Tips ior co1npleting the Missouri Department oi Mental Health Guardianship Packet

../ Al l forms should be typed. Many o r the forms will he attached as an exhibit to the petition for guardianship and filed with the court. Legibility is critical. If for some

unavoidable reason the form musl be hand written, please make sure that the hand writing is clear and legible.

,/ Completed packets must be sent to the l)epartment of Mental Heallh (DM H), Office

of General Counsel (OGC), 1706 East Elm, Jefferson Cily, MO 65102. Do not send

directly to the Attorney General's Office. Please send original docmncnts to the

OGC. v' If tllC guardianship packet is being completed by a community provider, the

comple ted packet must be forwarded to the Regional Office or appropriate DM H

Division designee, who will then be responsible for submitting the packet to the

OGC. v' If you believe that an emergency guardiansh ip may be necessary, please contact the

DMII General Counsel at 57:l -751-0091 to discuss the case prior to submilting the

packet. ../ As you are completing the packet, if you have questions, please contact the Assistant

General Counsel assigned to your facility/office or the General Counsel. Community Jlroviders should consult with their agency's private attorney or may contact the Regional Office or appropriate l)MH Division designee.

v' Always consider a limited guardianship. IL is critical that you look at each essential requircmenL (i.e. food, clothing, shelter, safety, medical) and identify whether Lhe

individual can meet each need through examples that have heen personally observed or assessed. The case manager/soda! worke r will be asked about each of

these areas during the hearing and needs to be very fami liar wi th the abilities and limitations of the individual.

v' The doctor's interrogatories need to have been completed with in 6 months of the

last doctor visit. Lle sure the consumer's name is included on the interrogatories, they arc signed and dated, notarized, and that the doctor has actually seen the dienl within the last few months.

v' The case man,1ger's/social worker's statement should be nu more than 6 months old.

v' The guardianship coordi11c1to1· for c<1ch faci lity /office s lioulcl review the checklist againslthe packet before submitting to the OGC to make sure everything is included.

Please look for obvious errors/omissions such as incorrect consumer name,

incomplete forms and interroga tories that arc not notarized. ,/ If the individual has been found permanently incompetent to proceed on criminal

charges, please include a copy of the court order wi.th the packet. ,/ Wben completing the case manager's/social worker's statement, please list up front

in the Mistory section the charges for which the individual was found permanently

incompetent to prncecd.

Proposed Ward: ----- - --- - ----- - - - ---- --

Case Manager/Social Worker: ------ - - - ---- - - - ---Name and Telephone Number

I Tas the client been found J'ermam:ntly Incompetent lo Procccd to Trial? ___ _

GUARDIANSHIP PACKET CHECKLIST

I . Doctor's I ntcrrogatories

2. Case Manager/Social Worker' s Guardianship/Conservalorship Stmt

3. foinanoial Statement

4. List of Relatives

5. List of Steps Taken to Locate Relatives

6. Information for Family Guardians or Conservators (do not include if proposed guardian is the Public Adminislrnlor)

7. Consent lo Appointment (do no! include if proposed guardian is the Public Administrn!or)

8. Designation or Resident Agent (include only if proposed guardian resides out-of-state)

9. Domicile Statement

JO. lnfonnalion Needed for Conficlenlial Filing Information Sheet

11. Statement Regarding Proposed Guardian

l 2. List of Prospective Witncsseg

13. Copy or Court Order finding client permanently incompetent to proceed (if applicable)

14. Statement Regarding Pending Criminal Charges

15. Cover Leller to General Counsel's Office

T n the Matter of: ) ) )

An alleged incapaci tated and disabled person, ) )

Respondent )

DRPOSTTTON OF'

On this __ day of 20_ , before me, ___ ______ _ a Notary Puhl ic within and for the State of Missouri, personally appeared _____ _

_ _ _ __ . who, atlcr being first duly sworn, tcstific<l as follows:

INTRRROGATORTF.S

I. Q. State your name, age and address.

J\ .

2. Q. What is your oecupalion, business or profession?

J\.

3. Q. Are you licensed to prnelice in the State of Missouri?

A .

4. Q. If your answer to Interrogatory number 3 above is artirmativc, is you,· license sul~jcct to any restrictions imposed by the State of Missouri?

A.

5. Q. lf in your practice you special i1.c in some particular field, please specify same.

/\ .

6. Q. Arc you self-employed '? lfnol, where arc you employed aml in what capacity?

A.

7. Q. /\re your duties such as will prevent your attendance in court as a wilness in this cause?

A

8. Q. /\re you acquainted with ___ ______ ___ _ ?

/\.

9. Q. Have you had occasion lo examine, observe and treat _ _ ________ ?

A.

10. Q. What was the date of such examinalion, or between what dales has _ _ --- - ------ -- been under your observation?

/\.

11. Q. Give the symptomatology which you observed and both the neurological and mental diagnoses whlch you have made, based upon your examination and observation of

Please provide detailed facts upon which yom diagnostic conclusions are based.

A.

12. Q. Do you consider , to be "incapacilale<l", that is unable by reason of any physical or mental condition to receive and evaluate in rormation or lo communicate decisions to such an extent that he/she lacks ability lo meet his/her essential requirements for food, clothing, shelter, safety, or mtdical care such that serious physica l injury, illness, or disease is likely to occur were a guardian not appointed for him/her?

/\.

13. Q. !'lease describe the cognitive or behavioral deficits upon which your answer to Interrogatory 12 is based. (Include examples of tasks/activities that lhe individual is unable lo perform clue to the incapacity)

A.

14. Q. Do you consider , lo be "disabled", that is, unable by reason of auy physical or mental condition, to receive and evaluate information or to communicate decisions to such an extent (hat hc/sl1c lacks ability to manage his/her financial afli1irs?

A.

15. Q. !'lease describe the cognitive or behaviornl deficits upon which yom answer !o lnterrogatory 14 is based. (include examples of tasks/adivitics that (he individual is unable lo perform due to the disability)

A.

16. Q. Do you consider i( for 's best interest lo bring about lhe appointment of a guardian lo protect his/her person?

A.

17. Q. Do you consider it in ' s best interest to bring ahout lhe appointment of a conservator to manage his/her rcsomces'!

A.

18. Q. State anything i'urther you may have to say regarding the alleged disability or incapacity or _____ _ ___ ___ _

A.

DEPONENT

KNOW ALL MEN RY THESE PRESENTS, that T, the undersigned No!ary Public, hereby certify lhat the above-named deponent was !Jrsl duly sworn by me to make true answers lo the foregoing interrogatories, that said interrogatories were read by me lo deponent, that the answers theteto are correctly recorded as hcrcinabove set forth, that this dcpo~ition was suhscrihcd to by the deponent and witness in my presence.

NOTARY PUBLTC

M.y Commission Expires:

CASE MANAGER'S/SOCIAL WORKER'S GUARDlANSHll'/CONSERVATORSTTTP STATEMENT

C,ise Manger's/Social Worker's Name: _ _ _

Address: - - - - ---- - ------- - --- ----- - - --

Telephone Number: - - - - --- - ------- - - ----- --­

Proposed Ward's Name:-------- --- - ----- --- ---

Address: _________ _ ___ _ ______ ___ _____ _

Telephone Number: ---- --- - ------ --- -----

Date ofBirth: --- - ------- --- ----- --- ---­

Admission Status: - - ---- ------- - -- ----- --- --

I. Please list your place of employment and your position.

2. Please describe your educational background.

3. Please describe your conlael with the proposed ward.

4. Who currently has custody ol' the proposed ward '?

5. Please describe the proposed ward 's admission and placcmenl history.

6. Please describe the proposed ward's ramily history.

7. !'lease describe the proposed ward's social functioning.

8. Whal arc the placement plans for lhe proposed ward?

9. Do you have a recommendation as lo whether the proposed ward is an incapacitated person; in that, if left unsupervised, s/he could not meet his or her essential needs for food , clothing. shelter. safely am] medical treatment to avoid serious physical injury?

I 0. List !be speci fie factual reasons for this opinion. (Please include functional limitations you have personally observed/assessed and include examples of tasks/activities that the individual is unable lo perform due to the incapacity)

11. Do you have a recommendation as to whether the proposed ward is a disabled person in that, iflel1 unsupervised, s/hc could not manage his or her financial resourecs?

