Washington State Courts - Programs and Organizations

eService Center

Office of Public Guardianship

	* Required Field
Verification of Referral
Referral Date:	*
Case Number:
Alleged Incapacitated Person (AIP) / Incapacitated Person (IP) Information
AIP/IP First Name:	*
AIP/IP Middle Name:
AIP/IP Last Name:	*
AIP/IP Social Security Number:	*More Info...* OPG runs a background check on every referred client, thus the AIP/IP's SSN is required. If you have any questions, please call Kim Rood at 360.705.5314
AIP/IP Date of Birth:	/ / MM/DD/YYYY
AIP/IP Known Aliases:	(Please list all known aliases separated by a comma)

Submitter Information
First Name:	*
Middle Name:
Last Name:	*
Relationship to AIP/IP:
Phone:
Email:	*

Petitioner Information
Petitioner First Name:
Petitioner Middle Name:
Petitioner Last Name:
Agency:
Petitioner Title:
Relationship to AIP:
Petitioner Phone:
Petitioner Email:

Guardian Ad Litem Information
GAL First Name:
GAL Middle Name:
GAL Last Name:
GAL Phone:
GAL Email:

Qualifying Information

Resides in Washington State in one of the following counties: *

The following conditions are true for the AIP/IP being referred (check all that apply):

Is aged 18 years or older

Verification Document/Method:

Income does not exceed 200 percent of the federal poverty level.

For 2012, income cannot exceed $22,340 annually or $1,862 monthly; this number may change from calendar year to calendar year and eligibility would change accordingly.

Please provide monthly income:

Please provide income sources: (check all that apply)
- SSI
- SSDI
- Medicaid
- Other, please list:

Verification Document/Method:

Is receiving long-term care services through the Washington State Department of Social and Health Services

Verification Document/Method:

There is no one else qualified, willing and able to serve

Verification Document/Method:

Please verify that you have determined that no family or friends are willing and able to serve.

Provide a list of persons contacted, include family members and professional guardians and their reasons for declining to serve.

First & Last Name	Reasons for Declining to Serve

Priorities (check all that apply):
	Indigent/Homeless
	At significant risk of harm from abuse, exploitation, abandonment, neglect or self-neglect. This determination is based on what information?
	In imminent danger of loss or significant reduction in public services that are necessary to live successfully in the most integrated and least restrictive environment that is appropriate for a specific individual. This determination is based on what information?

Current Living Arrangements of Alleged Incapacitated Person: *

* Provide Facility Name

Eastern State
Fircrest School
Frances Haddon Morgan Center
Homeless
Lakeland Village
Private Residence with Supported Living
Private Residence without Supported Living
Rainier Village
Western State
Yakima Valley School
* Adult Family Home
* Boarding Home
* ICF/MR
* Medical Hospital
* Nursing Facility

Provide a brief explanation of the AIP's current situation and the events or situations that provoked the request for a public guardian: *

Please attach a copy of the Petition for Guardianship and the detailed GAL Report
Petition for Guardianship:	*More Info...* The Petition for Guardianship is required for public guardians to determine their ability to serve. Requests for public guardians will not be fully processed without this document.
Detailed GAL Report:	*More Info...* The Guardian ad litem report is required for public guardians to determine their ability to serve. Requests for public guardians will not be fully processed without this document.
Form Security *
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