This form is extremely important. Your accuracy and completeness in responding will help me best represent you. Please bring this information with you to the appointment.

Date_________________________________ File No.

A. CONTACT PERSON

Full Name

Street Address

City __________________________________ State ___________________ Zip

Home Phone No. ________________________ Business Phone No.

E-mail Address ___________________________ Fax No.

Version of Software: _ WordPerfect _ Word _ Other

B. PROTECTED PERSON

Name of Ward (person to be protected)

Permanent Address (domicile)

City __________________________________ State ___________________ Zip

Home Phone No. ________________________ Date of Birth

Current Place of Residence: _ Home _ Nursing Home _ Hospital

Marital Status: _ Divorced _ Widowed - Date Of Death

Is it anticipated that proposed Ward will remain at current address for the next six (6) weeks?

_ Yes

_ No (please provide the anticipated address below)

Facility Name (if applicable)

Street Address

City __________________________________ State ___________________ Zip

Home Phone No. ________________________ Business Phone No.

E-mail Address ___________________________ Fax No.

C. PROPOSED GUARDIAN(S)

(if same as Contact Person, complete date of birth and relationship to ward sections only)

Full Name

Street Address

City __________________________________ State ___________________ Zip

Home Phone No. ________________________ Business Phone No.

E-mail Address ___________________________ Fax No.

Version of Software: _ WordPerfect _ Word _ Other

Date of Birth

Relationship to Ward or Interest in Proceedings

2. Proposed Co-Guardian

Full Name

Street Address

City __________________________________ State ___________________ Zip

Home Phone No. ________________________ Business Phone No.

E-mail Address ___________________________ Fax No.

Version of Software: _ WordPerfect _ Word _ Other

Date of Birth

Relationship to Ward or Interest in Proceedings

D. REFERRAL

By Whom Were You Referred To This Office?

Full Name

Street Address

City __________________________________ State ___________________ Zip

Home Phone No. ________________________ Business Phone No.

E-mail Address ___________________________ Fax No.

E. NAMES AND ADDRESSES OF PERSONS ENTITLED TO NOTICE OF HEARING

1. Ward's Father (if living)

Full Name

Street Address

City __________________________________ State ___________________ Zip

Home Phone No. ________________________ Business Phone No.

E-mail Address ___________________________ Fax No.

Date of Birth

2. Ward's Mother (if living)

Full Name

Street Address

City __________________________________ State ___________________ Zip

Home Phone No. ________________________ Business Phone No.

E-mail Address ___________________________ Fax No.

Date of Birth

3. Ward's Children (if applicable)

Full Name of Wards _ Son _ Daughter

Street Address

City __________________________________ State ___________________ Zip

Home Phone No. ________________________ Business Phone No.

E-mail Address ___________________________ Fax No.

Date of Birth

Full Name of Wards _ Son _ Daughter

Street Address

City __________________________________ State ___________________ Zip

Home Phone No. ________________________ Business Phone No.

E-mail Address ___________________________ Fax No.

Date of Birth

Full Name of Wards _ Son _ Daughter

Street Address

City __________________________________ State ___________________ Zip

Home Phone No. ________________________ Business Phone No.

E-mail Address ___________________________ Fax No.

Date of Birth

Full Name of Wards _ Son _ Daughter

Street Address

City __________________________________ State ___________________ Zip

Home Phone No. ________________________ Business Phone No.

E-mail Address ___________________________ Fax No.

Date of Birth

Full Name of Wards _ Son _ Daughter

Street Address

City __________________________________ State ___________________ Zip

Home Phone No. ________________________ Business Phone No.

E-mail Address ___________________________ Fax No.

Date of Birth

Full Name of Wards _ Son _ Daughter

Street Address

City __________________________________ State ___________________ Zip

Home Phone No. ________________________ Business Phone No.

E-mail Address ___________________________ Fax No.

Date of Birth

4. Administrator of Nursing Home in Which Ward is Living (if applicable)

Name of Nursing Home

Name of Administrator

Name of Social Worker

Street Address (if other than as indicated in Section B)

City __________________________________ State ___________________ Zip

Business Phone No.___________________________ Fax No.

E-mail Address

Date of Admission to Nursing Home (if applicable)

Name of Hospital prior to Nursing Home Admission (if applicable)

Date of admission to Hospital prior to Nursing Home Admission (if applicable)

Reason for admission to Hospital (if applicable)

F. REASON PROPOSED WARD NEEDS A GUARDIAN

Diagnosis

Date of Diagnosis

Examples of Incapacity

G. MEDICAL

Name of Physician Making Diagnosis

Street Address

City __________________________________ State ___________________ Zip

Business Phone No.___________________________ Fax No.

E-mail Address

Name of Second Proposed Examining Physician

Street Address

City __________________________________ State ___________________ Zip

Business Phone No.___________________________ Fax No.

E-mail Address

H. SUMMARY OF INCOME

Please list the Ward's estimated income and expenses for the current year from the following sources.

Monthly Amounts

Social Security ________________

Pension Benefits ________________

IRA Income ________________

Disability Income ________________

Rental Income ________________

Interest Income ________________

Dividends Income ________________

Annuity Income ________________

Other ________________

TOTAL ________________

I. REAL ESTATE

1. Tax Block _____________________________ Lot

Municipality____________________________ Assessed Value $

Market Value $_________________________(apply reciprocal of equalization ratio)

2. Tax Block _____________________________ Lot

Municipality____________________________ Assessed Value $

Market Value $_________________________(apply reciprocal of equalization ratio)

3. Tax Block _____________________________ Lot

Municipality____________________________ Assessed Value $

Market Value $_________________________(apply reciprocal of equalization ratio)

J. MEDICAID

Does the proposed ward receive Medicaid? _ Yes _ No

If so, provide date Medicaid benefits began

K. LIFE INSURANCE

1. Name of Company

Policy No. ____________________________ Face Amount of Policy $

Beneficiary

2. Name of Company

Policy No. ____________________________ Face Amount of Policy $

Beneficiary

3. Name of Company

Policy No. ____________________________ Face Amount of Policy $

Beneficiary

L. AUTOMOBILE

Make___________________________________ Model

Year ____________________ Estimated Resale Value $

M. FINANCIAL SUMMARY

Please insert the value of each asset/liability in the appropriate space.

N. MONTHLY COST OF NURSING HOME

Monthly Nursing Home Cost $_________________________

Monthly Prescription Cost $_________________________

Monthly Incontinent Cost $_________________________

Monthly Other Cost $_________________________

Total Monthly Cost $_________________________

The nursing home is paid through _________________________________________(month/year).

O. CERTIFICATION

The undersigned hereby represents to Roy W. Wilkes, Esquire The Elder & Disability Law Firm, and each of its attorneys that the information contained in this intake form is accurate and complete, and that the undersigned understands that the law firm and its individual lawyers will rely on this information. I understand that if the information contained herein is inaccurate or incomplete, the recommendations made by the law firm may not be appropriate.

Signature of Client/Client Representative: __________________________________________________________