Free Corporate Guardian Status Application-F60820 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance F-60820 (Rev. 07/08)

STATE OF WISCONSIN HFS 85.01, Wis. Admin. Code Page 1 of 2

CORPORATE GUARDIAN STATUS APPLICATION
Collection of the information on this form is required to assist the department in determining whether a non-profit corporation is a suitable agency and is qualified to serve as a guardian as stated in HFS 85.01, Wisconsin Administrative Code. Failure to provide the requested information may result in denial of the corporate guardian status. Questions about completion of this form may be directed to 608-264-9888.

I. ORGANIZATION INFORMATION
Name ­ Organization Mailing Address City Date Incorporated State Zip Code

Name - Contact Person

Title

E-mail Address

Telephone Number

Primary Purpose of Organization

Protective Services or Protective Placements Provided by the Organization

II. CORPORATE GUARDIAN SERVICES
Type of Service Class A [HFS 85.02(1)] Anticipated Number of Wards NOTE: Limits on the number of wards served by Class A or Class B agencies do not apply to temporary and standby guardianships. Permanent Guardianships Temporary Guardianship Standby Guardianships
Guardian of the Person ONLY Guardian of the Estate ONLY Guardian of the Person and/or Estate

Class B [HFS 85.02(2)]

Disability and Age Groups to be Served

Geographical Areas Served

III. CORPORATE STRUCTURE ­ BOARD OF DIRECTORS AND EMPLOYEES
Attach an organizational chart that delineates the lines of authority and identifies the board of directors, any advisory committees, consultants, lead person responsible for the corporate guardian program, staff / volunteers, and funding resources. Attach a copy of the articles of incorporation by-laws, latest periodic report, a list of the names and addresses of persons serving on the corporation's board of directors, and a list of employees of the guardianship program. a. List below only those board members or employees who also are members or employees of a community board, a county human services board, or county social services department as specified in HFS 85.03(4) and indicate the county or counties affected. (Attach additional pages if necessary.)

F-60820 (Rev. 07/08) Corporate Guardian Agency Role Other Agency Affiliation (Specify agency and role.)

Page 2 of 2

Name

County(ies) Affected

IV. STAFF
a. b. Name of Person Who Will Administer the Guardianship Program Attach a list of the names, addresses, and job titles of the guardianship program staff members. Include volunteers. Also provide job descriptions, job qualifications, and monthly hours or direct as well as indirect services to wards.

V. FUNDING
Identify all sources of actual or anticipated funding for the corporate guardian program. Attach copies of any funding contracts for corporate guardian services. Source Amount

Anticipated Annual Cost Per Ward

VI. ASSURANCES
The applicant corporation, through the actions of its guardianship program administrator, agrees to: a. Communicate any change in the internal assignment of responsibilities to the department, the local planning agency, or interagency mechanism designated under Chapter 55.02, Wis. Stats., the ward, and to the court within fourteen (14) days following its effective date. [HFS 85.03(7)] Be immediately accessible by phone during normal working hours to the local planning agency or interagency mechanism designated under Chapter 55.02, Wis. Stats. [HFS 85.03(9)] Ensure that the person responsible on behalf of the corporation for administering the guardianship shall be readily accessible in person or by phone to the ward and to other persons concerned. [HFS 85.03(9)] Submit such reports and answer such questions as the department shall require in monitoring corporate guardianships. [HFS 85.03(10)] Ensure periodic personal contact with the ward, at least once every three (3) months, to ascertain the status of the ward, take necessary action to see that the ward receives needed services, and to assure that the ward is well treated, properly cared for, and is provided with the opportunity to exercise legal rights. Personal contact with a ward protectively placed under Chapter 55.06, Wis. Stats., shall be onsite personal contact. Ensure that, when serving as guardian of the person of a ward, an annual report is filed on the condition of the ward to the court that ordered the guardianship and to the county agency designated under Chapter 55.02, Wis. Stats., as required by Chapter 880.38(3), Wis. Stats.
Title Date Signed

b. c. d. e.

f.

SIGNATURE ­ Organization Representative

If at any time the department determines that a non-profit corporation that the department had found suitable to assume responsibility for guardianships no longer meets the criteria set out in HFS 85.03, Wis. Admin. Code, the department may withdraw its finding of suitability upon 30-day notice to the non-profit corporation or former non-profit corporation, the court or courts that assigned the corporations' guardianships, the ward, his or her family, other interested parties, and the county agency designated under Chapter 55.02, Wis. Stats. Any party adversely affected by a decision of the department about the suitability of a corporation to serve as guardian may appeal that decision to the department's office of administrative hearings under Chapters 227.064 and 227.07 -13, Wis. Stats.