FORMS FOR INITIAL AND ANNUAL GUARDIANSHIP PLANS

(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; OR ( ) 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 .....(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)...... 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 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; OR ( ) 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. (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:

(c) Initial 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 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.] [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:

(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.] [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 (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: