A. Demographic information
- Name of alleged incapacitated person (AIP)
- Social Security Number of AIP or citizenship status of AIP
- Address or homelessness of AIP
- AIP county of residency (Denver only at this time)
- Date of birth of AIP (must be 21 or older)
- Veterans Status
- Confirmation of no pending guardianship proceedings by adult protective services
B. Income and asset information
The basis of indigency follows C.R.S. § 13-16-103 and the Supreme Court of Colorado Chief Justice Directive (CJD) 98-01. The requested information follows Form JDF 205. The Income Eligibility Guideline are as established by the U.S. Department of Health and Human Services (See Federal Register 84 CFR 1167, 02/01/2019) and will be updated accordingly.
If the AIP’s income is at or below the income eligibility guidelines and he or she has liquid assets of $1,500.00 or less, as determined by the OPG Indigency Evaluation Form, the AIP is indigent and eligible for public guardianship services.
If the AIP’s income is up to 25% above the income eligibility guidelines and he or she has liquid assets of $1,500.00 or less, and the monthly expenses equal or exceed the monthly income, as determined by the OPG Indigency Evaluation Form, the AIP is indigent and eligible for public guardianship services.
Income is gross income from all members of the household who contribute monetarily to the common support of the household. Income categories include wages, salary, commissions, profits, interest/investment earnings, social security benefits (including disability), Supplemental Security Income (SSI), maintenance (alimony), pension, workers’ compensation, and unemployment benefits. NOTE: Income from roommates should not be considered if such income is not commingled in accounts or otherwise combined with the AIP’s income in a fashion which would allow the applicant proprietary rights to the roommate’s income.
Gross income does not include TANF payments, food stamps, subsidized housing assistance, veteran’s benefits or child support.
Liquid assets include cash on hand and in accounts, stocks, bonds, certificates of deposit, equity, and personal property or investments which could readily be converted into cash without jeopardizing the AIP’s ability to maintain home or employment.
Expenses for nonessential items such as cable television, club memberships, entertainment, dining out, alcohol, cigarettes, etc. shall not be included.
- AIP income sources – employment, SSA
- Owner of real property and address; Liabilities
- Owner of a vehicle and car description; Liabilities
- Credit Cards
- ENABLE account
C. Incapacity information
- Primary Diagnosis
- Secondary Diagnosis
- Additional Diagnoses
- History of substance abuse
- Current corroborating evaluation and medical evidence regarding diagnosis and incapacity
- Specific description of how the diagnosis limit the AIP and deem them as incapacitated
D. Benefits information
- Name and contact information of caseworker
- Active/Denied Food stamps
- Active/Denied AABD
- Active/Denied Medicaid
- Active/Denied Medicare
- Social Security Administration (SSA) benefits
- SSA Representative Payee contact information
- Veteran’s Administration (VA) benefits
- VA Fiduciary contact information
E. Family member or friend availability and appropriateness information
- Name and contact information of all known family members
- Specific steps taken to contact each family member and to assess appropriateness
- Name and contact information of known interested friends
- Steps taken to contact each interested friend and to assess appropriateness
- Proposed Petition
- Evaluation and medical documentation
G. Pending criminal or other civil proceedings
- Include case identification information and upcoming hearing, if applicable