Free GUARDIAN AND CONSERVATOR BACKGROUND STUDY - Minnesota

REQUESTING COURT

COUNTY

COURT FILE NUMBER

PROPOSED CONSERVATEE / WARD

FIRST NAME

MIDDLE NAME

LAST NAME

PROPOSED CONSERVATOR / GUARDIAN

FIRST NAME

MIDDLE NAME

LAST NAME

LIST ANY OTHER NAMES BY WHICH THIS INDIVIDUAL HAS BEEN KNOWN

ADDRESS

CITY

STATE
ASIAN

ZIP CODE

1 9
DATE OF BIRTH SOCIAL SECURITY NUMBER (OPTIONAL)

BLACK

INDIAN

DRIVERS LICENSE NUMBER (OPTIONAL)

STATE

WHITE

UNKNOWN / OTHER M F

TELEPHONE NUMBER

GENDER (OPT)

RACE (OPTIONAL)

I have resided outside of Minnesota in the last 5 years. Yes No If yes, this form must be accompanied by a set of classifiable fingerprints. See instructions. I give consent to the Minnesota Department of Human Services to conduct a background study on me as provided in Minn. Stat. Sec. 524.5-118, and to release the results of the study to the court. __________________________________________________ _____________________________ Signature Date I hereby certify that this is an in forma pauperis proceeding (person only), and qualifies for exemption from fee payment pursuant to Minn. Stat. Sec. 524.5-118, subd. 1 (f) (1). Court Administrator By _________________________ Deputy Court Administrator

GAC103

State

ENG

Rev 8/03-D

www.courts.state.mn.us/forms

Page 1 of 2

GUARDIAN AND CONSERVATOR BACKGROUND STUDY CONSENT/INFORMATION FORM

BACKGROUND STUDY REQUIREMENT: Minnesota Statutes, section 524.5-118, requires a background study on you for the purpose of assisting the court in determining whether your appointment or continued appointment as a guardian or conservator is in the best interests of the ward or protected person. The background study will include a review of criminal conviction records held by the Minnesota Bureau of Criminal Apprehension (BCA) or Minnesota Department of Human Services (DHS) and records of substantiated maltreatment of vulnerable adults or minors held by DHS. There will also be a search of the Federal Bureau of Investigation's (FBI) national criminal records repository if you have not resided in Minnesota for the previous five years or if the BCA information indicates that you are a multistate offender or that your multistate offender status is undetermined.

NOTIFICATION OF RIGHTS: You have the following rights: · · · The right to be informed that the court will request a background study on you for the purpose of determining whether your appointment or continued appointment is in the best interests of the ward or protected person; The right to be informed of the results of the study and to obtain from the court a copy of the results; and The right to challenge the accuracy and completeness of information provided to the court by DHS or BCA by filing a challenge with the appropriate agency under Minnesota Statutes, section 13.04, subdivision 4. Please note that some challenges may be precluded by Minnesota Statutes, section 256.045, subdivision 3.

FEES AND PAYMENT: · · · · The basic fee for each study is $20. The fee for each fingerprint card is $30 in addition to the basic fee. There is no fee for cases proceeding in forma pauperis for guardians of the person as provided in Minnesota Statutes, section 524.5-118. For conservators of the estate, the fee is paid by the estate. Make check payable to: Licensing Div., Guardian Background Study.

INSTRUCTIONS: · · · · Type or legibly print the information on the reverse side of this form. If the proposed guardian or conservator has resided outside of Minnesota in the last 5 years, this form must be accompanied by a set of classifiable fingerprints on a card provided by DHS and available at the county court administrator's office. The proposed guardian or conservator must sign and date the reverse side of this form. Mail form with the appropriate fee(s) or court verification that the case is proceeding in forma pauperis to: Department of Human Services Licensing Div., Guardian Background Studies 444 Lafayette Road St. Paul, MN 55155-3842

WHERE FORMS AND FINGERPRINT CARDS CAN BE OBTAINED: · · County Court Administrator's Office DHS Licensing Division, 651-296-3971
August 1, 2003

GAC103

State

ENG

Rev 8/03-D

www.courts.state.mn.us/forms

Page 2 of 2