CONFIDENTIAL GUARDIANSHIP INTAKE QUESTIONNAIRE

File Information (To be completed by attorney) :

File Name: __________________________________

File #: ______________ Date Opened: _______________________

ALLEGED DISABLED PERSON :

Name: _____________________________________________________DOB:__________U.S.Citizen?___

Address: ______________________________________________________________________________

Phone Number: ________________________________

Spouse/Partner Name:_____________________________________________________________________

Current Power of Attorney:

Healthcare:______________________________________________Copy Provided? Y ___ N ___

Property: :_____________________________________________Copy Provided? Y ___ N ___

Existing Will or Trust? Y___ N___ Copy Provided? Y___ N___

Reason for seeking guardianship:____________________________________________________________

_______________________________________________________________________________________

_____________________________________________________________________________________

PROPOSED GUARDIAN:

(Required to be 18 years old, U.S. resident, of sound mind, and have not been convicted of a felony.)

Name:_________________________________________________________________________________

Address:_______________________________________________________________________________

Home Phone:__________________________________ Cell Phone:_______________________________

Email Address:_________________________________ Occupation:______________________________

DOB:_____________________________ Relationship: _______________________________________

Seeking (Choose One):

___ Guardian of the Estate Only ___ Guardian of the Person Only ___ Guardian of the Estate and Person

PROPOSED CO-GUARDIAN:

Name:_________________________________________________________________________________

Address:_______________________________________________________________________________

Home Phone:__________________________________ Cell Phone:_______________________________

Email Address:_________________________________ Occupation:______________________________

DOB:_____________________________ Relationship: _______________________________________

___ Guardian of the Estate Only ___ Guardian of the Person Only ___ Guardian of the Estate and Person


Alleged Disabled Person’s Nearest Living Relatives:

(Include Parents, Siblings, Spouse, and Children. If none, list closest next of kin.)

Name :__________________________________________________ Relationship:____________________

Address:_________________________________________________________Over 18 yrs? Y ___ N ___

Name :__________________________________________________ Relationship:____________________

Address:_________________________________________________________Over 18 yrs? Y ___ N ___

Name :__________________________________________________ Relationship:____________________

Address:_________________________________________________________Over 18 yrs? Y ___ N ___

Name :__________________________________________________ Relationship:____________________

Address:_________________________________________________________Over 18 yrs? Y ___ N ___

Name :__________________________________________________ Relationship:____________________

Address:_________________________________________________________Over 18 yrs? Y ___ N ___

NAME, ADDRESS, & RELATIONSHIP OF ALL PRESENT AT INITIAL CONSULTATION : (PRINT)

(To be completed at the 1st meeting with the attorney)

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________


ASSET AND LIABILITY SUMMARY

E nter the approximate value of the asset where applicable to indicate how title is held

and the amount , if any, owed on the item .

ALLEGED

DISABLED

TYPE OF ASSET: PERSON ($) SPOUSE ($) JOINTLY ($) DEBT ($)

PRIMARY RESIDENCE : _____________________________________________________________________________

OTHER REAL ESTATE : _____________________________________________________________________________

CASH:____________________________________________________________________________________________

TOTAL CHECKING: ________________________________________________________________________________

TOTAL SAVINGS : _________________________________________________________________________________

TOTAL MONEY MARKET : _________________________________________________________________________

TOTAL CDs : ______________________________________________________________________________________

TOTAL RETIREMENT

ACCOUNTS : ______________________________________________________________________________________

TOTAL MUTUAL FUNDS : __________________________________________________________________________

TOTAL STOCKS : __________________________________________________________________________________

TOTAL BONDS (& Type)

ANNUITIES : ______________________________________________________________________________________

LIFE INSURANCE : _________________________________________________________________________________

(Cash Value)

REFUNDABLE LTC

DEPOSIT : _________________________________________________________________________________________

BUSINESS INTERESTS : _____________________________________________________________________________

AUTOMOBILES : ___________________________________________________________________________________

RECREATIONAL

VEHICLES : _______________________________________________________________________________________

HOUSEHOLD GOODS : _____________________________________________________________________________

SAFE DEPOSIT BOX : _______________________________________________________________________________

COLLECTIBLES : ___________________________________________________________________________________

OTHER : __________________________________________________________________________________________

TOTALS : $ $ $ $

MONTHLY INCOME OF ALLEGED DISABLED PERSON:

Retirement/Pension: $

Social Security: $

VA Disability: $

Annuity: $

Other: $ Description:__________________________

Do you expect him/her to inherit from anyone, including a spouse? Yes or No (Please explain)

__________________________________________________________________________________________

I understand that this confidential questionnaire is designed to provide The Law Office of Kimberly J. Myers with important information for purposes of advising me on matters related to guardianship and that the attorney’s ability to effectively and accurately advise me depends upon the accuracy and completeness of the information that I provide. I hereby confirm that the information provided here is substantially correct and complete, and I understand that no contract for services is formed by completing this questionnaire.

_____________________________________________________________________ Date: _______________

SIGNATURE OF CLIENT OR REPRESENTATIVE

_____________________________________________________________________

PRINT NAME

Prepared by:

Law Office of Kimberly J. Myers

P.O. Box 332

Warrenville, IL 60555

Phone: (630) 272-7838

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