterans’ benefits

Bank or credit union name for the savings account

Workers compensation

Certificates of deposit or money market accounts

Income from absent family members

Stocks/bonds

Homestead Real Property*

Rental income

Other Real Property

Dividends or interest

Motor Vehicle*

Other kinds of income not on the list

Boat

Regular Gifts

EXPENSES OF THE PROPOSED WARD
(if person is currently receiving social security benefits, use the numbers you provide for expenses to social security)

Cost of Home/Shelter (FMV1 of share): $

Home/Shelter as defined by Social Security includes room, rent, mortgage payments, real property taxes, heating fuel, gas, electricity, water, sewerage, and garbage collection services.
https://secure.ssa.gov/poms.nsf/lnx/0603020045

For the proposed ward living with others, this would be his/her share of these costs (4 people living in the household, the share would be ¼ the total cost.) However, keep in mind what someone with low income could afford. For example, if 1/3 the cost is $1,000/month, that is not considered a reasonable rent for someone only receiving ~$800/month). This will be discussed at your meeting with the attorney.

Out of pocket medical/pharmacy: $

Total of Other: $

FMV of share of groceries, technology for education, rehabilitation, life enhancement, transportation, activities to enhance life, camp, etc

FMV

FMV = Fair market value