DOEA/SPGO Form 001 "Professional Guardian Registration Form" - Florida

What Is DOEA/SPGO Form 001?

This is a legal form that was released by the Florida Department of Elder Affairs - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2017;
  • The latest edition provided by the Florida Department of Elder Affairs;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of DOEA/SPGO Form 001 by clicking the link below or browse more documents and templates provided by the Florida Department of Elder Affairs.

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Download DOEA/SPGO Form 001 "Professional Guardian Registration Form" - Florida

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OFFICE OF PUBLIC AND PROFESSIONAL GUARDIANS
Professional Guardian Registration Form
This registration package is:
New
Annual
Amended (Please check one)
SECTION A.
PROFESSIONAL GUARDIAN INFORMATION
Mr._ Ms._ Last Name:
First:
MI:
DOB:
Business Address:
City:
State:
Zip:
E-Mail:
*Social Security No.:
Phone:
Fax:
Corporate Name (if applicable):
EIN:
Please indicate which counties you practice
SECTION B.
CREDIT AND CRIMINAL HISTORY
Documents
Please check one
FBI
Clerk to send
On file with OPPG/obtained within last 5 years
Completed electronically
FDLE
Clerk to send
On file with OPPG/obtained within last 5 years
Completed electronically
Credit
Clerk to send
On file with OPPG/obtained within last 2 years
Attached
*Fingerprinting for “Professional Guardian” generates a combined FBI/FDLE (Level II) report.
SECTION C.
EDUCATION
C1. 40-Hour Professional Guardian Course
Certificate of Completion Attached
(please check one)
Name of Course and Date Completed:
Yes
On file
C2. Continuing Education Credits
16 OPPG approved continuing education credits are required every two-calendar years after completion of the 40-
hour course. Please refer to the chart examples below:
Year of 40-hour Professional Guardian Course completion
Two-year reporting periods
Course completed in 1999 or earlier
2006-2007 (due 2008) 2008-2009 (due 2010)
Course completed in 2000, 2002, 2004
2007-2008 (due 2009) 2009-2010 (due 2011)
Course completed in 2001, 2003, 2005
2006-2007 (due 2008) 2008-2009 (due 2010)
Course completed in 2006
2007-2008 (due 2009) 2009-2010 (due 2011)
Course completed in 2007
2008-2009 (due 2010) 2010-2011 (due 2012)
Course completed in 2008
2009-2010 (due 2011) 2011-2012 (due 2013)
Course completed in 2009
2010-2011 (due 2012) 2012-2013 (due 2014)
Course completed in 2010
2011-2012 (due 2013) 2013- 2014 (due 2015)
Course completed in 2011
2012-2013 (due 2014) 2014-2015 (due 2016)
Course completed in 2012
2013-2014 (due 2015) 2015-2016 (due 2017)
Course completed in 2013
2014-2015 (due 2016) 2016-2017 (due 2018)
Course completed in 2014
2015-2016 (due 2017) 2017-2018 (due 2019)
DOEA/SPGO Form 001, February 2017
Rule 58M-2.001, FAC
Page 1 of 4
OFFICE OF PUBLIC AND PROFESSIONAL GUARDIANS
Professional Guardian Registration Form
This registration package is:
New
Annual
Amended (Please check one)
SECTION A.
PROFESSIONAL GUARDIAN INFORMATION
Mr._ Ms._ Last Name:
First:
MI:
DOB:
Business Address:
City:
State:
Zip:
E-Mail:
*Social Security No.:
Phone:
Fax:
Corporate Name (if applicable):
EIN:
Please indicate which counties you practice
SECTION B.
CREDIT AND CRIMINAL HISTORY
Documents
Please check one
FBI
Clerk to send
On file with OPPG/obtained within last 5 years
Completed electronically
FDLE
Clerk to send
On file with OPPG/obtained within last 5 years
Completed electronically
Credit
Clerk to send
On file with OPPG/obtained within last 2 years
Attached
*Fingerprinting for “Professional Guardian” generates a combined FBI/FDLE (Level II) report.
SECTION C.
EDUCATION
C1. 40-Hour Professional Guardian Course
Certificate of Completion Attached
(please check one)
Name of Course and Date Completed:
Yes
On file
C2. Continuing Education Credits
16 OPPG approved continuing education credits are required every two-calendar years after completion of the 40-
hour course. Please refer to the chart examples below:
Year of 40-hour Professional Guardian Course completion
Two-year reporting periods
Course completed in 1999 or earlier
2006-2007 (due 2008) 2008-2009 (due 2010)
Course completed in 2000, 2002, 2004
2007-2008 (due 2009) 2009-2010 (due 2011)
Course completed in 2001, 2003, 2005
2006-2007 (due 2008) 2008-2009 (due 2010)
Course completed in 2006
2007-2008 (due 2009) 2009-2010 (due 2011)
Course completed in 2007
2008-2009 (due 2010) 2010-2011 (due 2012)
Course completed in 2008
2009-2010 (due 2011) 2011-2012 (due 2013)
Course completed in 2009
2010-2011 (due 2012) 2012-2013 (due 2014)
Course completed in 2010
2011-2012 (due 2013) 2013- 2014 (due 2015)
Course completed in 2011
2012-2013 (due 2014) 2014-2015 (due 2016)
Course completed in 2012
2013-2014 (due 2015) 2015-2016 (due 2017)
Course completed in 2013
