NOTE: GRANDPARENTS OF A MINOR ARE NOT EXCLUDED, AND THEREFORE ARE REQUIRED TO COMPLY WITH THE REQUIREMENTS OF THE STATUTE.

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1 REQUIRED BACKGROUND SCREENINGS FOR ALL GUARDIANSHIP AND CONSERVATORSHIP CASES - INSTRUCTIONS Section , RSMo The requirements set forth herein SHALL NOT APPLY TO A PETITIONER who is: 1. The Public administrator; or, 2. The ward s, incapacitated person s, or disabled person s: spouse, parents, children who have reached eighteen years of age, or siblings who have reached eighteen years of age. NOTE: GRANDPARENTS OF A MINOR ARE NOT EXCLUDED, AND THEREFORE ARE REQUIRED TO COMPLY WITH THE REQUIREMENTS OF THE STATUTE. IF YOU ARE NOT EXCEPTED FROM THE REQUIREMENTS OF THE BACKGROUND SCREENING, CONTINUE READING. Section , RSMo requires that EACH PETITIONER submit, at their own expense, to a background screening. EACH PETITIONER seeking appointment as EITHER A GUARDIAN OR A CONSERVATOR must submit to a background screening that shall include: the disqualification lists of the departments of o mental health, o social services, and o health and senior services; the abuse and neglect registries for adults and children; a Missouri criminal record review; and, the sexual offender registry Section , RSMo also requires EACH PETITIONER seeking appointment as a conservator to ALSO submit, at their own expense, the following: a credit history investigation EACH PETITIONER shall file the results of the reports with the court at least ten days prior to the hearing date unless the time period is waived or modified by the court for good cause shown BY AN AFFIDAVIT FILED SIMULTANEOUSLY WITH THE PETITION. This waiver of the 10 day time period is generally allowed only in emergency situations requiring an expedited hearing. Section states that: An order appointing a guardian or conservator shall not be signed by the judge until such reports have been filed with the court and reviewed by the judge, who shall consider the reports in determining whether to appoint a guardian or conservator. 1 FCSR Background Screening Information Rev

2 MISSOURI FAMILY CARE SAFETY REGISTRY (FCSR) The following information about the FCSR is courtesy of Missouri Department of Health and Senior Services (DHSS). It is current as of DHSS created an electronic interface with the data systems maintained by the Missouri State Highway Patrol, Department of Social Services, Department of Mental Health, and various units within the Department of Health and Senior Services. It is called the Family Care Safety Registry. THE FAMILY CARE SAFETY REGISTRY (FCSR) WEB SITE IS LOCATED AT: How to Register with FCSR: A person may register with the FCSR two ways: 1. Online Registration with the FCSR is quick and easy. All an individual needs is Internet access, their Social Security number and address, and a valid credit or debit card for payment of the fee. The fee to register online is $13.00 plus a $1.25 processing fee. 2. Mail a Registration Form, a photocopy of the Social Security card, and a check or money order for the $13.00 registration fee (if applicable) to the Missouri Department of Health and Senior Services, Fee Receipts Unit, P.O. Box 570, Jefferson City, MO, Mailed forms are processed in the order received. Background Screenings can be obtained in three ways: 1. Approved FCSR Internet Users may request screenings via the Internet, by clicking on Internet Background Screening Login. 2. The FCSR maintains a toll-free call center to request background screenings. 3. The Background Screening Request form allows an inquiry. Forms are processed in the order received. 2 FCSR Background Screening Information Rev

3 Revised 09/2018 CHECKLIST Fees of $ due Add all parties: applicant and respondent Need Respondent & Petitioner SS# and date of birth Need list of prospective witnesses (including doctor) Need financial statement Need doctor s interrogatories Need signed Guardianship/Conservatorship information memo (unless requesting Public Administrator) Need certified copies of the documents required in Section (4) RSMo, as amended in 2018, for the proposed guardian/conservator unless said person is the respondent s parent, spouse, adult child, adult sibling or the Public Administrator. If co-guardians/conservators are requested, need an affidavit from petitioners explaining in detail why a co-guardian/conservator are in the best interest of the Respondent. Conservatorship Only: May need corporate surety bond in the amount of personal property rounded up to the next thousand. E-file bond and mail/deliver original. Bond is to include Acknowledgement of Principal, Acknowledgement of Surety and Power of Attorney. The Petition should contain the following: Need address of domicile Need legal mailing & residence address Need 3 most recent previous addresses (mailing & residence) for the 3 years prior to the filing of the petition Estimated value of real & personal property Need location & value of any real property owned by respondent outside of MO If respondent has no legal address or residence in MO, need county where the property of respondent is located Need name & address of any agent appointed by respondent in any durable power of attorney Need name & address of any presently acting trustee(s) of any trust where respondent is a grantor, qualified beneficiary, or is/was the trustee or co-trustee and the purpose of the power of attorney or trust Need name & address of any guardian of respondent or conservator of the estate of respondent appointed in MO or another state Relationship of petitioner to respondent Names of individuals for whom petitioner is already guardian or conservator Name of person who has custody of respondent Names & addresses of parents of respondent and whether living or deceased Name & addresses of any spouse and/or living children of the respondent (and age of children) Name & addresses & relationship of respondent s closest known relatives Name & addresses of any adults living with respondent Need specific physical or mental condition that makes respondent incapacitated and/or disabled If any of the required information is unknown, need the efforts made to obtain the

