Rule 5.900. Expedited Judicial Intervention Concerning Medical Treatment Procedures

(a) Petition. Any proceeding for expedited judicial intervention concerning medical treatment procedures may be brought by any interested adult person and shall be commenced by the filing of a verified petition which states:

(1) the name and address of the petitioner;

(2) the name and location of the person who is the subject of the petition (hereinafter referred to as the “patient”);

(3) the relationship of the petitioner to the patient;

(4) the names, relationship to the patient, and addresses if known to the petitioner, of:

(A) the patient’s spouse and adult children;

(B) the patient’s parents (if the patient is a minor);

(C) if none of the above, the patient’s next of kin;

(D) any guardian and any court-appointed health care decision-maker;

(E) any person designated by the patient in a living will or other document to exercise the patient’s health care decision in the event of the patient’s incapacity;

(F) the administrator of the hospital, nursing home, or other facility where the patient is located;

(G) the patient’s principal treating physician and other physicians known to have provided any medical opinion or advice about any condition of the patient relevant to this petition; and

(H) all other persons the petitioner believes may have information concerning the expressed wishes of the patient; and

(5) facts sufficient to establish the need for the relief requested, including, but not limited to, facts to support the allegation that the patient lacks the capacity to make the requisite medical treatment decision.

(b) Supporting Documentation. Any affidavits and supporting documentation, including any living will or designation of health care decision-maker, shall be attached to the petition.

(c) Notice. Unless waived by the court, notice of the petition and the preliminary hearing shall be served on the following persons who have not joined in the petition or otherwise consented to the proceedings:

(1) the patient;

(2) the patient’s spouse and the patient’s parents, if the patient is a minor;

(3) the patient’s adult children;

(4) any guardian and any court-appointed health care decision-maker;

(5) any person designated by the patient in a living will or other document to exercise the patient’s health care decision in the event of the patient’s incapacity;

(6) the administrator of the hospital, nursing home, or other facility where the patient is located;

(7) the patient’s principal treating physician and other physicians believed to have provided any medical opinion or advice about any condition of the patient relevant to this petition;

(8) all other persons the petitioner believes may have information concerning the expressed wishes of the patient; and

(9) such other persons as the court may direct.

(d) Hearing. A preliminary hearing on the petition shall be held within 72 hours after the filing of the petition. At that time the court shall review the petition and supporting documentation. In its discretion the court shall either:

(1) rule on the relief requested immediately after the preliminary hearing; or

(2) conduct an evidentiary hearing not later than 4 days after the preliminary hearing and rule on the relief requested immediately after the evidentiary hearing.

