The following forms shall be used for the purposes of this chapter:
STATE OF RHODE ISLAND PROBATE COURT OF THE COUNTY OF ______
PROBATE COURT OF THE ______
No. _________
ESTATE OF _________
PERSONAL ESTATE ESTIMATED AT $ _____________
CITY/TOWN OF
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20__________
PETITION FOR LIMITED GUARDIANSHIP OR GUARDIANSHIP
Petitioner hereby petitions the Probate Court of the city/town of _____________________________________ to appoint a limited guardian/guardian for _____________________________________ who currently resides at Address, in the city/town of _____________________________________ , and whose date of birth is _______________________________________.
Based upon an assessment conducted by _____________________________________ on Date, which functional assessment reflects the current level of functioning of Respondent, it has been determined that Respondent lacks decision-making ability in one or more of the following areas as indicated:
____ health care ____ financial matters ____ residence ____ association ____ other
Regarding each area indicated, please describe the specific assistance needed:
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_________ Indicate which of the following less restrictive alternatives to guardianship have been explored and deemed inappropriate as indicated:
____ Durable Power of Attorney for Health Care ____ Living Will ____ Power of Attorney ____ Durable Power of Attorney ____ Trusts ____ Joint Property Arrangements ____ Representative Payee ____ Money Management ____ Single Court Transactions ____ Government Benefit and Social Service Programs ____ Housing Options ____ Other
Please describe the basis for the determination that the alternative will not meet the needs of the respondent for each alternative explored and deemed inappropriate:
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_________ The following individual/agency is willing to serve as guardian: _________ _________ _________ Upon information and belief the above individual/agency has:
[] No conflict of interest that would interfere with guardianship duties
[] No criminal background that would interfere with guardian- ship duties
[] The capacity to manage financial resources involved.
[] The ability to meet requirements of law and unique needs of individual.
[] Demonstrated willingness to undergo training. The Respondent has the following heirs at law:
NAME:RESIDENCE:
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_________ Signature _________ Name _________ Address _________ Telephone
Subscribed and sworn to before me as to the truth of the above facts by ____ in ____ on the ____ day of ____, 20__.
_________ Notary Public _________ Print Name
DECREE
_________ _________ Dated PROBATE JUDGE
This notice should be served at once and returned to the clerk of the court.
NOTICE STATE OF RHODE ISLAND
BY THE PROBATE COURT OF THE ______ OF ______
BY THE COUNTY OF _____________________________________ AND STATE AFORESAID To _____________________________________ Estate or _____________________________________ Docket No. _____________________________________
GREETING:
A petition for Limited Guardianship/Guardianship has been filed in the Probate Court of the city/town of _____________________________________.
_________ has requested that the Probate Court appoint Petitioner a limited guardian/guardian for you.
A hearing regarding this Petition shall be held On: _____________________________________________________________________ date At: _____________________________________________________________________ time at the Probate Court for the town of _________.
_________ Address _________ The Petition requests that the Probate Court consider the qualification of the following individual/agency to serve as your limited guardian/guardian: _________ _________
A guardian ad litem will be appointed by the Probate Court to visit you, explain the process and inform you of your rights.
You have the right to attend the hearing to contest the petition, to request that the powers of the guardian be limited or to object to the appointment of particular individual/agency limited guardian/guardian. If you wish to contest the petition, you have the right to be represented by an attorney, at state expense, if you are indigent.
If the Petition is granted and a limited guardian/guardian is appointed, the Probate Court may give the limited guardian/guardian the power to make decisions about one or more of the following:
Your health care; your money; where you live; and with whom you associate.
Copies of this Notice will be mailed to: The administrator of any care or treatment facility where you live or receive primary services; your spouse, and heirs at law; any individual or entity known to petitioner to be regularly supplying protection services to you.
CERTIFICATION OF SERVICE
I certify that I hand-delivered and read this Notice to _____________________________________ on the _________ day of ___________________ , 20 _________.
_________ Signature _________ Print Name _________ Address
CERTIFICATION OF NOTICE
I certify that, as required by Rhode Island General Laws § 33-15-17.1(e), I mailed a copy of this Notice to the following persons, at the addresses listed, on the _________ day of ___________________ , 20 _________.
_________ Signature _________ Print Name _________ Address
Subscribed and sworn to before me this _________ day of ___________________ , 20 _________.
_________ Notary Public
WITNESS
Judge of the Probate Court of the _____________________________________ of _____________________________________ this _________ day of ___________________ , 20 _________.
_________ Clerk
DECISION-MAKING ASSESSMENT TOOL
Name of Individual being assessed: Current Address: _____________________________________ _____________________________________________________________________ _________ Date of Birth: Permanent Address (if different): _____________________________________ _________ _________
Instructions for Completion
This document will be used by a Probate Court to determine whether to appoint a guardian to assist this individual in some or all areas of decision-making.
This document has two parts. Please first complete the part which is right after these instructions, titled Assessment. Then complete the second section, titled Summary.
To a physician completing this document: The individual's treating physician must complete this document. If there is any information of which the treating physician completing this document does not have direct knowledge, he or she is encouraged to make such inquiries of such other persons as are necessary to complete the entire form. Those persons might include other medical personnel such as nurses, or other persons such as family members or social service professionals who are acquainted with the individual. If the physician has received information from others in completing the form, the names of those individuals must be listed on the Summary.
To a non-physician completing this document: Professionals or other persons acquainted with the individual being assessed may also complete this document. If there is information of which a non-physician completing this document does not have knowledge, such non-physician may either leave portions of the document blank, or also make inquiries or do such investigation as is necessary to complete the entire document. Again, the names of any individual from whom information is derived should be listed on the Summary.
The document must be signed and dated by the person completing it. It does not need to be notarized.
THE FOLLOWING IS BASED UPON A PHYSICAL EXAMINATION CONDUCTED BY ME ON
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(DATE)
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_________ How do the above medications, if any, affect the individual's decision-making ability? Please explain:
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If you circled any of the above, other than (A) or (1) for any of the above categories, please explain whether the situation is treatable or reversible, and if so, how:
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I hereby certify that I have reviewed sections A, B, & C attached hereto and based on such assessments that the individual's decision-making ability is as follows:
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_________ Signature _________ Name (Print or Type) _________ Title _________ Date
Names and titles of others who assisted in Preparation of This Assessment.
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STATE OF RHODE ISLAND PROBATE COURT OF THE COUNTY OF _______ ESTATE OF _________ Docket No. _________ ANNUAL STATUS REPORT
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(If more space is needed, please attach a supplement).
_________ Guardian _________ Date STATE OF RHODE ISLAND PROBATE COURT OF COUNTY OF THE _________ (Estate Name) _______ Probate Court No. _________
REPORT OF THE GUARDIAN AD LITEM
Now comes (Name of Guardian Ad Litem) for (Name of Proposed Ward) and reports that on (Date), I personally visited the proposed ward at (Address). I explained to (Name of Proposed Ward) the following:
* The nature, purpose, and legal effect of the appointment of a guardian;
* The hearing procedure, including, but not limited to, the right to contest the petition, to request limits on the guardian's powers, to object to a particular person being appointed guardian, to be present at the hearing, and to be represented by legal counsel;
* The name of the person known to be seeking appointment as guardian:
Based on such visit and the respondent's reaction thereto, I make the following determination regarding the respondent's desire to be present at the hearing, to contest the petition, to have limits placed on the guardian's powers and respondent's objection, if any, to a particular person being appointed as guardian.
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_________ Based on my review of the petition, the decision making assessment tool, my interview with the prospective guardian, my visit with the respondent, and interviews and discussions with other parties, I made the following additional determinations:
Regarding whether the respondent is in need of a guardian of the type prayed for in the petition:
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_________ Regarding whether the guardian ad litem has, in the course of fulfilling his or her duties, discovered information concerning the suitability of the individual or entity to serve as such guardian:
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Respectfully submitted, Date: _________ _________ (Name of Guardian Ad Litem)
R.I. Gen. Laws § 33-15-47