2016 Fifteenth Judicial Circuit Professional Guardian Registry for the Wheel INSTRUCTIONS Dear Professional Guardian, Thank you for your interest in applying for the Fifteenth Judicial Circuit Court Professional Guardian Registry for the Wheel. Please be aware that there are two phases to the application process:   Review and approval of the application by the Chief Judge or his designee(s); and Being placed on the professional guardian wheel which is maintained and administered by the Clerk’s Office. Please read all information below. A. APPLICATION INFORMATION 1. Professional Guardians seeking court appointed cases in the Fifteenth Judicial Circuit shall submit a completed application and submit any other information requested by Court Administration. NEW GUARDIANS: New professional guardians must first be registered by the Office of Public and Professional Guardians and complete the attached application. 2. All applicants must be registered by the Office of Public and Professional Guardians, and must submit a copy of their registration along with their application. Failure to attach the required information will make the application ineligible for consideration. 3. By submitting an application, the Professional Guardian attests that he/she has read and is familiar with the Policies and Procedures for Appointment of Professional Guardian found in Administrative Order 6.310-9/16 which can be found on the Circuit’s website at www.15thcircuit.com as well as Chapter 744 Florida Statutes. 4. Processing of the application may take up to 8 weeks. a. The application is reviewed and approved by the Chief Judge or designee(s). At the Chief Judge's discretion, a committee may be formed to review the applications. b. Once the application is reviewed and approved by the Chief Judge or designee, the professional guardian will receive a letter from Court Administration which will either inform the applicant that they have been approved to be on the Fifteenth Judicial Circuit Professional Guardian Registry ("Registry") or will list the deficiencies which must be remedied in order for the application review process to continue. Failure to remedy the deficiencies will result in the application being rejected. 1 of 9 B. APPOINTMENT INFORMATION 1. Applicants must understand and agree that unless there is full agreement among family members for a specific professional guardian, case appointments will be made by the Clerk's Office. Attorneys who are on the Registry will be placed on the general registry and/or specialty wheels based on their specialized skills. Through a computerized program, the Clerk's Office will choose the next attorney on the applicable wheel. Placement on a wheel does not guarantee appointments. 2. Court Administration makes no representations as to the number of cases in which the professional guardian may be appointed. The number of cases and the number of professional guardians included on the Circuit’s Registry will impact the frequency of appointments. 3. Failure by the professional guardian to accept appointments for any reason (e.g. rejection of the case, unavailability etc.) may result in the professional guardian being removed from the court appointed Registry. Once removed from the Registry, the professional guardian must file a new application to be reinstated. The professional guardian shall put in writing the reasons for declining an appointment and submit it to the Court within five (5) business days. 4. Applicants must understand and agree that they may be appointed to a case at any courthouse location throughout Palm Beach County as to ensure continuity of service to the ward who may relocate from their current residence. 5. Applicants must understand and agree that they may be subject to further agreements and requirements imposed by the Chief Judge in order to be maintained, considered or placed on the wheel. C. REQUIRED NOTIFICATION INFORMATION 1. Any professional guardian, whose registration from the Office of Public and Professional Guardians is, suspended, terminated, etc., or is otherwise the subject of discipline must notify Court Administration within seven (7) days of the discipline, suspension, or termination. In addition, any professional guardian who is under administrative, bar, or criminal investigation, if known, has pending criminal charges against him/her, has a pending civil lawsuit related to a guardianship matter, or has a claim made against their bond, must notify Court Administration within seven (7) days. Failure to provide such information may result in his/her immediate removal from the Registry. 2. The Applicant understands and agrees that Court Administration, or the Chief Judge or designee(s), reserves the right to remove any Applicant from the Registry upon discovering any information about the Applicant which was not previously disclosed, or has changed since the application was submitted. Applicants may be removed for any reasons which may disqualify Applicants from appointment, including but not limited to the factors set forth in §744.474. The Chief Judge reserves the right to remove the Applicant from the Registry at will. D. CONTACT INFORMATION 1. Professional Guardians must maintain a valid email address and must provide notice to Court Administration and to the Clerk upon any change in his/her address, email address and telephone number. 2 of 9 2. All professional guardians on the court appointed wheel agree to accept correspondence through email, and agree to register for e-service of court documents. E. SUBMISSION OF APPLICATION The Application is to be delivered by email only to: CAD-ProfessionalGuardians@pbcgov.org 3 of 9 FIFTEENTH JUDICIAL CIRCUIT’S APPLICATION TO SERVE ON PROFESSIONAL GUARDIAN WHEEL Please complete the following application to serve on the professional guardian wheel. This application must be completed in its entirety if you wish to be considered for appointment. A resume must be included with this application. Applicant Information: Name: Name of Organization (if applicable) Organization’s IRS legal status and type of Florida Corporation: _______________________________________ Business Address: (City) Business#: (State) (Zip Code) Cell#: Fax#: Email Address: ______________________________________________________________________________ What languages do you speak, read and write fluently? __________________________________________________________________ Which, if any, specialty wheels would you like to be on? Specialty wheels will be utilized if a ward has a particular issue that requires a guardian with specialized experience/education. By checking a specialty area below you are affirming you have such specialized experience/education. _____ Dementia, Alzheimer’s disease, Elderly Care _____ Developmental Disabilities _____ Mental Illness and Substance Abuse _____ Trauma Victims _____ Financial Management, Business Experience _____ Spanish Speaking, Writing and Reading Wards _____ Creole Speaking, Writing and Reading Wards Please check off if you have completed the following requirements: (NOTE: Application cannot be considered until the following requirements have been fulfilled.) Please initial each line. __ I am currently registered as a professional guardian by Office of Public and Professional Guardians and have served as a professional guardian for ___________years. Date of Certification: ________________ __ I will notify the Chief Judge of the Fifteenth Judicial Circuit if I become non-compliant with Florida’s guardianship registration requirements immediately in writing. I will explain why/how it happened and describe any effort(s) to restore compliance. __ I will keep all responses on this Application current and complete (including but not limited to change of address) on a timely basis. An update to the Application is considered timely if made as soon as possible but not later than 30 days after any occurrence that changes or renders incomplete any answer to any question on the Application. __ I have familiarized myself with Administrative Order No. 6.301-7/16 and all other Fifteenth Circuit Court Administrative Orders concerning Guardianship and agree to provide services in accordance with those Administrative Orders. __ I will notify and petition the Court in advance of any changes to my fee schedule. 4 of 9 __ I agree to provide 30 days written notice if I wish to be removed from the wheel(s). I agree that once removed, I must file a new application to be reinstated. __ I understand and agree that unless there is full agreement among family members for a specific professional guardian, if I am the petitioner in a case to determine incapacity I cannot be appointed as the professional guardian. I also understand and agree that if I work for an organization where another member of the organization is the petitioner that I cannot be appointed as the professional guardian. __ I agree to abide by the following billing and fee procedures: I acknowledge that it is customary in Palm Beach County for professional guardians with 0-5 years experience to bill an hourly rate up to $75 an hour for guardian services and for professional guardians with 5+ years of experience to bill an hourly rate up to $95 an hour for guardian services. I also acknowledge that final discretion on fees will be determined by the Court after reviewing actual services rendered. I also agree that I will not take a retainer or advancement of fees from a ward. __ I agree that I will have a court approved budget and that I will open a restricted depository for each ward for which I serve as a professional guardian including wards I currently serve and for any future wards. I also agree that I will submit my petitions for fees no more frequently than monthly and no longer than quarterly. I agree to only bill for actual time spent for the benefit of the ward and not using any block billing. __ I agree to accept at least one (1) new pro bono case during each fiscal year I am a professional guardian on the Fifteenth Circuit’s Registry. While not prohibited, I will not be required to have more than one pro bono case at any one time. All applicants please complete the following: 1. List names and types of all degrees, certifications, and licenses the Applicant currently holds: ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ 2. Has your Guardianship registration ever been suspended, surrendered or revoked? Yes________ No________ If yes, please explain: ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ 3. Describe the Applicant’s areas of practice or specialty relative to court referred clients (i.e., elderly care (dementia, Alzheimer’s disease, developmental disabilities, mental health/illness, substance abuse, trauma victims, financial management, etc.) (attach additional sheet(s) if more space is needed): ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ 4. List all the judicial circuits in which the Applicant provides guardianship services and length of time providing such services: ___________________________________________________________________________________________ ___________________________________________________________________________________________ 5 of 9 ___________________________________________________________________________________________ ___________________________________________________________________________________________ 5. Has a judicial circuit ever removed you for a reason listed in FS 744.474? Yes________ No_______ If so, please state the circuit, date terminated, and the reason for the termination: ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ 6. List all prior employers for the past five years, reasons for leaving employment, and include a reference contact: ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ 7. Describe any other professional experience or specific training the Applicant has that is pertinent to your ability to provide services as a professional guardian: ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ 8. How many clients did you serve in the past two years (list each year separately) and how many of such clients were ordered from the Court? ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ 9. Has the Applicant given specific training, presentations, or authored articles that demonstrate expertise in guardianship? If so, specify: ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ 10. Describe any training and/or experience the Applicant has pertaining to advocacy for health and financial services: ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ 11. Describe your technological expertise and the systems you use for complying with guardianship accounting requirements, tracking medical providers, preparing data for annual reports, etc. For example, if guardianship accountings were required to be submitted electronically by professional guardians into a broad based, web application that supports many different platforms, could your technological expertise and systems be adapted to meet such a requirement? ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ 6 of 9 12. Please provide the fee schedule used by the Applicant for professional guardian work, including: what is your fee schedule for billing for travel time vs. mileage? What is your fee schedule for billing for time involved with courtapproval of guardian fees and final guardian fees? What is your fee schedule for billing for administrative functions such as receiving mail, filing, sorting, copying, etc.? ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ 13. What guidelines does the Applicant follow in determining his/her fee schedule? ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ 14. Has the Applicant ever filed for bankruptcy or been subject to foreclosure or foreclosure actions or defaults on student loans? If yes, please explain: ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ 15. Does the Applicant agree to provide full and complete financial disclosure upon request? Yes_____________ No_____________ 16. Does the Applicant have professional and general liability insurance or the ability to obtain such insurance if required? Yes_____________ No_____________ If yes, please state limits of liability_____________________ 17. Has the Applicant ever been arrested for a crime? Yes_____________ No_____________ If yes, please explain: ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ 18. Has the Applicant ever been found guilty or adjudicated guilty of a crime in this or any other state or country? (Check yes, even if the disposition of guilt or judgment was withheld or if the criminal record was sealed or expunged. Include traffic crimes such as DUI, reckless driving, or driving without privileges, but not traffic infractions such as excessive speed). Yes_____________ No_____________ If yes, please explain: ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ 19. Does the Applicant have criminal charges or warrants pending or is on probation or parole in this state or any other state or country? Yes_____________ No_____________ If yes, please explain: ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ 7 of 9 20. Has the Applicant ever had any sort of petition for injunction filed against them in this or any other state or country? Yes_____________ No_____________ If yes, please explain: ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ 21. Has the Applicant been a party to, or is presently a party in a civil litigation matter, excluding paternity and dissolution of marriage matters? Yes_____________ No_____________ If yes, please explain: ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ 22. Does the Applicant have any relationship through blood, marriage, financial or occupational to any person or service providers in the guardianship arena or associated with any guardianship proceedings in Palm Beach County or elsewhere in Florida? Yes_____________ No_____________ If yes, please explain: ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ APPLICANT’S ORGANIZATIONAL STRUCTURE List the names of Applicant’s corporate officers and all persons with ownership interest in Applicant’s organizational structure (attach additional sheet if more space is needed): ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ List the names and types of all degrees, certifications, and licenses for each individual who will work as a guardian pr provide a service to the ward (attach additional sheet if more space is needed): ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ SUPPORTING DOCUMENTATION CHECKLIST Please attach the following documents and any other relevant documentation to this application. _____ Resume or curriculum vitae, reflecting a minimum of two (2) years post licensure/certification practice relative to guardianship service programs _____ Fee Schedule _____ Attestation and Authorization to Investigate and Release of Information _____ Documentation of criminal history, if any _____ Documentation of civil litigation history, if any 8 of 9 ATTESTATION AND AUTHORIZATION TO INVESTIGATE AND RELEASE OF INFORMATION I, ____________________________, whose address is _____________________________________________, authorize Florida’s Fifteenth Judicial Circuit or its designee to conduct a criminal history and background investigation on me/the Applicant. I authorize the release of information and/or documents to this Circuit from any city, county, state, and/or federal law enforcement agencies; any school, college or university; and any other entity. I release this Circuit and its designee from any and all liability and expense associated with this investigation or release of information and/or documents. I also swear/affirm that the information supplied on this Application and all documents provided are correct, that to the best of my knowledge that the Applicant is qualified to provide services as a Professional Guardian, and that I will notify in writing the Fifteenth Judicial Circuit of Florida, or designee(s) for this judicial circuit of the following within thirty (30) days of any such event: (a) address change; (b) legal name change; (c) change in fees; (d) any criminal conviction; or any change in the status of any requisite professional license or certification which is currently held. I understand that any omissions, falsifications, misstatements, or misrepresentations of the information provided in this Application, or information required to be subsequently provided, may be grounds for disqualification or dismissal from the Fifteenth Judicial Circuit’s Professional Guardian Wheel. Printed Name_____________________________________________Date______________________________________ Signature__________________________________________________________________________________________ STATE OF FLORIDA COUNTY OF PALM BEACH Sworn to or affirmed and signed before me by ____________________________________this _______day of _______20____. ____________________________________________ Notary Public _____________________________________________ (Print, type, or stamp name of Notary) _____Personally known _____Produced the following type of identification:________________________________________________________ 9 of 9