Fill and Sign the Budget Disbursements and Form

PT/Appr. Budget/Disbrsmnt/Ini.Pers. Care Plan (PTAPR) - Page 1 of 3WPF GDN 05.0100 (01/2009) RCW 11.92.040Superior Court of WashingtonCounty ofIn the Guardianship of:_______________________________, Incapacitated PersonNo. Petition For Approval Of Budget, Disbursements And Initial Personal Care Plan(PTAPR) I. Basis 1.1 Appointment of Guardian (Name) __________________________ was appointed Guardian of the Person and/or Estate of the Incapacitated Person and immediately thereafter qualified by filing an oath and obtaining bond in the amount ordered by this court. Letters of Guardianship were issued on (date) __________________________.1.2InventoryAn inventory of the assets of the Incapacitated Person as of the date of appointment is filed separately.1.3 Initial Personal Care PlanThe Incapacitated Person resides at (name of facility, if applicable, and address) _________________________________________________________________________. An Initial Personal Care Plan describing the Incapacitated Person’s condition, living circumstances and the actions of the Guardian taken to benefit the Incapacitated Person is filed separately. The Guardian asks that the court review this Initial Personal Care Plan. PT/Appr. Budget/Disbrsmnt/Ini.Pers. Care Plan (PTAPR) - Page 2 of 3WPF GDN 05.0100 (01/2009) RCW 11.92.0401.4 Income and Current Expenses The Incapacitated Person’s income is as follows:Interests/Dividends$Social Security$Pension (Including Veteran’s or Otherwise)$Other$ Total Monthly Income $1.5Authority of Guardian to Receive Income and Pay ExpensesThe Guardian should have authority to receive the Incapacitated Person’s income to be applied against the Incapacitated Person’s expenses. 1.6Proposed BudgetThe Guardian requests approval of the following budget for the twelve-month period following the appointment (fill in only those that apply):Room and Board$Medical$Rent/Mortgage$Personal and Incidental Expenses$Food and Household Expenses$Utilities$Guardian Fees$Attorney Fees and Costs$Other$Total Proposed Monthly Expenditures$1.7Medical and Dental Expenses The Guardian should be permitted to incur and pay any reasonable and necessary medical and dental expenses, which the Guardian determines to be in the best interest of the Incapacitated Person.1.8Income Tax Payment/Accounting Fees The Guardian may be required to file federal income tax returns and pay income tax due on Guardianship income. The Guardian should be permitted to pay fees for accounting services required in connection with the preparation of income tax returns. PT/Appr. Budget/Disbrsmnt/Ini.Pers. Care Plan (PTAPR) - Page 3 of 3WPF GDN 05.0100 (01/2009) RCW 11.92.040 II. Relief Requested The Guardian requests that the court enter an Order as follows:2.1[ ]Approval of BudgetApproving this proposed budget of the Guardian.2.2 [ ]Income and Expenses Authorizing the Guardian to continue receiving the Incapacitated Person’s income to be applied against the expenses set forth above.2.3 [ ]Reasonable Medical and Dental ExpensesAuthorizing payment by the Guardian of any reasonable and necessary medical and dental expenses which the Guardian determines to be in the best interest of the Incapacitated Person.2.4 [ ]Initial Personal Care Plan and InventoryApproving the Initial Personal Care Plan and Inventory separately submitted by the Guardian.2.5[ ]Miscellaneous ExpensesAuthorizing payment by the Guardian of miscellaneous expenses in an amount not to exceed $50.00 per month without further order of the court for court fees and other miscellaneous expenses which the Guardian may incur during the course of the administration of this Guardianship.2.6[ ]Other Order For any other Order that the court deems appropriate. I certify (or declare) under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct.Signed at (city) ________________________, (state) __________ on (date) ______________________._________________________________ ___________________________ ________________Signature of Guardian/AttorneyPrint Name of Guardian/Attorney [ ]WSBA [ ]CPG#___________________________________ ____________________________________________AddressCity, State, Zip Code________________________________________________________________________________*Telephone/Fax NumberEmail Address*If you do not want your personal phone number on this public form, you may list your telephone number on a separate form which may be available to parties and the court, as well as its staff and volunteers, but will not be made available to the public. Use Form WPF GDN 03.0100, Guardianship Confidential Information form (Telephone Numbers), for this purpose.