Committee Notes

This rule was submitted by the committee in response to the request contained in footnote 17 of In re Guardianship of Browning , 568 So. 2d 4 (Fla. 1990). See also Cruzan by Cruzan v. Director , Missouri Department of Health , 497 U.S. 261, 110 S. Ct. 2841, 111 L. Ed .2d 224 (1990). The promulgation of this rule is not intended to imply that judicial intervention is required to terminate life-prolonging procedures. Practitioners should note that the criteria and standards of proof contained in Browning differ from the criteria and standards of proof presently existing in chapter 765, Florida Statutes. Rule History 1991 Revision: New rule. 1992 Revision: This rule was created on an emergency basis and on further review, the committee decided it needed to clarify that the petition should include an allegation that the patient lacks capacity to make the requisite medical treatment decision, and that the patient should receive notice of the petition and hearing. Committee notes revised. Citation form changes in committee notes. 2008 Revision: Committee notes revised. 2019 Revision: Committee notes updated to reflect the legislative amendments to chapter 709, Florida Statutes. 2020 Revision, September 3, 2020: Rule was renumbered from 5.900 to 5.850 to allow forms to follow the rules set. Committee notes revised. 2020 Revision, December 31, 2020: Rule was renumbered from 5.850 to 5.900 to conform with statutory references. Committee notes revised. Constitutional Reference Art. I, § 23, Fla. Const. Statutory References § 393.12, Fla. Stat. Capacity; appointment of guardian advocate. §§ 709.2101–709.2402, Fla. Stat. Florida Power of Attorney Act. § 709.2109, Fla. Stat. Termination or suspension of power of attorney or agent’s authority. § 731.302, Fla. Stat. Waiver and consent by interested person. § 744.102, Fla. Stat. Definitions. § 744.104, Fla. Stat. Verification of documents. § 744.3115, Fla. Stat. Advance directives for health care. ch. 765, Fla. Stat. Health care advance directives. Rule References Fla. Prob. R. 5.020 Pleadings; verification; motions. Fla. Prob. R. 5.040 Notice. PART V — FORMS The following forms are sufficient for the matters that are covered by them. So long as the substance is expressed without prolixity, the forms may be varied to meet the facts of a particular case. The forms are not intended to be part of the rules and are provided for convenience only. RULE 5.901. FORM FOR PETITION TO DETERMINE INCAPACITY MODEL FORM FOR USE IN PETITION TO DETERMINE INCAPACITY PURSUANT TO FLORIDA PROBATE RULE 5.550 In the Circuit Court of the Judicial Circuit, in and for County, Florida Probate Division Case No. In Re: Guardianship of Respondent’s Name An Alleged Incapacitated Person PETITION TO DETERMINE INCAPACITY Petitioner, …(name of petitioner)…, files this petition seeking a determination of incapacity of the respondent and states: 1. Petitioner’s name: Petitioner’s age: Petitioner’s home address and mailing address: Petitioner’s relationship to the respondent: 2. Respondent’s name: Respondent’s age: Respondent’s home address, mailing address, county of residence: Primary language of the respondent: 3. The factual basis for alleging incapacity: 4. List all persons, with their name and address, known to have information relating to the basis for alleging incapacity: 5. Which rights are being sought to be removed under section 744.3215, Florida Statutes? Indicate which rights that the petitioner requests be removed from the respondent, but not delegated to a guardian: ( ) a. to marry. If the right to enter into a contract has been removed, the right to marry is subject to court approval; ( ) b. to vote; ( ) c. to personally apply for government benefits; ( ) d. to have a driver license; ( ) e. to travel; and ( ) f. to seek or retain employment. Indicate which rights that the petitioner requests be removed from the respondent, but may be delegated to the guardian: ( ) a. to contract; ( ) b. to sue and defend lawsuits; ( ) c. to apply for government benefits; ( ) d. to manage property or to make any gift or disposition of property; ( ) e. to determine his or her residence; ( ) f. to consent to medical and mental health treatment; and ( ) g. to make decisions about his or her social environment or other social aspects of his or her life. If all of the above are checked a determination of plenary incapacity is requested. If only some of the above are checked a determination of limited incapacity is requested. 6. Is a guardianship being sought? Yes No Check any possible alternatives to guardianship: ( ) a. trust agreements; ( ) b. powers of attorney; ( ) c. designations of health care surrogates; ( ) d. other advance directives; or ( ) e. other If a guardianship is being sought, explain why the checked possible alternatives to guardianship are insufficient to meet the needs of the respondent: 7. List the names, addresses, phone numbers, and relationships of the living next of kin of the respondent, including date of birth if the person is a minor. If married, this includes the spouse and all of his or her children: Name Address Relationship 8. Name, address, and phone number of family physician, if known: WHEREFORE, this court is respectfully requested to determine incapacity of the respondent, award attorney’s fees and costs pursuant to Chapter 744, Florida Statutes, and grant such other relief as the court deems just and proper. Under penalties of perjury, I declare that I have read the foregoing, and the facts alleged are true, to the best of my knowledge and belief. Signed on …(date)… Petitioner’s Signature Petitioner’s Printed Name: Petitioner’s Address: Petitioner’s Phone Number: Petitioner’s E-mail Address: RULE 5.902. FORM FOR PETITION AND ORDER OF GUARDIAN (a) Petition. In the Circuit Court of the Judicial Circuit, in and for County, Florida Probate Division Case No. In Re: Guardianship of Respondent’s Name PETITION FOR APPOINTMENT OF GUARDIAN Petitioner, , files this petition pursuant to section 744.1097, Florida Statutes, and alleges that: 1. The petitioner, proposed guardian …(name)…, who is years of age, whose residential address is and post office address is . The relationship of the petitioner to the respondent is . 2. Venue is proper in …(county)…, pursuant to section 744.1097(2), Florida Statutes, (choose one): ( ) a. the incapacitated person resides in …(county)…, Florida; ( ) b. the incapacitated person is not a Florida resident but owns property in …(county)…, Florida; or ( ) c. a debtor of the incapacitated person resides in …(county)…, Florida and the incapacitated person is not a Florida resident and does not own property in Florida. 3. The nature of the incapacity of the respondent: 4. The extent of the guardianship requested for the respondent: ( ) a. plenary; or ( ) b. limited. 5. The guardianship requested for the respondent is (choose one): ( ) a. of the person; ( ) b. of the property; or ( ) c. of the person and property. 6. The nature and value of the property subject to guardianship: 7. The names and addresses of the living next of kin of the respondent are: Name Address Relationship 8. Choose one: ( ) a. the petitioner proposes that …(name)… be appointed as guardian and that …(name)… is qualified to serve; ( ) b. a willing and qualified guardian has not been located; or ( ) c. the proposed guardian is a professional guardian and has complied with the registration requirements of section 744.2002, Florida Statutes. 9. The proposed guardian should be appointed because: 10. There are or are not alternatives to the appointment of a guardian, such as trust agreements, powers of attorney, designation of health care surrogate, or other advanced directive, known to petitioner. Under penalties of perjury, I declare that I have read the foregoing, and the facts alleged are true, to the best of my knowledge and belief. Signed …(date)… Signature: Petitioner Name: Address: Phone Number: E-mail Address: (b) Order. In the Circuit Court of the Judicial Circuit, in and for County, Florida Probate Division Case No. In Re: Guardianship of Respondent’s Name ORDER FOR APPOINTMENT OF GUARDIAN 1. By order of this court on …(date)…, the respondent …(name)… was adjudicated incapacitated and is now a ward as defined in section 744.102(22), Florida Statutes. The extent of the incapacity is …(plenary or limited)… The ward retains the rights listed in section 744.3215(a), Florida Statutes. 2. No alternative to guardianship exists that sufficiently addresses the respondent’s needs. 3. A …(plenary or limited)… guardianship of the: ( ) a. person; ( ) b. property; or ( ) c. person and property is consistent with the respondent’s welfare and safety, is the least restrictive alternative, and reserves to the respondent the right to make decisions in all matters commensurate with the ward’s ability to do so. 4. …(Name of guardian)… is qualified to serve as …(plenary or limited)… guardian of the: ( ) a. person; ( ) b. property; or ( ) c. person and property of the ward 5. ( ) a. …(Name of guardian)… is the standby guardian or preneed guardian; ( ) b. there is no standby guardian or preneed guardian; ( ) c. there is a standby guardian or preneed guardian, but such person is not qualified to serve pursuant to section 744.309, Florida Statutes; or ( ) d. there is a standby guardian or preneed guardian, but appointment of such person is contrary to the best interests of the ward because: 6. Any additional facts that support the selection of guardian: 7. ( ) a. No advance directive exists; ( ) b. the following advance directive exists and is entitled …(name of advance directive)… and is dated …(date of advance directive)…; ( ) c. the advance directive is being revoked or modified and the surrogate under the advance directive entitled …(name of advance directive)… and is dated …(date of advance directive)… was given notice of this proceeding and any motion to revoke or modify the advance directive; or ( ) d. if the advance directive is being revoked or modified the facts supporting the revocation or modification: ORDERED and ADJUDGED as follows: 8. The court hereby appoints …(name of guardian)… as the…(plenary or limited)… guardian of the: ( ) a. person; ( ) b. property; or ( ) c. person and property of the ward. 9. The guardian may exercise only those delegable rights that have been removed from the ward and specifically delegated to the guardian, which are: ( ) a. to contract; ( ) b. to sue and defend lawsuits; ( ) c. to apply for government benefits; ( ) d. to manage property or to make any gift or disposition of property; ( ) e. to determine the ward’s residence; ( ) f. to consent to medical and mental health treatment; and ( ) g. to make decisions about the ward’s social environment or other social aspects of the ward’s life. 10. The guardian may not exercise the following rights, even if such rights were removed from the ward: a. to marry; b. to vote; c. to personally apply for government benefits; d. to have a driver license; e. to travel; and f. to seek or retain employment. 11. The amount of the bond to be given by the guardian is: 12. The guardian: ( ) a. must; or ( ) b. is not required to place all, or part, of the property of the ward in a restricted account in a financial institution designated pursuant to section 69.031, Florida Statutes. 13. ( ) a. No known advance directive exists; ( ) b. the advance directive entitled …(name of advance directive)… and is dated …(date of advance directive)… is being modified or revoked as follows: ( ) i. the surrogate shall not continue to exercise any authority over the ward with regard to health care decisions; ( ) ii. the surrogate shall continue to exercise authority over the respondent with regard to health care decisions; ( ) iii. the surrogate shall exercise the following authority over the ward with regard to: ; or ( ) iv. The guardian shall exercise the following authority over the ward with regard to health care decisions: 14. The respondent …(may or may not)… have a license to carry a firearm or possess a weapon or firearm. ORDERED this …(date)… Judge RULE 5.903. LETTERS OF GUARDIANSHIP (a) Letters of Guardianship of the Person. FORM LETTERS OF GUARDIANSHIP OF THE PERSON In the Circuit Court of the Circuit, in and for County, Florida Probate Division Case No. In Re: Guardianship of the Person Ward An Incapacitated Person LETTERS OF …(PLENARY OR LIMITED)… GUARDIANSHIP OF THE PERSON TO ALL WHOM IT MAY CONCERN: WHEREAS, …(guardian’s name)… has been appointed …(plenary or limited)… guardian of the person of …(the ward)… and has taken the prescribed oath and performed all other acts prerequisite to issuance of …(plenary or limited)… letters of guardianship of the person of the ward. NOW THEREFORE, I, the undersigned judge, declare …(guardian’s name)… duly qualified under the laws of the State of Florida to act as …(plenary or limited)… guardian of the person of …(ward’s name)… with full power to exercise all power or the following powers and duties pertaining to the ward’s person: ( ) 1. to determine his or her residence; ( ) 2. to consent to medical and mental health treatment; and ( ) 3. to make decisions about his or her social environment or other social aspects of his or her life; except the guardian shall not exercise any rights enumerated under section 744.3215(1), Florida Statutes. The guardian shall not execute any power over any health care surrogate appointed by any valid advance directive executed by the ward, pursuant to section 744.345, Florida Statutes, except upon order of this court. ORDERED this …(date)… Judge (b) Letters of Guardianship of the Property. FORM LETTERS OF GUARDIANSHIP OF THE PROPERTY In the Circuit Court of the Judicial Circuit, in and for County, Florida Probate Division Case No. In Re: Guardianship of the Property Ward An Incapacitated Person LETTERS OF …(PLENARY OR LIMITED)… GUARDIANSHIP OF THE PROPERTY TO ALL WHOM IT MAY CONCERN: WHEREAS, …(guardian’s name)… has been appointed …(plenary or limited)… guardian of the property of …(the ward)… and has taken the prescribed oath and performed all other acts prerequisite to issuance of …(plenary or limited)… letters of guardianship of the property of the ward. NOW THEREFORE, I, the undersigned judge, declare …(guardian’s name)… duly qualified under the laws of the State of Florida to act as …(plenary or limited)… guardian of the property of …(ward’s name)… with full power to exercise all delegable legal rights and powers of the ward, (or these listed): ( ) 1. to contract; ( ) 2. to sue and defend lawsuits; ( ) 3. to apply for government benefits; and ( ) 4. to manage property or to make any gift or disposition of property; except the guardian shall not exercise any rights enumerated under section 744.3215(1), Florida Statutes. ORDERED on …(date)… Judge RULE 5.904. 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: 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 Report Begin Report End Report Due Signed Date Date 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 June July 1 June 30 October 1 July August 1 July 31 November August September 1 August 31 December 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 5.905. FORM FOR PETITION; NOTICE; AND ORDER FOR APPOINTMENT OF GUARDIAN ADVOCATE OF THE PERSON (a) Petition. FORM FOR USE IN PETITION FOR APPOINTMENT OF GUARDIAN ADVOCATE OF THE PERSON UNDER FLORIDA PROBATE RULE 5.649 In the Circuit Court of the Judicial Circuit, in and for County, Florida Probate Division Case No. In Re: Guardianship Advocacy of Respondent’s Name Person with Developmental Disability PETITION FOR APPOINTMENT OF GUARDIAN ADVOCATE OF THE PERSON Petitioner, , files this petition under section 393.12, Florida Statutes, and Florida Probate Rule 5.649 and alleges that: 1. The petitioner, proposed guardian advocate …(name)…, is years of age, whose residential address is and post office address is . The relationship of the petitioner to the respondent is . 2. …(Respondent’s name)… is a person with a developmental disability who was born on and who is years of age, who resides in County, Florida. The residential address of the respondent is and the post office address is . 3. The petitioner believes that respondent needs a guardian advocate: a. due to the following developmental disability: ( ) i. intellectual disability; ( ) ii cerebral palsy; ( ) iii. autism; ( ) iv. spina bifida; ( ) v. Down syndrome; ( ) vi. Phelan-McDermid syndrome; or ( ) vii. Prader-Willi syndrome, which manifested before the age of 18. b. The developmental disability has resulted in the following substantial handicaps: 4. The exact areas in which the person with the developmental disability lacks the ability to make informed decisions about the person’s care and treatment services or to meet the essential requirements for the person’s physical health or safety are as follows: ( ) a. to apply for government benefits; ( ) b. to determine residency; ( ) c. to consent to medical and mental health treatment; ( ) d. to make decisions about social environment/social aspects of life; ( ) e. to make decisions regarding education; and ( ) f. to bring an independent action for support. 5. There are no alternatives to guardian advocacy, such as trust agreements, powers of attorney, designation of health care surrogate, or other advanced directive, known to petitioner that would sufficiently address the problems of the respondent in whole or in part. Thus, it is necessary that a guardian advocate be appointed to exercise some but not all of the rights of respondent. 6. The names and addresses of the next of kin of the respondent are: Name Address Relationship 7. The proposed guardian advocate …(name)…, whose residence address is , and whose post office address is , is over the age of 18 and otherwise qualified under the laws of the State of Florida to act as guardian advocate of the person of respondent. The proposed guardian advocate is not a professional guardian. The relationship of the proposed guardian advocate with the providers of health care services, residential services, or other services to the respondent is (if none, indicate: NONE): 8. a. The petitioner(s) allege(s) that to their knowledge, information, and belief, the respondent has or has NOT executed an advance directive under chapter 765, Florida Statutes, (designated health case surrogate or other advance directive) or a durable power of attorney under chapter 709, Florida Statutes. b. The petitioner(s) also allege(s) to the petitioner’s knowledge, information, and belief, the respondent, has or has NOT executed a supported decisionmaking agreement under section 709.2209, Florida Statutes. c. The petitioner(s) allege(s) that the respondent has the documents referenced in subdivisions 8.a. or 8.b., but the documents are insufficient to meet the needs of the respondent because: (Do not complete if the respondent does not have the documents referenced in subdivisions 8.a. and 8.b.) 9. (If a Co-Guardian Advocate sought, complete this paragraph.) Petitioner requests that be appointed co-guardian advocate of the person of respondent. The proposed co-guardian advocate …(name)…, who is years of age, whose residence is , whose post office address is , is over the age of 18 and otherwise qualified under the laws of the State of Florida to act as guardian advocate of the person of respondent. The proposed co- guardian advocate is not a professional guardian. The relationship of the proposed co-guardian advocate with the providers of health care services, residential services, or other services to the respondent is (if none, indicate: NONE): The relationship and previous association of the proposed co-guardian advocate to the respondent is . The proposed co-guardian advocate should be appointed because: Under penalties of perjury, I declare that I have read the foregoing, and the facts alleged are true, to the best of my knowledge and belief. Signed …(date)… Signature: Proposed Guardian Advocate Name: Address: Phone Number: E-mail Address: Signature: Proposed Co-Guardian Advocate Name: Address: Phone Number: E-mail Address: (b) Notice. The notice of the filing of the petition for the appointment of guardian advocate of the person and notice of hearing must be served with the petition for appointment of guardian advocate of the person under subdivision (a) of this rule. FORM FOR NOTICE OF FILING OF A PETITION FOR APPOINTMENT OF GUARDIAN ADVOCATE OF THE PERSON UNDER SECTION 393.12(4), FLORIDA STATUTES, AND NOTICE OF HEARING In the Circuit Court of the Judicial Circuit, in and for County, Florida Probate Division Case No. In Re: Guardian Advocacy of Respondent’s Name Person with Developmental Disability NOTICE OF FILING OF A PETITION FOR APPOINTMENT OF GUARDIAN ADVOCATE AND NOTICE OF HEARING TO: …(Respondent)…, …(attorney for respondent)…, …(next of kin)…, …(healthcare surrogate)…, and …(agent under durable power of attorney)… YOU ARE NOTIFIED that a petition for appointment of guardian advocate of the person has been filed. A copy of the petition for appointment of guardian advocate of the person is attached to this notice. There will be a hearing on the petition as follows: You are to appear before the Honorable …, Judge, at …(time)…, on …(date)…, at the county courthouse of … County, in …, Florida for the hearing of this petition. The reason for this hearing is to inquire into the capacity of the respondent, the person with a developmental disability, to exercise the rights enumerated in the petition. (See § 744.102(12)(b), Fla. Stat.) The respondent has the right to be represented by counsel of the respondent’s own choice and the court has initially appointed the following attorney to represent the respondent: Attorney for the respondent: …(name)…, …(address)…, …(phone)…, …(e-mail)… Respondent has the right to substitute an attorney of the respondent’s own choice in place of the attorney appointed by the court. Signed …(date)… Signature: Signature: Proposed Guardian Advocate Proposed Co-Guardian Advocate (if any) Name: Name: Address: Address: Phone Number: Phone Number: E-mail Address: E-mail Address: CERTIFICATE OF SERVICE I CERTIFY that a copy of the foregoing notice of filing petition to appoint guardian advocate and notice of hearing and a copy of the petition for appointment of guardian advocate of the person was served on all persons indicated above, including on the attorney for the respondent, on …(date)… Signature: Signature: Proposed Guardian Advocate Proposed Co-Guardian Advocate (if any) Name: Name: Address: Address: Phone Number: Phone Number: E-mail Address: E-mail Address: If you are a person with a disability who needs any accommodation in order to participate in this proceeding, you are entitled, at no cost to you, to the provision of certain assistance. Please contact [identify applicable court personnel by name, address, and telephone number] at least 7 days before your scheduled court appearance, or immediately upon receiving this notification if the time before the scheduled appearance is less than 7 days; if you are hearing or voice impaired, call 711. (c) Order. 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 ORDER APPOINTING GUARDIAN ADVOCATE On consideration of the petition for the appointment of guardian advocate of the person, the court finds that …(respondent’s name)… has a developmental disability of a nature that requires the appointment of guardian advocate of the person based on the following findings of fact and conclusions of law: 1. The nature and scope of the person’s lack of decision-making ability are: 2. The exact areas in which the person lacks decision-making ability to make informed decisions about care and treatment services or to meet the essential requirements for the respondent’s health and safety are specified in number 4. 3. The specific legal disabilities to which the person with a developmental disability is subject to are: 4. The powers and duties delegated to the guardian advocate are: ( ) a. to apply for government benefits; ( ) b. to determine residency; ( ) c. to consent to medical and mental health treatment; ( ) d. to make decisions about social environment/social aspects of life; ( ) e. to make decisions regarding education; and ( ) f. to bring an independent action for support. 5. There are no alternatives to guardian advocacy, such as trust agreements, powers of attorney, designation of health care surrogate, or other advanced directive, known to petitioner that would sufficiently address the problems of the respondent in whole or in part. Thus, it is necessary that a guardian advocate be appointed to exercise some but not all of the rights of respondent. 6. Without first obtaining specific authority from the court, as stated in section 744.3725, Florida Statutes, the guardian advocate may not exercise any authority over any health care surrogate appointed by any valid advance directive executed by the disabled person, under Chapter 765, Florida Statutes, except on further order of this Court. ORDERED AND ADJUDGED: 1. …(Name)… is qualified to serve as guardian advocate and is hereby appointed as guardian advocate of the person of …(respondent’s name)… 2. The guardian advocate will exercise only the rights that the court has found the disabled person incapable of exercising on the disabled person’s own behalf, as outlined herein above. Said rights are specifically delegated to the guardian advocate. ORDERED this …(date)… Judge RULE 5.906. LETTERS OF GUARDIAN ADVOCACY FORM LETTERS OF GUARDIAN ADVOCACY In the Circuit Court of the Judicial Circuit, in and for County, Florida Probate Division Case No. In Re: Guardian Advocacy of Respondent’s Name Person with Developmental Disability LETTERS OF GUARDIAN ADVOCATE (CO-GUARDIAN ADVOCATES) OF THE PERSON TO ALL WHOM IT MAY CONCERN: WHEREAS, …(guardian advocate’s name(s))… has/have been appointed guardian advocate(s) of the person of …(the ward)…, a person with a developmental disability who lacks the decision-making capacity to do some of the tasks necessary to take care of the ward’s person; and NOW, THEREFORE, I, the undersigned, declare that …(guardian advocate’s name(s))… is/are duly qualified under the laws of the State of Florida to act as guardian advocate of the person of …(the ward)…, with full power to exercise the following powers and duties on behalf of the person with a developmental disability: ( ) 1. to apply for government benefits; ( ) 2. to determine residency; ( ) 3. to consent to medical and mental health treatment; ( ) 4. to make decisions about social environment and social aspects of life; ( ) 5. to make decisions regarding education; and ( ) 6. to bring an independent action for support. Without first obtaining specific authority from the court, under sections 744.3215(4) and 744.3725, Florida Statutes, the guardian advocate (co- guardian advocates) may not: a. commit the respondent to a facility, institution, or licensed service provider without formal placement proceedings under Chapter 393, Florida Statutes; b. consent to the participation of the respondent in any experimental biomedical or behavior procedure, exam, study, or research; c. consent to the performance of sterilization or abortion procedure on the respondent; d. consent to termination of life support systems provided for the respondent; e. initiate a petition for dissolution of marriage for the ward; or f. exercise any authority over any health care surrogate appointment by a valid advance directive executed by the disabled person, under Chapter 765, Florida Statutes, except on further order of this court. The respondent retains all legal rights except those that are specifically granted to the guardian advocate (co-guardian advocates) under court order. ORDERED this …(date)… Judge RULE 5.910. INVENTORY Judicial Circuit, in and for County, Florida Probate Division Case No. Judge: Amended Form? Yes* No *If yes, version of the Amended Form: In Re: Guardianship of INITIAL INVENTORY Date of letters of guardianship: Property guardianship type: SUMMARY Section A: Value of Real Property Assets $ Section B: Cash Assets/Cash Equivalent Assets $ Section C: Intangible Assets/Stocks/Bonds $ Section D: Tangible Personal Property $ Section E: Debts/Encumbrances/Liabilities/Liens $ Total $ Section A: Real Property Assets Do you have entries for Section A? Yes No Number Description and Address Full Value Is There Another Owner? Yes or No 1. 2. 3. Total for Section A $ Attach a copy of the property appraiser’s information or a copy of the deed for all real property. Section B: Cash Assets/Cash Equivalent Assets (checking account, savings account, money market account, certificate of deposit (CD)) Do you have entries for Section B? Yes No Are any of the entries held in a depository account? Yes No Number Institution Name Last 4 Digits of Account Number Type of Asset Full Value Is There Another Owner? Yes or No Is this a Depository Account? Yes or No 1. 2. 3. Total for Section B $ Attach a copy of the institution’s statement for each account from the creation date of the guardianship. Section C: Intangible Assets/Stocks/Bonds Do you have entries for Section C? Yes No Are any of the entries held in a depository account? Yes No Number Issuer Name and Address Type of Asset Full Value Last 4 Digits of Account Number Is There Another Owner? Yes or No 1. 2. 3. Total for Section C $ Attach a copy of the institution’s statement for each account from the creation date of the guardianship. Section D: Tangible Personal Property Assets (motor vehicles, jewelry, household furnishings, collectibles, fine art) Do you have entries for Section D? Yes No Number Description and Location Full Value Is There Another Owner? Yes or No 1. 2. 3. Total for Section D $ Attach a copy of the title for any motor vehicle. Section E: Debts/Encumbrances/Liens/Liabilities Do you have entries for Section E? Yes No Instructions: List each liability equal to or greater than $1,000. Number Creditor Full Amount of Liability Last 4 Digits of Account Number Is there Another Person who Owes on the Debt? Yes or No 1. 2. 3. Total for Section E $ A copy of documents detailing each listed liability. Section F: Sources of Income Do you have entries for Section F? Yes No Number Type Payor Estimated Monthly Amount 1. 2. 3. Total for Section F $ Is the guardian the representative payee of Social Security benefits? Yes No If no, who is the representative payee for the Social Security benefits? Section G: Lawsuits Against the Ward Do you have entries for Section G? Yes No Number Description of Lawsuit or Claim Estimated Amount of Claim Court Address Plaintiff’s Name and Address Describe Cause of Action Date of Debt Occurrence 1. 2. 3. Section H: Pending Litigation and/or Lawsuits the Ward May Bring if Court Approval Is Received Do you have entries for Section H? Yes No Number Descriptio n of Lawsuit or Claims Case Number and Court Address Defendant Name and Address Describe Cause of Action Attorney for Ward 1. 2. 3. Section I: Assets the Ward, as of the Date of the Letters of Guardianship, Was Entitled to Receive, but Has Not Received Do you have entries for Section I? Yes No Instructions: If the guardian has knowledge of assets the ward was entitled to receive as of the date of letters, but were not received the assets should be listed here. Examples: insurance policies, benefits, inheritance, or settlements from litigation. Number Description Estimated Date of Receipt Estimated Amount 1. 2. 3. Section J: Trusts Do you have entries for Section J? Yes No Number Name of Current Trustee and Address Ward’s Interest Estimated Date Trust was Created Value of the Ward’s Interest in the Trust 1. 2. 3. Section K. Safe-Deposit Box Does the ward lease a safe-deposit box? Yes No If yes, location and number of safe-deposit box: Does the ward lease a safe-deposit box with another individual or individuals? Yes No Who is the joint lessee with the ward? Was an inventory of the safe-deposit box filed with the court as required by section 744.365, Florida Statutes? Yes No Has the safe-deposit box been opened? Yes No [ A certificate of service as required by Florida Rule of Judicial Administration 2.516 must be included if the incapacitated person is not a minor under 14 years of age and is not 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: RULE 5.920. FORMS RELATED TO INJUNCTION FOR PROTECTION AGAINST EXPLOITATION OF A VULNERABLE ADULT (a) Petition for Injunction. Petitioners should take steps to protect confidential information within the petition for injunction under Florida Rule of General Practice and Judicial Administration 2.420 and minimize sensitive information within the petition for injunction under Florida Rule of General Practice and Judicial Administration 2.425. In the Circuit Court of the Judicial Circuit, in and for County, Florida Case No.: ADVERSARY PROCEEDING In re: Protection of Vulnerable Adult , Petitioner, and , Respondent. PETITION FOR INJUNCTION FOR PROTECTION AGAINST EXPLOITATION OF A VULNERABLE ADULT UNDER SECTION 825.1035, FLORIDA STATUTES Before me, the undersigned authority, personally appeared petitioner who has been sworn and says that the following statements are true: 1. The vulnerable adult, , whose age is , who resides at (address): 2. Section 825.101, Florida Statutes, provides that a vulnerable adult is a person whose ability to perform the normal activities of daily living or to provide for the vulnerable adult’s own care or protection is impaired due to a mental, emotional, sensory, long-term physical, or developmental disability or dysfunction, or brain damage, or the infirmities of aging. Please describe the vulnerable adult’s inability to perform the normal activities of daily living. 3. The petitioner’s relationship to the vulnerable adult is: , and the petitioner has the right to bring the petition because: 4. The respondent, , resides at (last known address): 5. The respondent’s last known place of employment is: 6. The physical description of the respondent is: Race: Sex: Date of Birth: Height: Weight: Eye Color: Hair Color: Distinguishing Marks/Scars: 7. Aliases of the respondent are: 8. The respondent is associated with the vulnerable adult as follows: 9. The following describes other causes of action: (a) there is/are 1 or more cause(s) of action currently pending between the petitioner and the respondent, and/or a proceeding under the Florida Guardianship Code, chapter 744, Florida Statutes, concerning the vulnerable adult. Describe causes of action here: (b) Related case numbers and county where filed, if available: (c) there are previous or pending attempts by the petitioner to obtain an injunction for protection against exploitation of the vulnerable adult in this or any other circuit. Describe attempts here: (d) The results of any such attempts: 10. The following describes the petitioner’s knowledge of: (a) Any reports made to a government agency, such as the Department of Elder Affairs or the Department of Children and Families: (b) Any investigations performed by a government agency relating to abuse, neglect, or exploitation of the vulnerable adult: and (c) The results of any such reports or investigations: 11. The petitioner knows or has reasonable cause to believe the vulnerable adult is either a victim of exploitation or is in imminent danger of becoming a victim of exploitation, because the respondent (include a description of any incidents or threats of exploitation by the respondent here): 12. The following describes: (a) The petitioner’s knowledge of the vulnerable adult’s dependence on the respondent for care: (b) Alternative provisions for the vulnerable adult’s care in the absence of the respondent, if necessary: (c) Available resources the vulnerable adult has for such alternative provisions: ; and (d) The vulnerable adult’s willingness to use such alternative provisions: 13. The petitioner knows the vulnerable adult maintains assets, accounts, or lines of credit at the following institutions: Institution Address Account Number 14. If petitioner is seeking to freeze assets of the vulnerable adult, petitioner believes that the vulnerable adult’s assets to be frozen are (check 1): Worth less than $1,500 Worth from $1,500 to $5,000 Worth more than $5,000 15. The petitioner genuinely fears imminent exploitation of the vulnerable adult by the respondent. 16. The petitioner seeks an injunction for the protection of the vulnerable adult, including (mark appropriate section or sections): Prohibiting the respondent from having any direct or indirect contact with the vulnerable adult. Immediately restraining the respondent from committing any acts of exploitation against the vulnerable adult. Freezing the below assets, accounts, and lines of credit of the vulnerable adult, listed below even if titled jointly with the respondent, or in the respondent’s name only, in the court’s discretion. Institution Address Account Number Providing any terms the court deems necessary for the protection of the vulnerable adult or the vulnerable adult’s assets, including any injunctions or directives to law enforcement agencies, including: 17. If the court enters an injunction freezing assets, accounts, and credit lines: (a) the petitioner believes that the critical expenses of the vulnerable adult will be paid for or provided by the following persons or entities: OR (b) The petitioner requests that the following expenses be paid notwithstanding the freezing of assets, accounts, or lines of credit from the following institution(s): I ACKNOWLEDGE THAT UNDER SECTION 415.1034, FLORIDA STATUTES, ANY PERSON WHO KNOWS, OR HAS REASONABLE CAUSE TO SUSPECT, THAT A VULNERABLE ADULT HAS BEEN OR IS BEING ABUSED, NEGLECTED, OR EXPLOITED HAS A DUTY TO IMMEDIATELY REPORT SUCH KNOWLEDGE OR SUSPICION TO THE CENTRAL ABUSE HOTLINE. I HAVE REPORTED THE ALLEGATIONS IN THIS PETITION TO THE CENTRAL ABUSE HOTLINE. I HAVE READ EACH STATEMENT MADE IN THIS PETITION AND EACH SUCH STATEMENT IS TRUE AND CORRECT. I UNDERSTAND THAT THE STATEMENTS MADE IN THIS PETITION ARE BEING MADE UNDER PENALTY OF PERJURY PUNISHABLE AS PROVIDED IN SECTION 837.02, FLORIDA STATUTES. Signature of Party Printed Name: Address: City, State, Zip: Telephone Number: Designated E-mail Address(es): STATE OF FLORIDA COUNTY OF Sworn to or affirmed and signed before me on …(date)… Printed Name Notary Public or Deputy Clerk Personally known or Produced identification Type of identification produced: (b) Temporary Protective Injunction Against Exploitation of a Vulnerable Adult. In the Circuit Court of the Judicial Circuit, in and for County, Florida Case No.: In re: Vulnerable Adult , Petitioner, and , Respondent. TEMPORARY PROTECTIVE INJUNCTION AGAINST EXPLOITATION OF A VULNERABLE ADULT AND NOTICE OF HEARING This cause came before the court, which has jurisdiction over the parties and subject matter under state law. The court having reviewed the petition and affidavits and considered argument of counsel, finds as follows: 1. Reasonable notice and opportunity to be heard was given to the respondent in a manner sufficient to protect the respondent’s due process rights. Date of service OR 2. The court conducted its review ex parte. 3. An immediate and present danger of exploitation of the vulnerable adult exists. 4. There is a likelihood of irreparable harm and unavailability of an adequate legal remedy. 5. There is a substantial likelihood of success on the merits. 6. The threatened injury to the vulnerable adult outweighs possible harm to the respondent. 7. Granting a temporary injunction will not disserve the public interest. 8. This injunction provides for the vulnerable adult’s physical or financial safety. 9. These findings were based on the following facts: Accordingly, it is hereby ADJUDGED that: The petitioner’s request for a temporary protective injunction is GRANTED. This injunction is valid for 15 days from the date of this order or . The full hearing is set for …(date)…, at …(time)… The hearing will be held before the Honorable at , Florida. It is further ordered that: The respondent must not commit any act of exploitation against the vulnerable adult. The respondent will have no contact with vulnerable adult. The vulnerable adult is awarded temporarily exclusive use and possession of any dwelling the vulnerable adult shares with the respondent. The respondent is barred from entering the residence of the vulnerable adult. The vulnerable adult’s assets, accounts, and credit lines are hereby frozen until further court order except: Institution(s) served on …(date)… The following institution(s) holding the vulnerable adult’s assets must use the vulnerable adult’s unencumbered assets to pay the clerk of court the following filing fee: $75.00 (if assets are between $1,500–$5,000) OR $200.00 (if assets are more than $5,000). If the court enters an injunction, these fees will be taxed as costs against the respondent. Law enforcement is hereby directed to: Other relief: This injunction is valid and enforceable in all Florida counties, does not affect title to real property, and law enforcement may use their section 901.15(6), Florida Statutes, arrest powers to enforce its terms. DONE and ORDERED on …(date)… at …(time)… Judge CC: All parties and counsel of record COPIES TO: (Check those that apply) Petitioner: by U. S. Mail by hand delivery in open court (Petitioner must acknowledge receipt in writing on the original order—see below.) Vulnerable Adult (if not petitioner) by U. S. Mail by hand delivery in open court Respondent: forwarded to Sheriff for service by U. S. Mail by hand delivery in open court (Respondent must acknowledge receipt in writing on the original order—see below.) by certified mail (May only be used when respondent is present at the hearing and respondent fails or refuses to acknowledge the receipt of a certified copy of this injunction.) by substitute service under section 825.1035, Florida Statutes. Other: Petitioner’s Attorney: by e-mail Respondent’s Attorney: by e-mail I CERTIFY the foregoing is a true copy of the original as it appears on file in the office of the clerk of the circuit court of County, Florida, and that I have furnished copies of this order as indicated above on …(date)… CLERK OF THE CIRCUIT COURT By: Deputy Clerk If you are a person with a disability who needs any accommodation in order to participate in this proceeding, you are entitled, at no cost to you, to the provision of certain assistance. Please contact [identify applicable court personnel by name, address, and telephone number] at least 7 days before your scheduled court appearance, or immediately upon receiving this notification if the time before the scheduled appearance is less than 7 days; if you are hearing or voice impaired, call 711. (c) Order Denying Injunction and Notice of Hearing. In the Circuit Court of the Judicial Circuit, in and for County, Florida Case No.: In re: Vulnerable Adult , Petitioner, and , Respondent. ORDER DENYING REQUEST FOR TEMPORARY INJUNCTION AND SETTING HEARING ON PETITION FOR INJUNCTION FOR PROTECTION AGAINST EXPLOITATION OF A VULNERABLE ADULT A petition for injunction for protection against exploitation of a vulnerable adult has been reviewed. This court has jurisdiction over the parties and of the subject matter. Based on the facts stated in the petition, the court finds: The facts supporting the denial of the request for an ex parte injunction are: The court finds that based on the facts, as stated in the petition alone and without a hearing in the matter, there is no appearance of an immediate and present danger of exploitation of a vulnerable adult. IT IS THEREFORE ORDERED: The request for a temporary injunction for protection against exploitation of a vulnerable adult is denied . A hearing is scheduled on the petition for injunction for protection against exploitation of a vulnerable adult. The petitioner has the right to promptly amend any petition consistent with court rules. NOTICE OF HEARING A hearing is scheduled regarding this matter on …(date)…, at …(time)…, when the court will fully hear the allegations in the petition for injunction for protection against exploitation of a vulnerable adult. The hearing will be before The Honorable …(name)…, at the following …(address)…, Florida. All witnesses and evidence, if any, must be presented at this time. IF EITHER PETITIONER OR RESPONDENT DO NOT APPEAR AT THE FINAL HEARING, THE PETITIONER OR RESPONDENT WILL BE BOUND BY THE TERMS OF ANY INJUNCTION OR ORDER ISSUED IN THIS MATTER. Nothing in this order limits petitioner’s rights to dismiss the petition. DONE AND ORDERED in, Florida, on …(date)… JUDGE COPIES TO: Sheriff of County CERTIFICATE OF SERVICE: Petitioner: by U. S. Mail by e-mail to designated e-mail address(es) Respondent will be served by sheriff, or by substitute service under section 825.1035, Florida Statutes. Vulnerable Adult will be served by sheriff. The financial institution will be served by sheriff. (If any assets, accounts, or lines of credit are requested to be frozen, insert names of the financial institutions.) I CERTIFY the foregoing is a true copy of the original as it appears on file in the office of the clerk of the circuit court of County, Florida, and that I have furnished copies of this order as indicated above. CLERK OF THE CIRCUIT COURT (SEAL) By: Deputy Clerk or Judicial Assistant If you are a person with a disability who needs any accommodation in order to participate in this proceeding, you are entitled, at no cost to you, to the provision of certain assistance. Please contact [identify applicable court personnel by name, address, and telephone number] at least 7 days before your scheduled court appearance, or immediately upon receiving this notification if the time before the scheduled appearance is less than 7 days; if you are hearing or voice impaired, call 711. (d) Final Protective Injunction. In the Circuit Court of the Judicial Circuit, in and for County, Florida Case No.: In re: Vulnerable Adult , Petitioner, and , Respondent. PERMANENT INJUNCTION FOR PROTECTION AGAINST EXPLOITATION OF A VULNERABLE ADULT This cause came before the court, which has jurisdiction over the parties and subject matter under state law. The court having reviewed the petition and affidavits and considered the testimony presented and argument of counsel, finds as follows: 1. Reasonable notice and opportunity to be heard was given to the respondent in a manner sufficient to protect the respondent’s due process rights. Respondent was served with the petition for injunction, notice of hearing, and temporary protective injunction, if issued. 2. A hearing was held on …(date)… 3. The vulnerable adult is a victim of exploitation or in imminent danger of becoming an exploitation victim. 4. There is a likelihood of irreparable harm and unavailability of an adequate legal remedy. 5. The threatened injury to the vulnerable adult outweighs possible harm to the respondent. 6. With regard to freezing the respondent’s assets, accounts, and lines of credit that were the proceeds of exploitation, there is probable cause that exploitation has occurred and a substantial likelihood that such assets, accounts, and lines of credit will be returned to the vulnerable adult. 7. This injunction provides for the vulnerable adult’s physical or financial safety. 8. These findings were based on the following facts: Accordingly, it is hereby ADJUDGED that: The petitioner’s request for a protective injunction is GRANTED. This injunction remains in effect until it has been modified or dissolved, and it is further ordered that: The respondent must not commit any acts of exploitation against, or have any direct or indirect contact with, the vulnerable adult. The vulnerable adult is awarded exclusive use and possession of any dwelling the vulnerable adult shares with the respondent. The respondent is excluded from the residence of the vulnerable adult. The respondent must, at the respondent’s own expense, participate in all relevant treatment, intervention, or counseling services to be paid for by the respondent. Unless ownership is unclear, any temporarily frozen assets, accounts, and credit lines of the vulnerable adult are to be returned to the vulnerable adult. If not already paid under the order granting temporary protective injunction against exploitation of a vulnerable adult, a final cost judgment is hereby entered against respondent and in favor of the clerk of courts in the amount of (check 1): $75.00 (if assets are between $1,500–$5,000) OR $200.00 (if assets are more than $5,000). All for which let execution issue forthwith. If the amount set forth above has already been paid to the clerk of courts, a final cost judgment is hereby entered against respondent and in favor of the vulnerable adult in the amount set forth above, all for which let execution issue forthwith. Any other costs associated with this judgment, including filing fees and service charges, are to be paid by the respondent. Other: This injunction is valid and enforceable in all Florida counties, does not affect title to real property, and law enforcement may use section 901.15(6), Florida Statutes, arrest powers to enforce its terms. DONE and ORDERED on …(date)… Judge CC: All parties and counsel of record COPIES TO: (Check those that apply) Petitioner: by U. S. Mail by hand delivery in open court (Petitioner must acknowledge receipt in writing on the original order—see below.) Vulnerable Adult (if not petitioner) by U. S. Mail by hand delivery in open court Respondent: forwarded to Sheriff for service by U. S. Mail by hand delivery in open court (Respondent must acknowledge receipt in writing on the original order—see below.) by certified mail (May only be used when respondent is present at the hearing and respondent fails or refuses to acknowledge the receipt of a certified copy of this injunction.) by substitute service under 825.1035, Florida Statutes. Department of Agriculture and Consumer Services Other: Petitioner’s Attorney: by e-mail Respondent’s Attorney: by e-mail I CERTIFY the foregoing is a true copy of the original as it appears on file in the office of the clerk of the circuit court of County, Florida, and that I have furnished copies of this order as indicated above on …(date)… CLERK OF THE CIRCUIT COURT By: Deputy Clerk RULE 5.930. AFFIDAVIT OF QUALIFIED CUSTODIAN OF ELECTRONIC WILL STATE OF FLORIDA COUNTY OF I, …(affiant)…, state under oath that: 1. The affiant is: a person domiciled in and a resident of Florida; or a representative authorized to sign on behalf of …(name of entity)… which is incorporated, organized, or has its principal place of business in Florida. 2. The affiant has been informed that …(name of “testator”)… has died. At the time of the testator’s death, the affiant or entity the affiant represents was the qualified custodian (the “qualified custodian”) who had custody of the electronic will …(date of the “electronic will”)… 3. The qualified custodian deposited the electronic will with the Clerk of Court of County, Florida on …(date)… 4. The electronic record that contains the electronic will was held in the custody of the qualified custodian at all times from …(date)… until it was deposited with the clerk of court. 5. To the best of the affiant’s knowledge, the electronic record that contains the electronic will was at all times, before being offered to the court, in the custody of a qualified custodian in compliance with section 732.524, Florida Statutes, and the electronic will has not been altered in any way since the date it was created. 6. The qualified custodian has (check all that apply): posted and maintained a blanket surety bond in compliance with the requirements of section 732.525(1)(a), Florida Statutes; or maintained a liability insurance policy in compliance with the requirements of section 732.525(1)(b), Florida Statutes. Affiant Sworn to (or affirmed) and subscribed before me by means of physical presence or online notarization, this day of , 20 , by …(name of person making statement)… Signature of Notary Public—State of Florida (Print, Type, or Stamp Commissioned Name of Notary Public) Personally Known or Produced Identification Type of Identification Produced