Dallas County Probate Guardianship Case Information Filing Cover Sheet
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2DALLAS COUNTY PROBATE GUARDIANSHIP CASE INFORMATION FILING COVER SHEET
DALLAS COUNTY PROBATE GUARDIANSHIP CASE INFORMATION FILING COVER SHEET
(REQUIRED ON ALL GUARDIANSHIP CASES)
(REQUIRED ON ALL GUARDIANSHIP CASES)
CAUSE NUMBER: _____________ GUARDIANSHIP OF (
CAUSE NUMBER: _____________ GUARDIANSHIP OF (
________________________
________________________
PROPOSED WARD):
PROPOSED WARD):
__________________________________________________________________________________________
__________________________________________________________________________________________
NOTICE REGARDING GUARDIANSHIP CASES
NOTICE REGARDING GUARDIANSHIP CASES
: On June 19, 2009, Governor Rick Perry signed into law H.B. 3352 relating to
: On June 19, 2009, Governor Rick Perry signed into law H.B. 3352 relating to
the collection, dissemination, and correction of certain judicial determinations for a federal firearm background check. The law, which became
the collection, dissemination, and correction of certain judicial determinations for a federal firearm background check. The law, which became
effective September 1, 2009, has had a significant impact on probate clerks. The ongoing reporting requirements are outlined in the new Government
effective September 1, 2009, has had a significant impact on probate clerks. The ongoing reporting requirements are outlined in the new Government
Code Section 411.0521, Report to Department Concerning Certain Person’s Access to Firearms. In order for the clerk to be in compliance with the
Code Section 411.0521, Report to Department Concerning Certain Person’s Access to Firearms. In order for the clerk to be in compliance with the
Presiding State Statutory Probate Judge’s Administrative Order 2009-2 and H.B. 3352 and to assist the Court Investigator’s Office with the timely
Presiding State Statutory Probate Judge’s Administrative Order 2009-2 and H.B. 3352 and to assist the Court Investigator’s Office with the timely
completion of the Court Investigator’s Report to the Court, the following information is required. All information provided will be secured in the
completion of the Court Investigator’s Report to the Court, the following information is required. All information provided will be secured in the
Court Investigator’s internal file or destroyed after reporting. Thank you for your cooperation!
Court Investigator’s internal file or destroyed after reporting. Thank you for your cooperation!
Check ( ) all applicable boxes.
Check ( ) all applicable boxes.
Please print clearly and legibly.
Please print clearly and legibly.
PROPOSED WARD’S GENERAL INFORMATON
PROPOSED WARD’S GENERAL INFORMATON
APPLICANT #1 INFORMATION
APPLICANT #1 INFORMATION
:
:
Non-family member? Y ( ) N ( )
Non-family member? Y ( ) N ( )
Full Legal Name of Proposed Ward:____________________________________
Full Legal Name of Proposed Ward:____________________________________
Name: ____________________________________________________________
Name: ____________________________________________________________
A/K/A: ___________________________________________________________
A/K/A: ___________________________________________________________
A/K/A:____________________________________________________________
A/K/A:____________________________________________________________
Race: ____________________________ Sex:: __________________________
Race: ____________________________ Sex:: __________________________
Address __________________________________________________________
Address __________________________________________________________
Date of Birth: _____________________________________________________
Date of Birth: _____________________________________________________
__________________________________________________________________
__________________________________________________________________
Any Known Identifying Number:
Any Known Identifying Number:
Date of Birth: ______________________________________________________
Date of Birth: ______________________________________________________
( ) Social Security Number: ________________________________________
( ) Social Security Number: ________________________________________
Telephone Numbers:
Telephone Numbers:
Home:____________________________________________________________
Home:____________________________________________________________
( ) Driver’s License Number (with State): _____________________________
( ) Driver’s License Number (with State): _____________________________
Work: ________________________ Cell:________________________________
Work: ________________________ Cell:________________________________
( ) State Identification Number (with State): ___________________________
( ) State Identification Number (with State): ___________________________
E-Mail Address: ____________________________________________________
E-Mail Address: ____________________________________________________
Does Proposed Ward receive Medicaid? Yes (
Does Proposed Ward receive Medicaid? Yes (
) No (
) No (
)
)
Does Proposed Ward receive income from any source(s) other than
Does Proposed Ward receive income from any source(s) other than
SSI? Yes ( ) No ( )
SSI? Yes ( ) No ( )
Who is the Proposed Ward’s Representative Payee?
Name: ___________________________________________________________
If yes, please list all sources and the monthly amounts of income:
If yes, please list all sources and the monthly amounts of income:
Address: __________________________________________________________
Source: _____________________________ Monthly $ _____________
Source: _____________________________ Monthly $ _____________
Source: _____________________________ Monthly $ _____________
Source: _____________________________ Monthly $ _____________
Telephone Number: _________________________________________________
Medicaid Eligibility Worker’s Name:
Source: _____________________________ Monthly $ _____________
Source: _____________________________ Monthly $ _____________
__________________________________________________________________
Source: _____________________________ Monthly $ _____________
Source: _____________________________ Monthly $ _____________
Address: __________________________________________________________
__________________________________________________________________
Source: _____________________________ Monthly $ _____________
Source: _____________________________ Monthly $ _____________
Telephone Number: _________________________________________________
Source: _____________________________ Monthly $ _____________
Source: _____________________________ Monthly $ _____________
INFORMATION FOR THE PERSON/ATTORNEY
APPLICANT #2 INFORMATION:
Non-family member? Y ( ) N ( )
COMPLETING THIS FORM:
Name: ____________________________________________________________
Name: ___________________________________________________________
A/K/A:____________________________________________________________
State Bar No. ______________________________________________________
Address __________________________________________________________
Address _________________________________________________________
__________________________________________________________________
_________________________________________________________________
Date of Birth: ______________________________________________________
Telephone Number: ________________________________________________
Telephone Numbers:
Fax Number: ______________________________________________________
Home: ____________________________________________________________
E-Mail: __________________________________________________________
Work: ________________________ Cell: _______________________________
Date Completed: ___________________________________________________
Pro Se (If not represented by an attorney)
E-Mail Address: ____________________________________________________
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