Free Guardianship - Incapacitated Person - Hawaii

PRO-SE PACKET GUARDIANSHIP -- INCAPACITATED PERSON FAMILY COURT OF THE FIRST CIRCUIT
This packet describes the steps necessary to establish a guardianship of an incapacitated person under the new Act 161 of 2004, which was effective as of January 1, 2005. Please note that this packet does NOT address the situation in which a guardian was previously appointed by a will or other written document. Information is provided on preparing documents and presenting them for filing. Samples of the basic forms are also included. We strongly recommend that you seek the services of an attorney. The Lawyer Referral Service (537-9140) of the Hawai`i State Bar Association may be able to provide names of attorneys, but they do not have information on any fees charged by the attorneys. The Volunteer Legal Services (528-7046) and the Legal Aid Society of Hawai`i (536-4302) offer assistance to people with low incomes who meet their financial criteria. Presently, Legal Aid's "Courthouse Assistance Program" office is on the second floor of the Kaahumanu Hale, First Circuit Court building, 777 Punchbowl Street in Honolulu and is open every weekday morning. You may also consult the yellow pages of the telephone book for attorneys who specialize in family law. Should you decide to proceed on your own without the assistance of an attorney, you may wish to review Hawai`i Revised Statutes (HRS) §§ 560:1-401 and 560:5-304 to 560:5-311 pertaining to Guardians of Incapacitated Persons. You are responsible for ensuring that your documents comply with Rule 3 of the Rules of the Circuit Court, applicable Hawai`i Family Court Rules, applicable sections of the Hawai`i Revised Statutes, as well as any memoranda issued by the Family Court. Copies of these statutes, rules and memoranda are available at the Hawai`i Supreme Court Law Library - 417 South King Street, behind the King Kamehameha statue). Court rules and statutes are also available on-line at www.courts.state.hi.us (rules) and www.capitol.hawaii.gov (statutes). OVERVIEW OF DOCUMENTS IN THIS PACKET This packet includes the following forms. Should you wish to have more than one person serve as co-guardians, you will need to amend pertinent portions of the documents to show that this is a co-guardianship case.

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1) "Petition for Appointment of a Guardian of an Incapacitated Person" states the factual and legal basis for the appointment of a guardian and asks the court to issue an Order appointing a guardian. 2) "Notice of Hearing" is attached to the Petition. Court personnel will schedule the hearing and fill in the blank spaces for the date and time of hearing. (see the instructions on page 4.) 3) "List of Exhibits" - this cover sheet organizes supporting documents that are submitted at the time of the filing the Petition. 4) "Waiver of Notice and Consent to Guardianship" informs the court that a person, who is otherwise entitled to notice, agrees to have the guardianship proceedings take place without his or her involvement. This document may be filed to support the Petition for Appointment of a Guardian of an Incapacitated Person. The proposed guardian and the alleged incapacitated person are always expected to attend the hearing, unless previously excused by the court. The alleged incapacitated person cannot waive notice of the hearing. This form allows interested parties to be able to waive the requirement that they be given at least 14 days advance notice of the hearing on the Petition. It also has a check off box if the interested party wants to waive notice of any future hearings. 5) Order Appointing Guardian with [ ] Limited [ ] Unlimited Authority; Exhibit A - contains the Judge's findings and states, among other things, the conditions under which the guardian shall serve and the events that will terminate the guardianship. See other documents listed under the heading, "After the Hearing."

HOW TO PREPARE DOCUMENTS FOR FILING
Typing If you wish to add the information to the blank forms, please type in the information. Also, please adjust or delete phrases (noted on the sample forms, in parentheses) to fit the information in your case. If you type your own documents on your computer, then all documents must be typed in black ink using 12-point pica size print. A 10-point elite size print is not acceptable. On the first page of each document, the name of the Court (for example, "Family Court of the First Circuit") shall be centered and be not less than 3" from the top of the page. Top and bottom margins on the other pages must be 1". The left and right-hand margins shall not be less than 1". Documents must be dated and signed in legible, dark ink. -2-

Signature

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Terms:

The "Petitioner" is the person requesting the guardianship. Any person interested in the alleged incapacitated person's welfare may submit the petition. The Petition requests that someone be appointed as the "Guardian." In the Petition, the alleged incapacitated person is referred to as the "Respondent." After a guardianship is granted, the incapacitated person is referred to as the "Ward."

Case name and number: All documents filed in the same case record must have the same case name (the name of the Respondent noted in the case caption on the left hand side of the caption on the first page. These documents should also have the same "FC-G" (for example, FC-G No. 06-1-0002) case number in the right-hand side of the caption on the first page of the document. Name: Be sure to print the Petitioner's name, address and phone number on the upper left-hand corner of the first page of each document. A daytime or cell phone number is important so that the court can call and notify you that your documents are ready to be picked up for filing. You are responsible for filing your documents. The Court cannot file the documents for you. You need to make enough copies of each original document. Each person who is required to receive notice (see section entitled "Service of Documents") must have a copy. Be sure to keep a copy for yourself. All documents must be filed with the Legal Documents Branch which is located on the first floor of the Kaahumanu Hale, First Circuit Court building at 777 Punchbowl Street in Honolulu. "Filed" means that the original documents (the original document with original signatures; not copies) has an original file-stamped (date and time) and the name of the Documents Filing Clerk on the upper right-hand corner of the first page of the document. This "filed" original is kept by the Family Court as part of the guardianship case record.

Copies

Filing:

Conforming copies: All copies must be "conformed." "Conforming" means that any changes the Court made to your original documents and added to your copies, so that the text of the copies are identical to the original document. For example, if a date and time for a court hearing are added to the Notice of Hearing, you must add this same date and time to ALL copies of the Notice of Hearing. This ensures that all persons receiving the Notice of Hearing will have the same information.

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PRESENTING DOCUMENTS FOR INITIAL FILING To get a hearing date, after completing all of the necessary forms, present the original document plus the necessary number of copies to one of the clerks at the counter in the Judicial Services Branch, 2nd Floor of the Kaahumanu Hale. You must leave the documents for processing so that the Calendar Clerk will add the date and time of the hearing. You will be contacted--by telephone--to pick up the documents. Again, we emphasize the importance of including your daytime or cellular phone number on documents turned in to the court. When you pick up the documents, you will notice that the date and time of the hearing has been filled in on the original copy only of the Notice of Hearing. You must conform the copies (i.e.,, fill in this same information on all of the other copies you submitted). You may do this by writing in or stamping the information that the court added to the original document. Be sure that the information is exactly the same as on the original. As an alternative, you may photocopy the documents after you pick them up from the court. It is critical that you include the date and time of the hearing on all copies of the Notice of Hearing. To file the documents, present the original and all copies to a Documents Receiving Clerk in the Legal Documents Branch on the first floor of the Kaahumanu Hale. Submit as many copies as you need to give to the persons who must receive notice (see section entitled "Service of the Documents"), including the one for yourself. A $175.00 filing fee is required to file the Petition. Filing fees may be paid in person by cash, cashier's check or money order. Please make all cashier's checks or money orders payable to "Chief Clerk, First Circuit Court". The Court does NOT accept personal checks. If you are paying by cashier's check or money order, the Documents Receiving Clerk will accept your cashier's check or money order, assign a case number, and file your documents and return copies to you. A receipt will be mailed to the filing party within 48 hours to confirm the payment. If you are paying in cash, the Documents Receiving Clerk will assign a case number and direct you to the Cashier's Section to pay the filing fee and surcharge. After you have paid your fees, return to the Legal Documents Branch counter to have the documents filed. It is preferable that certified copies of your documents be served on the parties. The Documents Receiving Clerk will certify as many copies as requested at the time of filing of your documents. There is an additional charge should you request certified copies at a later date.

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SERVICE OF THE DOCUMENTS You must serve copies of the "Petition for Guardianship" and the "Notice of Hearing" on all parties entitled to notice under HRS §560:5-309 by the appropriate method of service as described in that section, in HRS §560:1-401, and in Rule 4 of the Hawai`i Family Court Rules. You are reminded that in all cases, the alleged incapacitated person ("Respondent") must be served personally. Please note that the new law requires that the Notice of Hearing include a statement that the Respondent must be physically present unless excused by the Court, inform the Respondent of the Respondent's rights at the hearing, and include a description of the nature, purpose, and consequences of the appointment. The Court will not grant your petition if you fail to serve the Respondent with a notice substantially complying with these requirements. Pursuant to HRS §560:5-309 and §560:1-401, the following persons must be served with a copy of the Petition and Notice of Hearing at least 14 days prior to the hearing. Service on the persons listed below, except for the Respondent, may be made by certified, registered or first class mail (HRS §560:1-401(a)(1): A) B) C) D) Respondent - personal service only* (See HRS §560:5-309( a)); current spouse or reciprocal beneficiary of the Respondent; adult with whom Respondent resided for more than 6 months before the filing of the petition( if there is no spouse or reciprocal beneficiary); Respondent's adult children; If there are no adult children; then notice should be given to Respondent's parents and adult siblings; if the Respondent has none, then notice should be given to at least one adult nearest in kinship to Respondent who can be found; Respondent's current custodian (including care home provider) Respondent's legal representative, if any; any person nominated as the guardian by the Respondent; any agent appointed by the Respondent under any medical directive, mental health care directive, or health care power of attorney; or if none, then any designated surrogate under the Uniform Health Care Decisions Act (HRS §327E-5(f)); any proposed guardian. any interested persons, per HRS Section 560:5-116

E) F) G) H)

I) J)

* "personal service" means that either a process server (ask the Family Court Service Center for a list of names) or an adult (defined as a person who is 18 years of age or older), other than yourself, delivers the document to the Respondent. The person who

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served the document must complete a Proof of Service, which must be filed with the Court, under the same FC-G case name and number noted on the Petition. For each person listed in #A-J, if applicable, you must have one of the following: 1) 2) 3) 4) written proof of service (required for the Respondent), a signed waiver of notice and consent to guardianship (except for the Respondent ), a statement of mailing attaching the Post Office receipt and completed returned receipt indicating that the person received the document by mail, a sworn statement that has been filed or stated on the record at the hearing, if the person listed is deceased.

If you do not have at least one of the documents noted above (#1-4) for each person listed in Items A-J, if applicable, that person must be present at the hearing. If you received prior approval from the Court to serve notice by publication, it should be coordinated so that the last day of the publication is at least 10 days prior to the hearing (HRS §560:1-401(a)(3)). At the Court hearing, you must be able to prove that: / Respondent is incapacitated (HRS §560:5-311). Prior to the hearing, the court may require you to file under seal (HRS §560:5-307) a doctor's or psychologist's or other qualified person's written report, containing information required in HRS §560:5-306. Respondent resides in the First Circuit (Oahu) (HRS §560:5-108(b)(1)) the proposed guardian(s) is/are qualified (HRS §560:5-310) that the Respondent's identified needs cannot be met by less restrictive means (HRS §560:5-311) all notices were personally served or mailed at least 14 days prior to hearing (HRS §560:1-401 and §560:5-309), except that the Respondent cannot be served by mail but must be personally served.

/ / / /

These requirements are mandated by HRS §560:5-304 to §560:5-309. If they are not met, your case will be dismissed. You may file birth, death or marriage certificates or proof of divorce, but they are not required. LIMITED OR UNLIMITED GUARDIANSHIP The Court may appoint a limited or unlimited guardianship. Whenever feasible, the Court will grant to the guardian only those powers which are necessary due to the Ward's limitations and needs.

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GUARDIAN AD LITEM OR KOKUA KANAWAI The Court may appoint either a Guardian Ad Litem or a Kokua Kanawai* to assist the Court by meeting with the Respondent and investigating the need for a guardianship. *See definition in HRS § 560:5-102. You may have to pay for these services. ATTORNEY FOR THE RESPONDENT The Court will appoint an attorney to represent the Respondent if requested by the Respondent, recommended by the Kokua Kanawai, or as determined by the Court. You may have to pay for these services. PROFESSIONAL EVALUATION The Court may order a professional evaluation of the Respondent by a physician, psychologist, or other qualified individual to evaluate the Respondent's alleged impairment. You will have to pay for these services. AFTER THE HEARING 1) Order Appointing Guardian with [ ] Limited [ ]Unlimited Authority:

If the court appoints a guardian, you must prepare an Order Appointing Guardian with [ ] Limited [ ] Unlimited Authority and submit the Order to the court for the Judge's signature within ten (10) days of the hearing, unless otherwise requested. After the Order has been signed, the court will advise you to pick up the document or they will mail them back to you if you had provided them with a stamped, self-addressed envelope. After you receive the document, you are responsible for filing the documents with the Legal Documents Branch, which is located on the first floor of the Kaahumanu Hale. The court cannot file the documents for you. 2) Notice of Appointment of Guardian and Notice of Right to Request Modification or Termination; Certificate of Service

Within 14 days after the Guardian is appointed by the Court, the Guardian is required to send or deliver to the ward and to all other persons who were notified of the hearing , a copy of the Order and a notice of the right to request modification or termination of the guardianship. The Guardian must also complete the attached Certificate of Service which indicates the names and addresses of all persons who were notified and the date of such notification.

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3)

Annual Reports:

Within 30 days of the appointment of a guardian, the Guardian must submit a written report to the Court on the condition of the ward and an account of the money and other assets in the Guardian's possession or subject to the Guardian's control. Annual written reports must be submitted to the Court, addressing the following: (1) The current mental, physical, and social condition of the ward; (2) The living arrangements for all addresses of the ward during the reporting period; (3) The medical, educational, vocational, and other services provided to the ward and the guardian's opinion as to the adequacy of the ward's care; (4) A summary of the guardian's visits with the ward and activities on the ward's behalf and the extent to which the ward has participated in decision-making; (5) If the ward is institutionalized, whether the guardian considers the current plan for care, treatment, or habilitation to be in the ward's best interest; (6) Plans for future care; and 7) A recommendation as to the need for continued guardianship and any recommended changes in the scope of the guardianship. Please note that the Court may appoint a Kokua Kanawai to review a report, interview the ward or guardian, and make any other investigation the Court directs. 4) Notice of the Filing of the Guardian's Report: to be delivered or sent within 14 days after the filing of the report.

The Guardian is required to give notice of the filing of the guardian's report together with a copy of the report, to the ward and any other person the court directs. The notice shall be delivered or sent within 14 days after the filing of the report. This notice is attached to the Annual Report form. CONFIDENTIALITY The written reports of a Kokua Kanawai and any professional evaluation will be kept as confidential documents, with limited access. Court hearings and records are open to the public. A Court hearing may be closed upon the request of the Respondent and a showing of good cause.

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Pro Se Petitioner's Name: Address: Telephone Number: Pro Se Petitioner

IN THE FAMILY COURT OF THE FIRST CIRCUIT STATE OF HAWAI`I In the Matter of the Guardianship of (full legal name) , ) ) ) ) ) ) ) ) ) FC-G No. (leave blank)

PETITION FOR APPOINTMENT OF A GUARDIAN OF AN INCAPACITATED PERSON; NOTICE OF HEARING

An Incapacitated Person.

PETITION FOR APPOINTMENT OF A GUARDIAN OF AN INCAPACITATED PERSON TO THE HONORABLE PRESIDING JUDGE OF THE FAMILY COURT: Petitioner respectfully alleges as follows: 1. for This petition is for the appointment of a guardian

(full legal name) , hereinafter referred to as "Respondent,"

who is an Incapacitated Person residing or present within the jurisdiction of this Court, pursuant to HRS §§ 560:5-106 and 560:5-108(b).

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2. Petitioner: Name:

The following information concerns the above-named

Residence and Current Address, if different: Relationship to Respondent: Interest in the Appointment: 3. Respondent: Name: Age: Principal Residence: Current Street Address and, if different, Address of Dwelling if appointment is made: 4. The following person is suitable to be appointed The following information concerns the above-named

guardian of the Respondent: Name: Residence and Current Address: (If different):

The proposed guardian should be selected because: (state reason.)

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5.

The names and addresses of the individuals

required by law, HRS § 560:5-304(b), to be notified of these proceedings are (note if deceased or whereabouts unknown or "none":) (a) Spouse or Reciprocal Beneficiary or (if there is no spouse or reciprocal beneficiary) Adult with whom Respondent has resided for more than six months before the filing of this Petition:

(b)

Adult Children or (1) (2) (3) (4) Mother: Father: Adult siblings: Adult(s) nearest in kinship to the Respondent (if there is no adult child or adult siblings):

6.