4 information Signed & dated by petitioner under oath and affirmation or notarized Signed by attorney

5 MISSOURI CIRCUIT COURT, TWENTY-SECOND JUDICIAL CIRCUIT PROBATE DIVISION, CITY OF ST. LOUIS IN THE MATTER OF: Respondent No. PETITION FOR APPOINTMENT OF GUARDIAN AND CONSERVATOR* Come(s) now, of lawful age, the petitioner herein, and being first duly sworn, states: That the above named respondent, a male person, who is years of age, and whose domicile address is _ and whose legal mailing address is _ and whose residence address is is. incapacitated/disabled/incapacitated and disabled The three most recent previous addresses (mailing and residence) for the three years prior to the filing of the petition are: The respondent owns property having an estimated value of: Real Property $ Personal Property $ The location and value of any real property owned by the respondent outside of Missouri: Respondent s finances are detailed on Exhibit B attached hereto. If the respondent has no legal address or residence in Missouri, the county where the property of the respondent is located:. Name and address of any agent(s) appointed by the respondent in any durable power of attorney:. Name and address of any presently acting trustee(s) of any trust where the respondent is a grantor, qualified beneficiary, or is or was the trustee or co-trustee and the purpose of the power of attorney or trust:. Name and address of any guardian of the person or conservator of the estate of the respondent appointed in Missouri or another state:. Petitioner is the of the respondent and requests that letters of Relationship

6 Guardianship be granted to conservator for any wards or protectees (except as follows):, whose address is, and who is not now guardian or Name That respondent is in the custody of Name Street Address City State Zip Code Names and addresses of the parents of the respondent and whether they are living or deceased. NAME ADDRESS (include zip code) Mother (indicate if deceased) Father (indicate if deceased) Name and addresses of any spouse and any living children of the respondent. NAME AGE ADDRESS (include zip code) Spouse (indicate if deceased) Son/Daughter Son/Daughter Son/Daughter Son/Daughter Name and addresses of the respondent s closest known relatives. NAME AND RELATIONSHIP ADDRESS (include zip code)

7 NAME AND RELATIONSHIP ADDRESS (include zip code) NOTE: If the respondent has no spouse, mother, father or children, the names of the nearest known relatives who are over the age of eighteen must be listed above. The name and addresses of any adults living with the respondent. NAME ADDRESS (including zip code) The reasons why the appointment of a guardian is sought are: [For Guardianship of the Person Only per (9) R.S.Mo.] The specific physical or mental conditions which prevent the respondent from being able to receive and evaluate information or to communicate decisions to such an extent that he/she lacks capacity to meet essential requirements for food, clothing, shelter, safety, or other care such that serious physical injury illness or disease is likely to occur are: [For Conservatorship of Estate Only per (1) R.S.Mo.] The physical or mental conditions which prevent the respondent from being able to receive and evaluate information or to communicate decisions to such an extent that he/she lacks ability to manage his/her financial resources are: _

8 If any of the previous information is unknown, the efforts made to obtain the information: The names and addresses of the witnesses who may be called to testify in support of the petition are set forth on Exhibit A attached hereto. WHEREFORE, petitioner prays that a hearing and inquiry be held and the court appoint Guardian of the person and as Conservator of the estate for the respondent, on giving the required bond, and for such other and further orders as the court deems right and proper in the premises. The foregoing is made this day of,, under oath or affirmation and its representations are true and correct to the best of petitioner s knowledge and belief, subject to the penalties of making a false affidavit or declaration. Signature of Attorney for Petitioner Signature of Petitioner Attorney s Name (Typed) Petitioner s Name (Typed) Street Address Street Address City State Zip Code City State Zip Code Telephone Number With Area Code Telephone Number With Area Code Address Missouri Bar Number Publish Notice of Letters in: St. Louis City Monitor St. Louis Daily Record Other

9 EXHIBIT A LIST OF PROSPECTIVE WITNESSES Following are the names and addresses of witnesses who may be called to testify in support of the foregoing Petition for the Appointment of a Guardian and/or Conservator. NAME ADDRESS

10 EXHIBIT B FINANCIAL STATEMENT PERSONAL PROPERTY: Checking Accounts Saving Accounts Stocks and Bonds $ Vehicles Other TOTAL PERSONAL PROPERTY $

11 FINANCIAL STATEMENT MONTHLY INCOME: Social Security Payee $ Veterans Administration Benefits $ Pension Source $ Interest $ Other Source $ TOTAL MONTHLY INCOME: $ REAL PROPERTY: (List Location and Value) $ $ $ $

12 GUARDIAN/CONSERVATOR INFORMATION MEMORANDUM To help you perform your duties properly, described below are the general duties and obligations of a guardian and conservator. Follow the advice of your attorney. Talk to your attorney before taking any action. If you have been appointed guardian, you are responsible for the ward's person. If you have been appointed conservator, you are responsible for the ward's property. If you have been appointed both guardian and conservator, you are responsible for the ward's person and property. Your authority as guardian and/or conservator may be limited by the court order appointing you. You should consult with your attorney as to the extent of your authority. As guardian, you have the duty to take charge of the person of the ward and to provide for the ward's care, treatment, habilitation, education, support and maintenance. Your powers and duties include: a) assuring that the ward lives in the best and least restrictive environment which is reasonably available; b) assuring that the ward receives medical care and other services that are needed; c) promoting and protecting the care, comfort, safety, health and welfare of the ward; and d) providing required consents on behalf of the ward. If you are the guardian of an adult ward who the Court has determined to be incapacitated or disabled, you will be required to file with the Probate Court a personal status report each year updating the information regarding the care, welfare and placement of your ward. The Court will you a Notice to File Annual Status Report and a blank copy of the Report on the anniversary of your appointment as Guardian. The completed Annual Status Report must be filed with the Court within thirty (30) days of the date that you receive the Notice. You may file the completed Report by , postal mail or electronic filing through Missouri Casenet. If you do not have an address, the Notice to File Annual Report and the copy of the Report will be sent to your last known home address. It is your responsibility to maintain a valid address and/or home address on file with the Probate Court. Failure to file the Report on time may result in your removal as Guardian. As conservator, you must take possession of your ward's property to the extent authorized by the Court. Missouri State law requires that the property, income and bank accounts of the ward be kept separate from your own funds. If you are the conservator for more than one person you must maintain a separate account for each ward, even if they are your own children. You must invest the ward's funds according to law and you are personally liable for any imprudent or unauthorized investments. You may only spend the ward's funds for purposes authorized by state statute or Court order. You may apply for an order of continuing support and maintenance authorizing you to spend a budgeted sum each month for the ward. You will be required to file an annual accounting (called a settlement) showing in detail all receipts and expenditures occurring during the preceding year. Each entry must be explained and each 11 expenditure must be authorized by statute or Court order. You may not sell, trade, lease, mortgage, transfer or discard your ward's property without Court approval, even though the ward is your child or other relative.

13 In the event the ward dies or you or the ward move from one address to another, you have a duty to notify the Court in writing of such death or new address as soon as possible. If the ward does not live with you, Missouri state law requires that you visit the ward at least once a year. If you fail to perform any of your duties as guardian and/or conservator, you can be removed as guardian and/or conservator and be personally liable for any loss or damage sustained by the ward by reason of your failure. You are under a duty, at all times, to act in the best interests of your ward and to avoid conflicts of interest which impair your ability to act on your ward's behalf I (we) hereby acknowledge that I (we) have read and do understand the above information. Date (Print name) (Signature) (Print name) (Signature) 12

14 MISSOURI CIRCUIT COURT, TWENTY-SECOND JUDICIAL CIRCUIT PROBATE DIVISION, CITYOF ST. LOUIS In the Matter of Respondent No. AFFIDAVIT IN SUPPORT OF PETITION FOR APPOINTMENT OF GUARDIAN-CONSERVATOR following: of lawful age, being duly sworn upon his/her oath, states the I am a physician licensed to practice medicine in the State of Missouri. My license to practice medicine is not subject to any restrictions imposed by the Board of Healing Arts of the State of Missouri; I am aware that the information provided herein will be used solely in the course of a judicial proceeding and therefore constitutes an exception to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) under the provisions of 45CFR I have been the attending physician for since, and last examined him/her on. My diagnosis (es) for is/are: Primary Diagnosis: Secondary Diagnosis: My diagnosis(es) is/are based upon the following, tests, observations or other findings:

15 _ In my opinion, based upon a reasonable degree of medical certainty, I (consider-- do not consider) to be unable by reason of said physical or mental condition to receive and evaluate information or to communicate decisions to such an extent that he/she lacks ability to meet his/her essential requirements for food, clothing, shelter, safety, or medical care such that serious physical injury, illness, or disease is likely to occur. In my opinion, based upon a reasonable degree of medical certainty, I (consider--do not consider) to be unable by reason of said physical or mental condition to receive and evaluate information or to communicate decisions to such an extent that he/she lacks ability to manage his/her financial affairs. Date: AFFIANT KNOW ALL MEN BY THESE PRESENTS, that I, the undersigned Notary Public, hereby certify that the above-named deponent was first duly sworn by me to make true answers to the foregoing interrogatories and that this affidavit was subscribed to by the deponent in my presence. NOTARY PUBLIC My Commission Expires: