CONFIDENTIAL GUARDIANSHIP QUESTIONNAIREThe following questionnaire is designed to expedite our efforts in representing you in the Article 81 Guardianship proceeding. Whether you are a new or an established client, we have found this questionnaire extremely helpful, and therefore ask you to complete it prior to your appointment. Those questions that do not apply to your family or financial situation may simply be left blank. Please feel free to attach additional pages where space is needed or to provide other information you feel is relevant. There is a space below to upload any of your documents securely. Our site uses SSL Encryption to protect your data. NOTE: IF YOU NEED TO COME BACK TO COMPLETE THE QUESTIONNAIRE, YOU CAN HIT “SAVE AND CONTINUE” AT THE BOTTOM OF THIS PAGE. YOU WILL RECEIVE AN EMAIL WITH A LINK TO CONTINUE/COMPLETE THE QUESTIONNAIRE.GUARDIANSHIP TERMINOLOGYGuardianship proceedings under New York State law require a basic understanding of certain terminology. The legal definition of the person for whom you are requesting a Guardian is the Alleged Incapacitated Person (AIP); the person who petitions the Court is the Petitioner; and the person whom the Court appoints is the Guardian of Personal Needs and/or Property Management. The Petitioner and the Guardian may be the same person, or different persons. One person may be the Guardian for both Personal Needs and Property Management, or there may be a separate Guardian for each. NOTE: IF YOU NEED TO COME BACK TO COMPLETE THE QUESTIONNAIRE, YOU CAN HIT "SAVE AND CONTINUE" AT THE BOTTOM OF THIS PAGE. YOU WILL RECEIVE AN EMAIL WITH A LINK TO CONTINUE/COMPLETE THE QUESTIONNAIRE.NOTE: IF YOU NEED TO COME BACK TO COMPLETE THE QUESTIONNAIRE, YOU CAN HIT “SAVE AND CONTINUE” AT THE BOTTOM OF THIS PAGE. YOU WILL RECEIVE AN EMAIL WITH A LINK TO CONTINUE/COMPLETE THE QUESTIONNAIRE.Today's Date:(Required) Name(Required) First Middle Last Address(Required) Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzechiaDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussian FederationRwandaSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTürkiyeTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Phone(Required)Phone (Other)Email(Required) Name of Alleged Incapacitated Person (AIP)Address of AIP Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzechiaDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussian FederationRwandaSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTürkiyeTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Relationship, if any, of AIP to youAIP's Date of Birth Will you propose a change of residence for the AIP? Yes No Do you believe the AIP will oppose appointment of a Guardian? Yes No If Yes, why do you believe a change of residence may be necessary?If you are not interested in being Guardian, provide the name(s) of proposed GuardiansNameAddressPhone NumberRelation Add RemovePlease use the + button to the right to add additional proposed Guardians. Would any of the proposed Guardians have difficulty obtaining a bond? Yes No A bond is a required insurance policy which may be required by the Court ensuring that the Guardian properly discharge their duties.Why do you believe the AIP needs a Guardian to make financial decisions?Why do you believe the AIP needs a Guardian for personal needs?Why do you believe proposed Guardian(s) is/are suitable?Are there any emergencies requiring immediate action? (Check all that apply) Health Hazards Fire Hazards Utility shut offs Foreclosure or eviction Lapse in health insurance Lapse in home/renter insurance Lapse in car insurance Functional Limitations of AIPPlease indicate whether the AIP can or cannot perform the following by themselves.WalkingCanCannotEatingCanCannotDressingCanCannotGroomingCanCannotToiletingCanCannotTransfer from bed to chair or toiletCanCannotHousekeepingCanCannotMaking investment decisionsCanCannotDealing with pension, retirement, IRA, KEOGH/SEP and other similar plansCanCannotMaking decisions regarding social environment and social activitiesCanCannotLeaving residence by self without getting lostCanCannotApplying for Government entitlementsCanCannotConsenting to or refusing routine medical treatmentCanCannotShoppingCanCannotReading MailCanCannotAnswering the phoneCanCannotMaking bank depositsCanCannotWriting checksCanCannotDriving a car or using public transportationCanCannotPlease provide any necessary detail on your above answersWhat functions can the AIP currently perform?Have there been any unusual or potentially dangerous behaviors? Describe in detail.Has the AIP done anything with their possessions that you disapprove of?Describe the AIP's current gift-giving patterns. Who are the beneficiaries and what are their relationships, if any, to the AIP?Is the AIP currently employed? Yes No If Yes, what is the AIP's occupationName of employerAddress of employerDoes the AIP have business responsibilities? Yes No If Yes, please describeDoes the AIP have responsibilities for others? Yes No If Yes, please describeAIP Health InformationDoes the AIP have any medical or psychiatric problems and diagnoses? Yes No If Yes, please provide detailList any health care providersNameSpecialtyPhone Number Add RemovePlease use the + to the right to add additional health care providersMedications the AIP is currently prescribedMedicationDosePharmacy Add RemovePlease use the + to the right to add additional medicationsRecent hospitalizationsHospitalDateLength of Stay Add RemovePlease use the + to the right to add additional datesHow is payment made for medical bills? (check all that apply) Medicare Medicare insurance supplement Private insurance Medicaid Cash Does the AIP have a Health Care Proxy? Yes No If Yes, please provide the name of the Proxy and date signedDoes the AIP have a Living Will? Yes No If Yes, please provide the date signedDoes the AIP have a Do Not Resuscitate Order (DNR)? Yes No Should competency of the AIP at the time of signing any of the above be questioned? Yes No Relatives of AIPPlease list spouse, parents, adult siblings, adult children or other close relatives of the AIP.RelativeNameRelationAddresss Add RemovePlease use the + button to the right to add additional relatives. Other Interested PartiesPlease other interested parties.Person(s) with whom the AIP residesNameAddressPhone Number Add RemovePlease use the + button to the right to add additional names. Person(s) with whom the AIP appointed under a Health Care ProxyNameAddressPhone Number Add RemovePlease use the + button to the right to add additional names. Person(s) with whom the AIP appointed under a Power of AttorneyNameAddressPhone Number Add RemovePlease use the + button to the right to add additional names. Person(s) who regularly visit the AIPNameAddressPhone Number Add RemovePlease use the + button to the right to add additional names. Any Public Agency that assists the AIPNameAddressPhone Number Add RemovePlease use the + button to the right to add additional names. Person(s) who regularly communicate with the AIP (ie: phone, email, mail)NameAddressPhone Number Add RemovePlease use the + button to the right to add additional names. AIP's Professional AdvisorsPlease provide contact information for attorneys, financial advisors, brokers, insurance agents, etc.AdvisorNameTitleEmail AddressPhone Number Add RemovePlease use the + button to the right to add additional advisors. AIP's AssetsPlease provide information regarding any personal assets of the AIP. If you have statements, deeds, property tax bills, etc., please attach them below, or bring them to your appointment. Please List Any of the AIP's Monthly Income (ie: Wages, Social Security, Retirement, Other)Income SourceAmount Add RemovePlease use the + button to the right to add additional income. Please List the AIP's Monthly Expenses (ie: Rent, Mortgage, Vehicle Loans, Food, Utilities, Etc.)ExpenseAmount Add RemovePlease use the + button to the right to add additional expenses. Bank AccountsName of Financial InstitutionAccount ValuePurpose of Account Add RemovePlease use the + button to the right to add additional accounts. Does the AIP Own Real Property? Yes No If Yes, Who Holds the Mortgage?What is the Estimated Market Value?What is the Amount MortgagedWhen Does the Mortgage Mature?Please List Any Valuable Personal Property Belonging to the AIP (ie: Vehicles, Jewelery, Home Furnishings, Artwork)ItemEstimated Value Add RemovePlease use the + button to the right to add additional personal property. Please describe any changes in economic position since the AIP became incpacitatedLarge withdrawals of money from bank or stock accounts, transfers of real property, trusts created, etc.Thank YouThank you for taking the time to complete this questionnaire; it is very helpful for your appointment. If you have any questions regarding this questionnaire or your appointment, please contact James Gonda at 518-459-2100.
