Fill and Sign the Declaration Assets Form

Superior Court of Washington Sealed County of In the Guardianship of: _______________________________, Incapacitated Person No. Declaration of Guardian: Assets Held in Financial Institutions (DCLR) Sealed Financial Source Document [ ] Clerk’s Action Required File this declaration under a completed form WPF GDN 03.0200, Sealed Confidential Guardianship Document Cover Sheet. The Guardian of the Estate of the person named above makes the following affidavit pursuant to the provisions of RCW 11.92.096: 1. Cause Number: ______________________________. 2. The Guardian was appointed by order entered on _____________________________________. 3. The Incapacitated Person’s name is: _______________________________________________. 4. The number of each account holding the assets of Incapacitated Person and the number of the Safety Deposit Box, if any, in the Incapacitated Person’s name are: Account Number: ______________________________ Account Number: ______________________________ Safety Deposit Box Number: ______________________________ 5. Address of client or depositor. The incapacitated client of depositor has the following address: ____________________________________________________________________________. 6. Name and Address of Guardian to be provided assets or access to assets: _________________ ____________________________________________________________________________. Decl. Gdn Assets Held in Financial Inst. (DCLR) - Page 1 of 3 WPF GDN 04.0400 (01/2009) RCW 11.92.096 7. The description of and the value of the assets, or, where the value cannot be readily ascertained, a reasonable estimate thereof is in the attachment or as follows: _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________; and the Guardian receives delivery or control of each asset solely in the capacity of Guardian. 8. The date the Guardian assumed control over the assets was: __________________________. 9. A true and correct copy of the Letters of Guardianship duly issued by a Court to the Guardian is attached to this declaration. 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 Print Name of Guardian [ ]WSBA [ ]CPG# *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 . Important information for the person completing this form : Delivery of Assets to Guardian All financial institutions as defined in RCW 30.22.040 (12), all insurance companies holding a certificate of authority under chapter 48.05 RCW, or any agent who constitutes a salesperson or broker dealer of securities under the definitions of RCW 21.20.005 (hereafter individually and collectively referenced as “institution”) shall provide the Guardian access and control over the asset(s) described in (a)(vii) of RCW 11.92.096, including but not limited to delivery of the asset to the Guardian, upon receipt of the affidavit as outlined therein. Instructions Per RCW 11.92.096 : Envelope, with postage prepaid, addressed to the Clerk of the Court issuing letters of Guardianship . The affidavit shall be sent in the envelope by the institution to the Clerk of the Court together with a statement signed by an agent of the institution that the description of the asset set forth in the affidavit appears to be accurate, and confirming in the case of cash assets, the value of the asset [RCW 11.92.096(b)]. Safety Deposit Box . Any Guardian provided with access to a safety deposit box pursuant to subsection (1) of section RCW 11.92.096 shall make an inventory of the contents of the box and attach this inventory to this affidavit before this affidavit is sent to the Clerk of the Court and before the contents of the box are released to the Guardian. Any inventory shall be prepared in Decl. Gdn Assets Held in Financial Inst. (DCLR) - Page 2 of 3 WPF GDN 04.0400 (01/2009) RCW 11.92.096 the presence of an employee of the institution and the statement of the institution required under subsection (1) of section RCW 11.92.096 shall include a statement executed by the employee that the inventory appears to be accurate. The institution may require payment by the Guardian of any fees or charges then due in connection with the asset or account and of a reasonable fee for witnessing preparation of the inventory and preparing the statement required by this subsection or subsection RCW 11.92.096 of this section. Any institution to which an affidavit complying with subsection (1) of RCW 11.92.096 is submitted and rely on the affidavit without inquiry and shall not be subject to any liability of any nature whatsoever to any person whatsoever, including but not limited to the institution’s client or depositor or any other person with an ownership or other interest in or right to the asset, for the reliance or for providing the Guardian access and control over the asset, including but not limited to delivery of the asset to the Guardian. Decl. Gdn Assets Held in Financial Inst. (DCLR) - Page 3 of 3 WPF GDN 04.0400 (01/2009) RCW 11.92.096