This section is about protecting the legal rights of the family member. Attach copies of court orders or other legal papers. Don't leave any blanks. If a certain item doesn't pertain to your family member, write "N/A". If you have already completed Section A on a form for another life area, you may skip it and go on the Section B. Otherwise, provide information for each item below.

Section A

(1) Name of family member to which this document applies

(2) Name of person completing this form

Relationship to the person named in (1) above.

Section B

I am the legal guardian/guardian advocate
Yes
No

A legal guardian/guardian advocate was appointed by the court on
/ /

Type of guardianship:
guardian advocate
of the person
of the estate
full
limited.

Following is the information on the legal guardian/guardian advocate appointed by the court.
Name:
Address:
Phone Number:
Relationship to the person:

This is the information for the co-guardian/guardian advocate (if any).
Name:
Address:
Phone Number:
Relationship to the person:

We have chosen the following successor (standby) guardian/guardian advocate, who is willing to accept this role:
Name:
Address:
Phone Number:
Relationship to the person:

The family member named above in (1) can give informed consent.
Yes
No

If yes, he/she:
has made a living will (attach copy).
has not made a living will.

I have set up the following named Special Needs Trust to benefit my family member:

with this trustee(s):
Name:
Address:
Phone Number(s) ,
Relationship:

There is a Representatives Payee, to receive and manage government benefit checks, like SSI or Social Security:
Yes
No

The name of that representative payee is: