WARD
GUARDIAN
Name*
Address
City, State, Zip
Home Phone
Cell Phone
Email*
DOB
Marital Status
Spouse’s Name
Citizenship
US citizenNaturalized citizenResident alien
SSN
Occupation
Occupation Status
RetiredEmployed
Military Status
NoneActiveVeteran
Dates of Service:
Children
NoYes
How Many:
JointMineStepAdoptedFoster
Grandchildren
Guardian’s Relationship to Ward: Do you have Power of Attorney? YesNo
Referred by: Name: Company:
Financial AdvisorAccountantFamily/FriendWebsiteWorkshop/ClassOther
Financial Advisor: Firm: Phone:
Accountant: Firm: Phone:
Brief Explanation as to why I am applying for guardianship:
Any other details we should know regarding the ward:
EXISTING ESTATE PLAN
LOCATION OF DOCS
DATE EXECUTED
Will
YesNo
Trust
Power of Attorney
Health Care Proxy
Living Will
Long-Term Care Insurance
Funeral & Burial Plans
Current health status: GoodConcernProblem
Specific concern/problem:
Does ward require long term care?
If receiving care currently, please indicate the facility and date of admission:
Has the ward ever been in a hospital or rehab facility for thirty days or more?
List all of ward’s CHILDREN and immediate family (if applicable)
Name: MaleFemaleDate of Birth:
Address:Phone:
Child of:jointwardspouseadoptedfoster childOther relation
studentemployed - Occupation:
SingleMarried1st2ndother- how long? Spouse’s name: Occupation:
Children: none How many? Ages:
Special needs/considerations:
Potential problems/hardships/issues:
MONTHLY INCOME: ** It is very important you indicate in each category ownership and dollar amount separately, as well as total value.**
SOURCE
SPOUSE
JOINT
TOTAL
Wages
$
Pension
Social Security
Investments
Other
Total Value
TYPE OF ASSET
Cash, Checking, Savings, CDs, Money Market & Cash Management Accounts
Investment/Broker-held Accounts (not including cash) and Mutual Fund Accounts
Retirement Accounts: IRA, 401K, 403B, SEP, etc.
Life Insurance: death benefit and cash value
D.B. $
C.V. $
Stocks you hold outside of brokerage accounts
Bonds you hold outside of brokerage accounts
Annuities: $ = original amount invested date=month/year purchased CV=current value
date
CV
Real estate: residence (per tax bill)
Real estate: other
Vehicles: automobile, motorcycle, boats, snowmobiles, etc.
TYPE
Mortgage
Loans Payable
Amount Withheld from Social Security for Medicare
Cost of Medicare Supplement
Farm
Partnership or LLC Interest
Corporation
Other:
Notes/Comments: