Fill and Sign the Illinois Short Guardian Form

APPOINTMENT OF SHORT-TERM GUARDIAN (755 ILCS 5/11A-3.2) IT IS IMPORTANT TO READ THE FOLLOWING INSTRUCTIONS: By properly completing this form, a guardian is appointing a short-term guardian of the disabled person for a cumulative total of up to 60 days during any 12 month period. A separate form shall be completed each time a short-term guardian takes over guardianship duties. The person or persons appointed as the short-term guardian shall sign the form, but need not do so at the same time as the guardian. 1. Guardian and Ward. I, ___________________________________ (insert name of appointing guardian), currently residing at _________________________________________________ (insert address of appointing guardian), am the guardian of the following disabled person: ___________________________________ (insert name of ward). 2. Short-term Guardian. I hereby appoint the following person as the short-term guardian for my ward: ___________________________________ (insert name and address of appointed person). 3. Effective date. This appointment becomes effective: (check one if you wish it to be applicable) (       ) On the date that I state in writing that I am no longer either willing or able to make and carry out day-to-day care decisions concerning my ward. (       ) On the date that a physician familiar with my condition certifies in writing that I am no longer willing or able to make and carry out day-to-day care decisions concerning my ward. (       ) On the date that I am admitted as an in-patient to a hospital or other health care institution. (       ) On the following date: ______________________________ (insert date). (       ) Other: ___________________________________ (insert other). [NOTE: If this item is not completed, the appointment is effective immediately upon the date the form is signed and dated below.] 4. Termination. This appointment shall terminate on: ______________________________ (enter a date corresponding to 60 days from the current date, less the number of days within the past 12 months that any short-term guardian has taken over guardianship duties), unless it terminates sooner as determined by the event or date I have indicated below: (check one if you wish it to be applicable) (       ) On the date that I state in writing that I am willing and able to make and carry out day-to-day care decisions concerning my ward. (       ) On the date that a physician familiar with my condition certifies in writing that I am willing and able to make and carry out day-to-day care decisions concerning my ward. (       ) On the date that I am discharged from the hospital or other health care institution where I was admitted as an in-patient, which established the effective date. (       ) On the date which is (state a number of days) days after the effective date. (       ) Other: ___________________________________ (insert other). [NOTE: If this item is not completed, the appointment will be until the 60th day within the past year during which time any short-term guardian of this ward had taken over guardianship duties from the guardian, beginning on the effective date.] 5. Date and signature of appointing guardian. This appointment is made this       (insert day) day of _____________ , 20       (insert month and year). Signed: __________________________________________________ (appointing guardian) 6. Witnesses. I saw the guardian sign this instrument or I saw the guardian direct someone to sign this instrument for the guardian. Then I signed this instrument as a witness in the presence of the guardian. I am not appointed in this instrument to act as the short-term guardian for the guardian's ward. (insert space for names, addresses, and signatures of 2 witnesses) Witness Signature: ________________________________________________________ Witness Name: Address: Witness Signature: ________________________________________________________ Witness Name: Address: 7. Acceptance of short-term guardian. I accept this appointment as short-term guardian on this       (insert day) day of ___________ , 20       (insert month and year). Signed: _____________________________________________________ (short term guardian)