The person(s) responsible for care or custody of

the Respondent:(Ex. care home, hospital, long term care facility, or if the Respondent lives alone, so state.) 7. The person(s) serving as Respondent's

legal representative(s): (also include title of legal

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representative- including attorney, representative payee, guardian, conservator, trustee or custodian of a trust or custodianship of which Respondent is a beneficiary, and agent designated under a power of attorney, whether for health care or property). If the person has been appointed conservator or

guardian of the property, provide the case name and number. 8. as guardian: 9. The person(s) appointed by the Respondent as an The person(s) nominated by the Respondent to serve

agent under any medical directive, or health care power of attorney: 10. The person designated as a surrogate authorized to

make a health care decision for Respondent under the Hawai`i Uniform Health-Care Decisions Act (in the absence of an agent appointed by the Respondent under a medical directive, or health care power of attorney) is: 11. The following interested person(s) (has/have)

filed with the Circuit Court of the First Circuit, pursuant to HRS § 560:5-116, a request for notice before entry of any order in a guardianship or protective proceeding relative to the abovenamed Respondent: (also include relationship to Respondent)

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12.

Petitioner has made inquiry of all reasonable

sources as to the names and addresses of persons in paragraphs 5 through 11, where applicable, and has not been able to obtain information other than as alleged in said paragraphs. 13. Such appointment is necessary because the

Respondent is unable to receive and evaluate information or make or communicate decisions to such an extent that (he/she) lacks the ability to meet essential requirements for physical health, safety, or self-care, even with appropriate and reasonably available technological assistance because (describe briefly

the nature and extent of Respondent's alleged incapacity.)

This is based on the _____________________________ (and list other supporting documents, if any) attached to the List of Exhibits which is submitted separately. 14. (Check appropriate box) An [ ] unlimited [ ]

limited guardianship is requested because: (explain why a limited guardianship is inappropriate or if a limited guardianship is requested, state powers to be granted to the limited guardian.)

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15.

The following information concerns the

Respondent's property: General statement of Respondent's property:

Estimated value (including insurance or pension):

Source and amount of other anticipated income or receipts:(do not include Social Security numbers, bank account nos., etc.)

16. [

(Check appropriate box) The Respondent [

]is

] is not represented by counsel. 17. (Check appropriate box) The Respondent [ ]is

[

] is not expected to attend the hearing.

(If not, provide an

explanation, and include the following: "The Petitioner respectfully requests the Respondent's attendance be excused pursuant to HRS § 560:5-308(a)).

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18.

The Petitioner further requests the appointment of

a Guardian ad Litem for the Respondent and/or of a Kokua Kanawai, if deemed necessary by the Court, pursuant to HRS §§ 560:5-115 and 5-305(a). The duties and reporting

requirements of the Kokua Kanawai should be, as follows:

WHEREFORE, Petitioner prays that: 1. A time and place be set for hearing on the issue of

incapacity hereof, and that due notice of the foregoing matter and of the time and place of hearing on this petition be given to all required persons. 2. The Court (excuse the Respondent's attendance appoint a Guardian ad Litem

pursuant to HRS § 560:5-308(a) and)

for the Respondent and/or a Kokua Kanawai, if deemed necessary by the Court, pursuant to HRS §§ 560:5-115 and 5-305(a). 3. (a) (b) The Court make the following findings: that this Court has jurisdiction in this matter; that (Full Legal Name of Respondent) is an

Incapacitated Person as defined in HRS §560:5-102;

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(c)

(check appropriate box) [ ]limited [

that the appointment of a

]unlimited guardianship is

necessary in order to provide continuing care and supervision of said Incapacitated Person; and (d) that (Name of Proposed Guardian) , the nominee

named in paragraph 4 above, is a fit and proper person to serve as guardian. 4. (Name of Proposed Guardian) be appointed

guardian of the above-named Incapacitated Person, to continue in office until such guardianship is terminated by order of this Court or by operation of law. 5. The guardian of the person of the above-named

Incapacitated Person shall serve without bond and without compensation. PETITIONER DECLARES UNDER PENALTY OF PERJURY THAT PETITIONER HAS READ THIS PETITION FOR GUARDIANSHIP AND KNOWS AND UNDERSTANDS THE CONTENTS HEREOF; AND THAT THE STATEMENTS MADE HEREIN ARE TRUE OF PETITIONER'S OWN KNOWLEDGE EXCEPT AS TO MATTERS HEREIN STATED UPON INFORMATION AND BELIEF. AS TO THOSE MATTERS, PETITIONER BELIEVES THEM TO BE TRUE. DATED: Honolulu, Hawai`i

(signature) Petitioner

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IN THE FAMILY COURT OF THE FIRST CIRCUIT STATE OF HAWAI`I In the Matter of the Guardianship of (full legal name) An Incapacitated Person ) ) ) ) ) ) ) ) ) FC-G No. (leave blank)

NOTICE OF HEARING

NOTICE OF HEARING STATE OF HAWAI`I TO: (List names and addresses of all parties in paragraphs The petition for appointment of a guardian of the person of the above-named person will be heard in the Family Court, Kaahumanu Hale, 2nd Floor, 777 Punchbowl Street, Honolulu, Hawai`i 96813, on at . m. If you fail to appear at the hearing, or to file an answer with the Office of the Chief Clerk of the First Circuit , State of Hawai`i, located in the Kaahumanu Hale, 1st Floor, 777 Punchbowl Street, Honolulu, Hawai`i, and whose mailing address is P.O. Box 619, Honolulu, Hawai`i 96809, before the date of the hearing, further action may be taken in this cause without further notice to you. , , 3-11 of the Petition.)

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NOTICE TO THE RESPONDENT:
The outcome of this proceeding may limit or completely take away your right to make decisions about your personal affairs or financial affairs or both. You must appear in person unless excused by the court. You have the right to be represented by an attorney of your choice at your expense and the right to request a court-appointed attorney. At the hearing, you may: request a professional evaluation present evidence, subpoena witnesses and documents; question all witnesses and experts and otherwise participate in the hearing. You may ask that the hearing be conducted in a manner that reasonably accommodates you. You may ask that the hearing be closed to the public. This Notice of Hearing shall not be personally delivered between 10:00 p.m. and 6:00 a.m. on premises not open to the public, unless a judge permits, in writing, on the Notice of Hearing, personal delivery during those hours. Failure to obey the Notice of Hearing may result in an entry of a default and default judgment against the person noticed. DATED: Honolulu, Hawai`i,

Clerk of the above-entitled Court

In accordance with the Americans with Disabilities Act and other applicable state and federal laws, if you require a reasonable accommodation for a disability, please contact the ADA Coordinator at the First Circuit Court Administration office at phone number 539-4400, FAX # 539-4402, or TTY 539-4853, at least ten (10) working days prior to your hearing.

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Pro Se Petitioner's Name Address: Telephone Number: Pro Se Petitioner

IN THE FAMILY COURT OF THE FIRST CIRCUIT STATE OF HAWAI`I In the Matter of the Guardianship of (full legal name) , ) ) ) ) ) ) ) ) ) FC-G No. (leave blank)

LIST OF EXHIBITS

An Incapacitated Person.

LIST OF EXHIBITS The exhibits attached hereto are submitted for filing in the above entitled proceeding: 1. 2. 3. DATED: Honolulu, Hawai`i, . . . .

Petitioner

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Pro Se Petitioner's Name Address: Telephone Number: Pro Se Petitioner IN THE FAMILY COURT OF THE FIRST CIRCUIT STATE OF HAWAI`I In the Matter of the Guardianship ) ) ) of ) ) (full legal name) , ) ) An Incapacitated Person. ) ________________________________) FC-G No. (case number)

WAIVER OF NOTICE AND CONSENT TO GUARDIANSHIP

WAIVER OF NOTICE AND CONSENT TO GUARDIANSHIP I acknowledge receipt of a filed copy of the Petition requesting the appointment of (Proposed Guardian) as guardian of the above-named Incapacitated Person and the Notice of Hearing in this action. I consent to the guardianship, appointment of the proposed guardian, and waive the requirement that I receive notice of the hearing at least fourteen days before the hearing on the Petition. Also, [ ] I do not want to be notified of any further hearings and understand that the Court may grant the petition without further notice to me. [ ] I want to be notified of all future hearings but do not require that I be given at least fourteen days advance notice. DATED: Honolulu, Hawai`i, . (signature) *Name: Address: *This document may be signed by the person or his/her attorney.

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Pro Se Petitioner's Name Address: Telephone Number: Pro Se Petitioner IN THE FAMILY COURT OF THE FIRST CIRCUIT STATE OF HAWAI`I In the Matter of the Guardianship of (full legal name) , ) ) ) ) ) ) ) ) ) FC-G No. (leave blank)

PROOF OF SERVICE ON RESPONDENT

An Incapacitated Person.

PROOF OF SERVICE ON RESPONDENT I served a certified copy of the Petition for Appointment of a Guardian of an Incapacitated Person and Notice of Hearing in this action on the above-named Incapacitated Person (Respondent) at the following address: on (date) at (time) .

DATED: Honolulu, Hawai`i ________________________________ (Signature of Serving Officer or Adult) ________________________________________ (Print complete name)(Badge# for serving officer)

(Address, if other than Serving Officer) ________________________________________

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Pro Se Petitioner's Name Address: Telephone Number: Pro Se Petitioner IN THE FAMILY COURT OF THE FIRST CIRCUIT STATE OF HAWAI`I In the Matter of the Guardianship of (full legal name) , ) ) ) ) ) ) ) ) ) FC-G No. (leave blank)

STATEMENT OF MAILING RE: (NAME OF PARTY); EXHIBITS 1 AND 2

An Incapacitated Person.

STATEMENT OF MAILING RE: (NAME OF PARTY) I represent that I mailed a certified copy of the Petition for the Appointment of a Guardian of an Incapacitated Person and Notice of Hearing by certified or registered mail, return receipt requested, [ ] restricted delivery to addressee as follows: NAME:__________________________________________________________ ADDRESS: ______________________________________________________ CITY/STATE/ZIPCODE: ___________________________________________ At the time of mailing, the Post Office receipt attached hereto as Exhibit "1" was postmarked and dated. DATED: Honolulu, Hawai`i (Signature) ________________________________________ (Print complete name) Thereafter, the return receipt attached as Exhibit "2" was received.

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Instructions: Submit a separate Statement of Mailing for each party served by mail.

(ATTACH POST OFFICE RECEIPT)

(ATTACH RETURN RECEIPT)

EXHIBIT 1

EXHIBIT 2

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Pro Se Petitioner's Name: Address: Telephone Number: Pro Se Petitioner

IN THE FAMILY COURT OF THE FIRST CIRCUIT STATE OF HAWAI`I In the Matter of the Guardianship of (full legal name) , ) ) ) ) ) ) ) ) ) FC-G No. (case number)

ORDER APPOINTING GUARDIAN WITH [ ]LIMITED [ ]UNLIMITED AUTHORITY; EXHIBIT A HEARING DATE: JUDGE:

An Incapacitated Person.

[

ORDER APPOINTING GUARDIAN WITH ]LIMITED [ ]UNLIMITED AUTHORITY

This matter came on for hearing on the above-mentioned date before the Honorable (Full Name of Judge) , Judge of the

Family Court, First Circuit. Following that hearing and after full consideration of all of the evidence, the Court finds that:

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1.

This Court has jurisdiction and is the proper

venue in this matter; 2. The material allegations of the petition for

appointment of a Guardian of an incapacitated person are true; 3. evidence that: A. (Name of Subject) is an incapacitated person It has been proven by clear and convincing

as defined in HRS § 560:5-102. B. The Incapacitated Person's identified needs

cannot be met by less restrictive means, including the use of appropriate and reasonably available technological assistance; 4. Appointment of a Guardian is necessary in order

to provide continuing care and supervision of said incapacitated person; 5. The Incapacitated Person was properly served with

a notice which complies with the provisions in HRS § 560:5-309(a); 6. (Name of Proposed Guardian) is a fit and

proper person and the best qualified to serve as Guardian;

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[

]

7.

The Guardian shall have unlimited authority

because:

[

]

The Guardian's authority shall be limited.

NOW, THEREFOR, IT IS HEREBY ORDERED that (Name of Proposed Guardian) (Name of Incapacitated

be and is hereby appointed Guardian of

Person), to make decisions regarding the Incapacitated Person's support, care, education, health and welfare, subject to the provisions in HRS §§ 560:5-314, 560:5-315, and 560:5-316. The Guardian shall exercise authority only as needed due to the incapacitated person's limitations and if possible, shall encourage his/her participation in decisions regarding his/her personal affairs, acting on his/her own behalf, and developing or regaining the capacity to manage his/her own personal affairs. The Guardian shall consider the expressed desires and

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personal values of the Incapacitated Person to the extent known to the Guardian. At all times, the Guardian shall act in the

Incapacitated Person's best interests and exercise reasonable care, diligence and prudence. IT IS HEREBY ORDERED THAT the Guardian shall have the following duties: 1) to become and remain personally acquainted with the Incapacitated Person and maintain sufficient contact with the person to know the person's capacities, limitations, needs, opportunities, and physical and mental health; 2) take reasonable care of the Incapacitated Person's personal effects and bring protective proceedings if necessary to protect the Incapacitated Person's property; 3) expend any monies of the Incapacitated Person, received by the Guardian, for the Incapacitated Person's current needs for support, care, education, health and welfare; 4) conserve any excess money of the Incapacitated Person for that person's future needs; provided that if a conservator has been appointed for the Incapacitated Person's estate, the Guardian shall pay the money to the conservator, at least quarterly, to be conserved for the Incapacitated Person's future needs;

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5)

immediately notify the court if the Incapacitated Person's condition has changed so that the person is capable of exercising rights previously removed; and

6)

inform the court of any change in the Incapacitated Person's custodial dwelling or address; IT IS HEREBY ORDERED THAT THE GUARDIAN SHALL HAVE:

[

] limited authority as provided below:

_______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ [ ] unlimited authority

to make these decisions including but not limited to the authority to: 1) apply for and receive money payable to the Incapacitated Person, Guardian, or custodian for the Incapacitated Person's support under the terms of any statutory system of benefits or insurance or any private contract, devise, trust, conservatorship, or custodianship; 2) if consistent with any court orders relating to custody, take custody of the Incapacitated Person and establish that person's residence, provided that prior court approval is

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needed if the Incapacitated Person is to live or be moved to a location outside of Hawai`i; 3) if there is no conservator, then the Guardian may initiate an action to compel a person to support the Incapacitated Person or pay money for that person's benefit; 4) consent to medical or other care, treatment or service for the Incapacitated Person; 5) consent to the marriage or divorce of the Incapacitated Person; and 6) if reasonable under all of the circumstances, delegate to the Incapacitated Person certain responsibilities for decisions affecting that person's well being. IT IS HEREBY FURTHER ORDERED that the Guardian may not revoke any health care directions set forth in any medical directive or health care power of attorney, without authorization of the Court. However, appointment of this

guardianship automatically terminates the authority of any agent designated in the medical directive or health care power of attorney. IT IS HEREBY FURTHER ORDERED that if the Public Guardian is appointed guardian, the Public Guardian shall have authority to delegate the responsibilities and duties of the Public Guardian to a professional member of the Public Guardian's staff.

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IT IS HEREBY FURTHER ORDERED that the Guardian shall provide a written report to the Court of the condition of the Incapacitated Person, account for money and other assets in the Guardian's possession or control, and such other matters as the Court may direct within thirty days of the filing of this Order and at least annually thereafter by the (day) of (month),

and whenever ordered by the Court, and shall give notice, within fourteen days of the filing of this report, together with a copy of the report to the Incapacitated Person [ (name and address): ] and

. IT IS HEREBY FURTHER ORDERED that the Guardian shall serve without bond and, with prior court approval, is entitled to reasonable compensation from the Incapacitated Person's estate for services as Guardian and to reimbursement for room, board and clothing provided to the Incapacitated Person. Exhibit A IT IS HEREBY FURTHER ORDERED that the Guardian shall be discharged upon the death of the Incapacitated Person or upon further order of the Court, but termination does not affect the liability of the Guardian for prior acts, nor the Guardian's obligation to account for funds and assets of the Incapacitated Person. See

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IT IS HEREBY FURTHER ORDERED that, within fourteen days of the filing of this Order, the Guardian shall send or deliver a copy of this Order to the Incapacitated Person and all other persons noticed of the hearing on this petition, together with notice of the right to request termination or modification of this Order.

DATED:

Honolulu, Hawai`i

Judge of the above-entitled Court

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§560:5-314 Duties of guardian. (a) Except as otherwise limited by the court, a guardian shall make decisions regarding the ward's support, care, education, health, and welfare. A guardian shall exercise authority only as necessitated by the ward's limitations and, to the extent possible, shall encourage the ward to participate in decisions, act on the ward's own behalf, and develop or regain the capacity to manage the ward's personal affairs. A guardian, in making decisions, shall consider the expressed desires and personal values of the ward to the extent known to the guardian. A guardian at all times shall act in the ward's best interest and exercise reasonable care, diligence, and prudence. (b) A guardian shall: (1) Become or remain personally acquainted with the ward and maintain sufficient contact with the ward to know of the ward's capacities, limitations, needs, opportunities, and physical and mental health; (2) Take reasonable care of the ward's personal effects and bring protective proceedings if necessary to protect the property of the ward; (3) Expend money of the ward that has been received by the guardian for the ward's current needs for support, care, education, health, and welfare; (4) Conserve any excess money of the ward for the ward's future needs; provided that if a conservator has been appointed for the estate of the ward, the guardian shall pay the money to the conservator, at least quarterly, to be conserved for the ward's future needs; (5) Immediately notify the court if the ward's conditions has changed so that the ward is capable of exercising rights previously removed; and (6) Inform the court of any change in the ward's custodial dwelling or address.

§560:5-315 Powers of guardian. (a) Except as otherwise limited by the court, a guardian may: (1) Apply for and receive money payable to the ward or the ward's guardian or custodian for the support of the ward under the terms of any statutory system of benefits or insurance or any private contract devise, trust, conservatorship, or custodianship; (2) If otherwise consistent with the terms of any order by a court of competent jurisdiction relating to custody of the ward, take custody of the ward and establish the ward's place of custodial dwelling, provided that a guardian may only establish or move the ward's place of dwelling outside this State upon express authorization of the court; (3) If a conservator for the estate of the ward has not been appointed with existing authority, commence a proceeding, including an administrative proceeding, or take other appropriate action to compel a person to support the ward or to pay money for the benefit of the ward; EXHIBIT A

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§560:5-315 Powers of guardian con't (4) (5) (6) (b) Consent to medical or other care, treatment, or service for the ward; Consent to the marriage or divorce of the ward; and If reasonable under all of the circumstances, delegate to the ward certain responsibilities for decisions affecting the ward's well being. The court may specifically authorize the guardian to consent to the adoption of the ward.

§560:5-316 Rights and immunities of guardian; limitations. (a) A guardian shall be entitled to such reasonable compensation from the ward's estate for services as guardian and to reimbursement for room, board, and clothing provided to the ward, as is approved by order of the court. (b) A guardian is not: (1) Legally obligated to use the guardian's personal funds for the ward's expenses; (2) Unless otherwise provided in the contract, individually liable on a contract properly entered into in the guardian's representative capacity in the exercise of the duties and powers as guardian unless the guardian fails to reveal the guardian's capacity and the identity of the ward in the contract; (3) Personally liable to a third person for acts of the ward solely by reason of the relationship; and (4) Liable for injury to the ward resulting from the wrongful conduct of a third party that provides medical or other care, treatment, or service to the ward, if the guardian exercised reasonable care in choosing the third party. (c) A guardian, without authorization of the court, may not revoke any health care directions set forth in any medical directive or health care power of attorney of which the ward is the principal. However, the appointment of a guardian automatically terminates the authority of any agent designated in the medical directive or health care power of attorney. (d) A guardian shall not initiate the commitment of a ward to a mental health-care institution except in accordance with the State's procedure for involuntary civil commitment.

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Pro Se Petitioner's Name (or Attorney's Name and Number): Address: Telephone Number: Pro Se Petitioner (or Attorney for Petitioner)

IN THE FAMILY COURT OF THE FIRST CIRCUIT STATE OF HAWAII In the Matter of the Guardianship of (full legal name) , ) ) ) ) ) ) ) ) ) ) FC-G No. (case number)

NOTICE OF APPOINTMENT OF GUARDIAN AND NOTICE OF RIGHT TO REQUEST MODIFICATION OR TERMINATION; CERTIFICATE OF SERVICE

An Incapacitated Person.

NOTICE OF APPOINTMENT OF GUARDIAN AND NOTICE OF RIGHT TO REQUEST MODIFICATION OR TERMINATION STATE OF HAWAI`I TO: (List names and addresses of the Ward and all parties in paragraphs 3-11 of the Petition.)

Notice is hereby given that

(Name of Guardian) (Name of

has

been appointed by the court to be the guardian of Incapacitated Person) .

You have a right to request the termination or modification of the attached Order Appointing Guardian with [ [ ] Limited

] Unlimited Authority by filing a written petition to

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terminate or modify the guardianship order and notice of hearing with the Office of the Chief Clerk of the First Circuit, State of Hawai`i, located in the Kaahumanu Hale, 1st Floor, 777 Punchbowl Street, Honolulu, Hawai`i, and whose mailing address is P.O. Box 619, Honolulu, Hawai`i 96809. File-stamped copies of this

Petition to Terminate or Modify the Guardianship and a Notice of Hearing must be mailed to the Guardian at the following mailing address; _______________________________________________________ _________________________________________________________________ and to the Ward and all other parties at the addresses noted above. DATED: Honolulu, Hawai`i

(Signature) of Guardian

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2

CERTIFICATE OF SERVICE I hereby certify that, on the date noted below, I caused to be mailed to the below-mentioned persons, copies of the attached document: NAME ADDRESS DATE OF SERVICE

DATED: Honolulu, Hawai`i: ____________________________

_______________________________________ Signature of person certifying service _______________________________________ Print complete name

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FO R M S /2004fcg/IN IT IA L RE P O R T 1/31/06

IN THE FAMILY COURT OF THE FIRST CIRCUIT STATE OF HAWAI`I In the Matter of the Guardianship of ___________________________, An Incapacitated Person. ) ) ) ) ) ) ) ) FC-G No. INITIAL REPORT OF THE GUARDIAN OF AN INCAPACITATED PERSON

INITIAL REPORT OF THE GUARDIAN OF AN INCAPACITATED PERSON

(Incapacitated Person)/Ward's Age:

1.

INFORMATION ON GUARDIAN(S) a. Guardian's Name Date Appointed

Residence Address, City, State, Zip Code

Mailing Address, City, State, Zip Code

Home Phone No.

Business Phone No.

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b. Guardian's Name Date Appointed

Residence Address, City, State, Zip Code

Mailing Address, City, State, Zip Code

Home Phone No.

Business Phone No.

2.

RESIDENTIAL ARRANGEMENTS (if Ward is living with other than Guardian)

Ward's Residence Address, City, State, Zip Code

Phone No.

Caregiver's Name

Phone No.

3.

PRESENT CONDITION OF THE WARD (please describe the present condition of the Ward)

4.

FINANCIAL SITUATION A. Was a Conservator (other than yourself) appointed by the First Circuit Court, State of Hawai`i, to manage ward's financial affairs? Yes No

Name of Conservator

Phone No.

FC Case No.

2

B.

Monthly Income: (including income received from Social Security, Pensions, retirement, etc. Do not include account numbers/social security numbers) Source Amount Payee

C.

List assets (checking, savings, etc. - Do not include account numbers/ social security numbers), presently in the Guardian's possession or subject to the Guardian's control, as of thirty days after the guardianship appointment: Provide balance and date:

THE UNDERSIGNED SOLEMNLY AND SINCERELY DECLARES, UNDER PENALTY OF PERJURY, THAT THE STATEMENTS MADE HEREIN ARE COMPLETE, TRUE AND TO THE BEST OF HIS/HER KNOWLEDGE, INFORMATION AND BELIEF.

FOR OFFICIAL USE

______________________________________ Guardian's Signature Date

_________________ Date Reviewed ______________________________________ Guardian's Signature _________________ Family Court Officer Date

Return completed form to:

Attention: Helen Rauer Office of the Chief Court Administrator First Judicial Circuit P.O. Box 3498 Honolulu, Hawai'i 96811-3498 3

FORMS/2004fcg/REPORT ANNUAL 1 /31/06

IN THE FAMILY COURT OF THE FIRST CIRCUIT STATE OF HAWAI`I In the Matter of the Guardianship ) ) of ) ) «FirstName» «MiddleName» «LastName», ) ) ) Incapacitated Person. ) ) «CaseNumber» ANNUAL REPORT OF THE GUARDIAN OF AN INCAPACITATED PERSON FOR «AnnualReportPeriod»; NOTICE OF FILING OF ANNUAL REPORT

ANNUAL REPORT OF THE GUARDIAN OF AN INCAPACITATED PERSON FOR «AnnualReportPeriod»

(Incapacitated Person)/Ward's Age: ____________ 1. INFORMATION ON GUARDIAN(S) a. ____________________________________________________ Guardian's Name Date Appointed ________________________________________________ Residence Address, City, State, Zip Code ________________________________________________ Mailing Address, City, State, Zip Code ________________________________________________ Home Phone No. Business Phone No.
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b.

_______________________________________________ _________ Guardian's Name Date Appointed _______________________________________________R esidence Address, City, State, Zip Code _______________________________________________M ailing Address, City, State, Zip Code _______________________________________________H ome Phone No. Business Phone No.

2.

RESIDENTIAL ARRANGEMENTS (during the period covered by this Annual Report) _____________________________________________________ Ward's Residence Address, City, State, Zip Code Phone No. __________________________________________________________ Caregiver's Name Phone No.

3.

PRESENT CONDITION OF THE WARD (please describe the current mental, physical and social condition of the Ward)

4.

SERVICES PROVIDED TO THE WARD (please provide the medical, educational, vocational and other services provided to the ward and your opinion as to the adequacy of the ward's care during the period covered by this Annual Report. Please include the Individualized Service Plan (ISP))

2

5.

SUMMARY OF GUARDIAN S VISITS WITH WARD, ETC. (please provide a summary of your visits with the ward and activities on the ward's behalf and the extent to which the ward has participated in decision-making)

6.

CURRENT PLAN FOR CARE, TREATMENT, OR HABILITATION (if the Ward is presently in an institution, is the current plan for care, treatment or habilitation in the ward's best interests?)

7.

PLANS FOR FUTURE CARE (please describe if there are any plans for future care)

8.

NEED FOR CONTINUED GUARDIANSHIP AND/OR ANY CHANGES: (please provide your recommendation as to whether or not the guardianship needs to continue and if there are any recommended changes in the scope of the guardianship)

9.

FINANCIAL SITUATION A. Was a Conservator (other than yourself) appointed by the First Circuit Court, State of Hawai`i, to manage ward's financial affairs? Yes No

_____________________________________________________ Name of Conservator Phone No. FC Case No. 3

B.

Monthly Income: (including income received from Social Security, Pensions, retirement, etc. Do not include account numbers/social security numbers) Source Amount Payee

C.

List current assets (checking, savings, etc. - Do not include account numbers/social security numbers) Provide balance and date:

THE UNDERSIGNED SOLEMNLY AND SINCERELY DECLARES, UNDER PENALTY OF PERJURY, THAT THE STATEMENTS MADE HEREIN ARE COMPLETE, TRUE AND TO THE BEST OF HIS/HER KNOWLEDGE, INFORMATION AND BELIEF. FOR OFFICIAL USE ______________________________________ Guardian's Signature _________________ Date Reviewed ______________________________________ Guardian's Signature _________________ Family Court Officer Date Report Due: «AnnualReportDt», 2006___ Date Date

Return completed form to: Attention: Helen Rauer Office of the Chief Court Administrator First Judicial Circuit P.O. Box 3498 Honolulu, Hawai`i 96811-3498

4

IN THE FAMILY COURT OF THE FIRST CIRCUIT STATE OF HAWAI`I

In the Matter of the Guardianship

) ) of ) ) «FirstName» «MiddleName» «LastName», ) ) ) An Incapacitated Person. ) __________________________________)

«CaseNumber» NOTICE OF FILING OF ANNUAL REPORT «AnnualReportPeriod»;

NOTICE OF FILING OF ANNUAL REPORT

STATE OF HAWAI`I TO:

Notice is hereby given that

has submitted the

attached Annual Report to the Family Court of the First Circuit and that copies will be forwarded to the above-named person(s) no later than fourteen (14) days after the date noted below. DATED: Honolulu, Hawai`i ____________________________________

________________________________