12. List the specific factua l reasons for this opinion. (Please include functional limitations you have personally observed/assessed and include examples of tasks/activities [hat lhc indiviuual is unable lo perform due to the incapacity.)

13. Who are you recommending to serve as .guardian of the proposed ward and/or conservator of the pror)osed ward's estate?

14. I las the person listed in number 13 above (unless the person listed is lhe public administrator) ever been appointed as guardian of the person or conservator of'thc estate of any .other peic~on?

Ir so, please list tbc names and addresses of such wards or disabled J)ersons.

15. Docs the proposed ward l111ve a guardian appointed in th is or any other state? Ir so, please provide the name and address of the guardian and the stale where tbc guardianship was obtained.

16. Has the proposed ward ever exeeute<l a will or power of attorney? Ir so, please attach a copy of the document.

The foregoing is made under oath or al1innalion and its representations are true and correct lo the bes! knowledge and belief of the undersigned subject lo the penallies of making false ,iffidavil or declaration.

Signature

State of Missouri ) ) ss

County of ______ .,

On , 20 I_, the above witness personally appeared before me, and after being duly sworn, slated on oath that the answers written above were the witness' s true answer to the questions. l certify that the witness signed am! swore lo this statement in my presence on the date stated above. In testimony whereof', I have set my hand and otlicial seal at my office in County, Missouri , on the date above written.

Notary l'ublic (SEAL) My Commission Ex.pires: ________ _

FINANCIAL STAT~MENT

PEUSONAL PROPERTY:

Checking Accounts

_ _ ______ _ Bank $ ____ _ ___ _

------ --- nank $ _ _____ _

____ ___ __ Bank $

Savings Accounts

_ _ ___ ____ Bank $ ____ _ __ _

_ _____ _ _ _ nank $ ___ ___ _ _

_____ ___ __ Rank $ _ ___ ___ _ _

Stocks and Bonds

____ ___ ___ Value $ _ ___ _ _ _ _

Vehicle Value$ _ ___ ___ _ _

Year, Make and Model

Value$ _ _ ___ ___ _ Y car, Make and Model

Otbet $ - --- --- --

$

TOTAL PERSONAL PROPERT Y $ _ _ __ _

MONTHLY TNCOMF::

Social Sc::cmity

Payee

SST

Payee ___ _ __ _

Veterans Administration Benefits

Pension:

Source _ _ _ ___ _ _

Interest:

Source _ _ ___ _ _

*Trust income:

Source

\

Other:

Source

TOTAL MONTHLY INCOMR:

$ _ _ _ _ _ _ _ _

$ - - - - --- --

$ - - ------- -

$ _ _ _ ___ _

$ --- - - -

$

$ - ------- -

REAL PROPERTY: (List Location and Value, including property outside Missouri)

$ ------- - -$ - -$ _____ _ _ - --

$

*lf the client is the gr:mtor, a qualified beneficiary, or a trustee or co-trustee of a trnst, please provide the name and address of the presenlly acting trustees or such trust and the purpose of the trust as well as a copy of the ll'ust.

PARENTS:

SPOUSR:

CHILDREN:

SIBLINGS:

LIST OF RELATIVES

Mother: t\ddress:

father: Address:

Spouse: Address:

Daughter: Address:

t\gc:

Daughler: Address:

t\ge:

Son: Address:

t\ge:

Son: t\ddrcss:

Age:

11rother: t\ddress:

Age:

OTHER CLOSE RELATTVES:

OTHER ADULTS LTVTNC W/ INDIVIDUAL:

Brother: Address:

Age:

Sister: Address:

Age:

Sislel': Address:

Age:

Name: Address:

Relationship:

Name: Address:

Relationship:

Name: Address:

Relationship:

Name: Address:

Relationship:

***H there is 1111 known spouse, adult child, or J>areut, then you must include the names aud addresses of the siblings and child rcu of deceased siblings of the alleged incapacitated person.

LIST 01• STEPS TAKEN TO LOCATE RELATIVES

1. Were you able to locale an address for the proposed ward's mother and father?

2. Were you able to locate an address for all of the proposed ward's brothers and sisters'!

3. We1:e you able to locate an address for all oflhe proposed ward ' s children?

4. Were you able lo locale an address for the proposed ward's spouse?

5. If you answered no to any of the foregoing questions, yon will need to conduct a due aud diligent sear ch for these family memhers. Please take the followi ng steps and initial on the line after you completed this step.

l searched the client's cniirc DMH file; I asked tinnily members and the client about the missing person's whereabouts; I checked telephone directories and information in the county of the last known address of the missing person; T conducted an Internet search !'or the missing person; T sent a certified letter to the last known address of the person.

6. TTow long has it been since the missing person had any contact with the proposed ward'?

INFORMATION FOR GUARDIANS AN D CONSERVATORS

To help you perform your duties properly, described below are the general du!ies and obligat ion of a guardian and conservator.

1. A guardian or conserva!or is appointed upon the adjudication of an individual (respondent) as incapacita!ed (guardian) or disabled (conservator). If you have been appointed guardian, the rcspondett! is known as a "ward." 1 ( you have been appointed conservator, the respondent is known as a "protcctce." lfyou have been appointed both guardian and conservator, the respondent is known as both a "ward and protcctcc."

2. An incapacitated person lacks the legal ability to make medical or psychiatric treatment decisions, to make placement decisions, to vote, to drive an automobile. A disabled person lacks the legal ability lo handle his or her own fi nancial resources. If the respondent is adjudicated to be only partially incapacitated or disabled, the extent lo which the respondeni's rights are limi ted will be specified by court order. 11 is lhe guardian ' s and conservator' s duty to prevent lhe ward or protectcc from exercising righ ts limited or rescinded by adjudication.

3. As guardian, you have the duty to lake charge of the person of the ward and lo provide for the ward ' s care, treatment, habilitation, education, support and maintenance; and the powers and duties shall include (a) assuring that the ward re.sided in the best and least restrictive setting reasonably available: (b) assuring lhal the ward receives medical care and other services lhal arc needed; (c) promoting and protect ing the care, comfort, safely, heal th, and welfare of the ward; and (d) providing required consents on behalf of the ward. You will be required to 11le a personal status report annually concerning the care, welfare, and placement of your ward.

4. As conservator. you must lake possession or your protcctcc' s properly to the extent authorized by lhe courl. The property, income, llnd bank accounts must he kept separate from your own fund~ in your name as conservator for the proleclcc. You must invest the protectee's funds according to law and you arc personally liable for imprudent or unauthorized invest1mmls. You may apply for an order of continuing support and mainlenancc authorizing you lo spend a budgeted sum each month for the proteclee. You wi ll he required to file and annual accounting (called a selllemenl) showing in detail all receipts and cxpcnditutes occurring during the preceding year. Each entry must be explained and each expenditure must be authorized by slltlule or court order. You may not sell, trade, lease, mortgage, transfer, or discard your prolectcc' s properly without court approval, even though the protectee is your child or other relative.

5. Your authority as guardian and conservator '(described in paragraphs 3 and 4 above) may be limited by the orde1' appointing you. Consult your attorney as to legal limitations re.suiting from your ward's or 1>1·otectee's adjudication and as to the extent of your authority.

6. Tn the event the ward or protcctce dies or you or the ward or protectcc move from one address to another, you have a duly lo notify the court in writing of such <lea th or new address as soon as possible.

7. You arc under a duty, at all times, to act in the best interests of your ,.varcl­protcctcc and Lo avoid conflicts of interest that ~viii impair your abi lity so to act. Tf you foil lo perform any of your duties as guardian or conservator, you arc liable to be removed from otlicc and may be held personally liable for any loss or damage sustained by the ward or protectee by reason of your 11tilure.

8. In certain cases, expenses of bond and other costs may be saved by placing funds in restricted deposits and/or securing waiver or fi ling the annual selllement. Consult your attorney.

9. Under Missouri law, a conservator who is not a licensed attorney cannot represent the protectee's estate in conneclion with court proceedings, w hether appearing in court 01· 1>repari11g pleadings to be filed with the court. You must retain an attorney to perform lhose legi1I services required or you. On order of the comt, the attorney may be compensated for services reasonably necessary from the proteclee's es!ale. lf only limited funds or public assistance (SSI) is available, you may qLrnlify for lt'ee legal aid.

