R.I. Gen. Laws § 33-15-47
The following forms shall be used for the purposes of this chapter:
STATE OF RHODE ISLAND PROBATE COURT OF THE COUNTY OF _______________ ______________________
No. _________________
ESTATE OF ____________________________
PERSONAL ESTATE ESTIMATED AT $________ CITY/TOWN OF
________________
20 ____________
PETITION FOR LIMITED GUARDIANSHIP OR GUARDIANSHIP
______________________hereby petitions the Probate Court of the city/town of ______________ Petitioner to appoint a limited guardian/guardian for ______________ who currently resides at ________________________, in the city/town of __________________, and whose date of birth Address is __________________.
Based upon an assessment conducted by ________________ on ______________, which Date functional assessment reflects the current level of functioning of ______________, it has been Respondent determined that _____________ lacks decision-making ability in one or more of the following Respondent areas as indicated:
____ health care
____ financial matters
____ residence
____ association
____ other Regarding each area indicated, please describe the specific assistance needed:
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
____ Supported Decision-Making, see chapter 66.13 of title 42
____ 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:
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 guardianship 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:
___________________________________
Signature
___________________________________
Name
___________________________________
Address
__________________________________
Telephone Subscribed and sworn to before me this 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 a limited Petitioner 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.
__________________________
(DATE)
How do the above medications, if any, affect the individual's decision-making ability? Please explain:
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:
If you circled (C), (D), or (E), is situation treatable or reversible? If so, how?
Is individual willing to accept assistance? _____________________________________________
Is individual able to arrange for assistance? ____________________________________________
(CIRCLE ONE IN (A) AND IN ONE IN (B))
SUPPORT:
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:
(Circle one for each category. If you circle "limited" for any category, please explain.)
__________________________________
Signature
_______________________________
Name (Print or Type)
______________________________
Title
______________________________
Date
______________________________
Names and titles of others who assisted in Preparation of This Assessment.
STATE OF RHODE ISLAND PROBATE COURT OF THE COUNTY OF ___________________
Estate of ________________________ Docket No. ________________
ANNUAL STATUS REPORT
(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.
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:
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:
Respectfully submitted,
Date: ________________________ _______________________
(Name of Guardian Ad Litem)
R.I. Gen. Laws § 33-15-47