Signature of proposed Guardian/Conservator

CONSENT TO APPOINTMENT

Pursuant lo the provisions of Section 475.055(2), RS Mo, the undersigned,

- - ------ --- ---• hereby consents to ael as guardian and/or

conservator of the estate of _____ _ _ _ ____ _ , and states as follows :

I. I am over lhe age of eighteen ( 18).

2. T have never p led gui lty to nor been convicted of a felony.

3. I res ide at:---- ---- ------ - ---- - - --- -City: _ ___ _____ _ _ State: _ _ _ __ Zip: _ ___ _ _

4. The name and address ofmy employer is as follows:

S. I have not been atijudicatcd incapacitated or disabled.

6. I understand the du lies of a guardian and/or conservator.

7. I will visit the ward at least once a year.

8. I understand that l must 11le an aimual report with the court.

9. I have/have not been appointed by a court to serve as guardian of the

person and/or conservator of the estate of another person. Ir so, the 11ame

and address of the ward/protectec is as follows: _ _ _ _ _____ _

I 0. I will keep the comt informed or my current address and telephone number.

T swear that the matters set forth are true and correct to the best of' my knowledge

and belief, subject to the penalties of making a false atlidavit or declaration.

Dated: _____ __ _

Proposed Guardian/Conservator

Street Address

City State Zip

Telephone Number with Area Code

DESIGNATION OF AGENT FOR SERVICE OF PROCESS AND RECEIPT OF NOTICE

Come(s) now ~ a non-resident of the. Slate of Missouri, and designates the following resident of the State o!' Missouri as /\gent for the se1vicc of all proce.ss on and the receipt. of notice by such non-resident, and further slates that the followi ng is the name, address and signature ol'lheAgcnt:

Name of Agent

Residence

City, Stale and Zip Code

Residence

Signa.tw·e of Agent

The foregoing is made under oath or affirmation and its rcpresen!ations are true and correct to the licsl knowledge and belief or the undersigned, subject to the penalties of making a false anidavit or declaration.

Dated this _ _ day of __ _ _ _ _,20

Signature or Non-Resident

DOMICILE STATEMENT

1. Name of Cl icnt/patient:

2. Where does the client cnn·ently reside?

Street ------- --------- - ------ ---

City: _ _ _____ _ _ _ State: _ _ ___ Zip: ___ _ _ _

County:-- - ----- - ----- - --- - --- - ·

Length of"time at this address: - ------ - --- _ __ _

With whom does s/he reside?

ls this a placement or natural home? - - - - --- - --- - --

3. Prior to this residence, where did the client reside? * **You must include the prior residences, up to three, for the three years prior to filing for guardianship. 1f unknown, yon must explain what you did to try to identify and locate prior residences. When listing addresses, t>lease include those addresses where the client lived by choice (i.e., do not list correctional institutio11s, hospitals or l>MH inpatient facilities).

Street __________ - ---- - --- - ---

City: _ ______ _ _ _ State: _ _ __ _ Zip: _ _ _ _ _

County:-- - - --------- - - -------

Dates and length of time at this address: -------- - - --- - ­

With whom did s/he reside?

Was this a placement or natural home?

If unknown, what efforts were made to locate prior residence?

Street -------------------------

City: State: __ _ Zip: _ ___ _

County: - --- - ---------------------

Dates and length of time at this address:--------------- -

With whom did s/hc reside? _________________ _

Was this a placement or natural home? - -------------

1 f nnknown. what efforts were made to locate prior residence?

Street

City: --- - --- ----State: _____ Zip: _____ _

County: _______ _

Dates and length of time al this address: _________ ~-~-

With whom did s/hc reside?

Was this a placement or natural home?

Ir unknown, what efforts were made to locate prior residence?

4. Does the pat ient own property in !his or any other county in Missouri? 11 Yes D No

Tfycs, btieOy describe the property and state the location of the property.

5. Docs the patient own property iu any oilier slate? 11 Yes 11 No

If yes, briefly describe the property and the localion of the properly.

6. Date when (s)he first entered the mental health system either as an inpatient or a placement made by tJ1e department: - - - --- - ---- - - ___ _ __ _

a. Age at the time:

b. Complete address a l that lime: - - - - ----- - - - ----

c. Length of lime at this address: - - - ~-- - ---- - --- ---

INFORMATION NRRDED FOR CONFIDENTIAL FILING JNFORMATTON SHEET

l. Prnposcd Ward's Full Name:

Pirst Middle T.ast

2. Proposed Ward's Social Security Number:

3. Prnposcd Guardian's N,nne:

F irst Middle Last

4. Proposed Cluar<lian's Social Securily Number (not needed for Public A dminislrnlor):

5. l'ropose<l Guardian' s Dale o f' 11irth (not ne.cded for Public Administrator):

6. Proposed Guard ian's Full Address (not needed for Public Administrator):

7. Proposed Guardian's Telcphouc Number (no! needed for Public Administrator):

STAT EMENT REGARDING PROPOSED GUA RDIAN

l. Who did you consider lo serve as guardian and/or conservator?

2.

3.

4.

Name Relationship lo Client

Name RelaLionship lo Client

Name Relationship to Client

Name Relationship to Client

Name Relationship to Client

N11 me Relationship to Client

Who arc you recommending serve as guardian and/or conservator?

Why are you recommending this person'!

Does this person understand the client's disability as well as al l of his/her needs, including medical and placement needs?

5.

6.

7.

Have you explained the duties of guardianship to this person, including acting in the best interest of the ward and filing an annual status report with the court?

Ir you are not recommending a family member to se1ve as guardian/conservator, please explain in detail below the reasons you arc not recommending a family member serve as guardian/conservator?

Has tile client ever nomina ted a person to make dec isions on his behalf in a will or a Power of Attorney'! ll'so, plciisc provide that person' s name and address as we11 as a copy of the wi11 or power of attorney.

LIST OF PROSPECTIVE WITNESSES

Narne (l'hysician or Licenst:d Psychologist)

Name (Social Worker or Service Coordinator

Name (Proposed Guardian)

Name

l\ddrcss

City, State, and Zip Code

Address

City, State, and Zip Code

Address

City, State, and Zip Code

Address

City, State, and Zip Code

Statement Regarding Pending Criminal Cliarges

Proposed Ward: _ ______ _ - - ---- - - -------

Proposed Ward's Date of Birth: ____ _

1. Arc there currently any criminal charges pending ;igainsl Lhe client? _ _ _

l r so, please complete the fol lowing:

A. Charge. Pending: _

11 Court Where Pending: _ _ _ --- ------- ---- -

C. Cause Number: - - --- ------ - - ---- - - -

D. nrief description of the alleged conduct that is the basis for the charge.

E. l las lhe person been found by the court Lo be permanently incompetent to proceed on the pending charge?

If so, please allach a copy of the court order.

Ir this is the only charge pending, please go Lo question 2.

lftherc arc other pending charges, please complete !he following:

A. Charge !'ending: _______ ___ ________ _

B Comt Where Pending: _ _ ____ ________ __ _

C. Cause Number:

D. Brief description of the alleged conduct that is the basis for the charge.

r.. Has the person been found by lhe court to be permanently incompetent lo

proceed on the pending charge'! --------- - ----

If so, please altach a copy of the court order.

lf olher charges arc pending, please attach a separate sheet and include the information requested above.

2. Does Lhe client have any olhcr criminal hislory of which you arc aware'!

Ir so, briefly describe his or her criminal history:

Proposed Ward:

Case Maoager/Sodal Worker: _ _ _ _ Name and Telephone Number

Successor Guardianship Checklist

I. Cci"tificd Copy or Death Certiticate of Guard.ian or Resignation of Guardian

2. Copy of Lellers of Guardianship

3. Social Worker's Statement

4 . Lisi of Relatives

5. List ofSteJJS Taken lo T .ocatc Relatives

6. Information for Family Guardians or Conservators (do not include if proposed guardian is the Public AdminisLralor)

7. Consent to Appointment signed by Propnscd Successor Guardian (do not include if proposed guardian is the Public Administrator)

8. Signed statement signed by each close relative slating his or her name, address, and relationship to the ward and whether he or she has an objection lo the appointment of the proposed successor guardian

9. Designation of Resident Agent (include only if proposed guardian resides out-of·~statc)

I 0. In formation Needed for Conftdenlial Filing lnfmmalion Sheet

11. Statement Regarding Proposed Guardian

12. Cover Letter to General Counsel's Oflice