2014-2015 (due 2016) 2016-2017 (due 2018)
Course completed in 2014
2015-2016 (due 2017) 2017-2018 (due 2019)
DOEA/SPGO Form 001, February 2017
Rule 58M-2.001, FAC
Page 1 of 4
C3. Continuing Education Courses
Date Completed
# of Credits
SECTION D.
EXAMINATION (Please check one)
Date of Examination:
Passed
OPPG waived my exam on
(date of waiver)
SECTION E.
BLANKET FIDUCIARY BOND
Name of Bonding Company:
Amount: $
Bond Anniversary Date:
Bonds must be payable to the Governor and his or her successors in office. Proof of renewal is required for
annual registrants. First time registrants must attach a copy of your bond.
SECTION F.
STAFFING
F1. Please list each professional guardian employed (attach additional sheets if necessary).
* For each professional guardian listed above, you must submit a professional guardian employee
registration form (DOEA/OPPG Form 002). All forms must be submitted together; do not submit your form
without all your professional guardian employees’ forms.
F2.
Other employees with fiduciary responsibilities
Please complete the section(s) below for each employee, other than professional guardians, that has
fiduciary responsibility to wards. Fiduciary responsibility is defined as having a position of trust.
Last Name:
First:
MI:
DOB:
Business
Address:
City:
State:
Zip:
E-Mail:
*Social Security No.:
Phone:
Fax:
Documents
Date Submitted
Please check one
FBI
Clerk to send
On file with OPPG/obtained within last 5 years
Completed electronically
FDLE
Clerk to send
On file with OPPG/obtained within last 5 years
Completed electronically
Credit
Clerk to send
On file with OPPG/obtained within last 2 years
Last Name:
First:
MI:
DOB:
Business Address:
City:
State:
Zip:
E-Mail:
*Social Security No.:
Phone:
Fax:
DOEA/SPGO Form 001, February 2017
Rule 58M-2.001, FAC
Page 2 of 4
Documents
Date Submitted
Please check one
FBI
Clerk to send
On file with OPPG/obtained within last 5 years
Completed electronically
FDLE
Clerk to send
On file with OPPG/obtained within last 5 years
Completed electronically
Credit
Clerk to send
On file with OPPG/obtained within last 2 years
Last Name:
First:
MI:
DOB:
Business Address:
City:
State:
Zip:
E-Mail:
*Social Security No.:
Phone:
Fax:
Documents
Date Submitted
Please check one
FBI
Clerk to send
On file with OPPG/obtained within last 5 years
Completed electronically
FDLE
Clerk to send
On file with OPPG/obtained within last 5 years
Completed electronically
Credit
Clerk to send
On file with OPPG/obtained within last 2 years
Last Name:
First:
MI:
DOB:
Business Address:
City:
State:
Zip:
E-Mail:
*Social Security No.:
Phone:
Fax:
Documents
Date Submitted
Please check one
FBI
Clerk to send
On file with OPPG/obtained within last 5 years
Completed electronically
FDLE
Clerk to send
On file with OPPG/obtained within last 5 years
Completed electronically
Credit
Clerk to send
On file with OPPG/obtained within last 2 years
* Fingerprinting for “Professional Guardian” generates a combined FBI/FDLE (Level II) report.
SECTION G.
FEES
G1. Registration Fees
a. Number of professional guardians registering
b. Registration Fee
$35.00
c. Total Registration Fees (multiply lines a and b)
$
G2. Expedited Processing Fees (optional)
Registrations are processed within 30 days of receipt. If you opt for expedited processing, please choose one
of the following in addition to standard Registration Fee:
a.
For expedited processing within 14 days
$45.00
b.
For expedited processing within 7 days
$55.00
c.
For expedited processing within 48 hours
$65.00
d. Number of professional guardians registering
e. Total Processing Fees (multiply line a, b, or c by line d)
$
G3. Total Fees Due
a. Total Registration Fees from G1
$
b. Total Expedited Processing Fees from G2 (if applicable)
$
c. Total Fees Due (Add lines a and b)
$
Please enclose a check for this amount made payable to the Office of Public and Professional
Guardians.
DOEA/SPGO Form 001, February 2017
Rule 58M-2.001, FAC
Page 3 of 4
APPLICANT STATEMENT: I declare that my answers and all statements made by me herein are true and correct.
APPLICANT SIGNATURE:
DATE:
Please submit this form along with all fees to: Office of Public and Professional Guardians, Department of Elder
Affairs, 4040 Esplanade Way, Tallahassee, FL 32399-7000.
For Office Use Only
Reg. Period:
Registration #:
Check #:
Check Amount:
Credit Results Date:
FBI Results Date:
FDLE Results Date:
Exam/Waiver Date:
Status:
Status:
Status:
Status:
Reviewer Initials:
Reviewer Initials:
Reviewer Initials:
Reviewer Initials:
Date Reviewed:
Date Reviewed:
Date Reviewed:
Date Reviewed:
Bond Expiration Date:
CEU Due Date:
Status:
Status:
Reviewer Initials:
Reviewer Initials:
Date Reviewed:
Date Reviewed:
Date Entered into CE Broker:
*The collection of social security numbers for record keeping is mandatory pursuant to Section 744.2002, F.S., and will not be available to
the general public.
DOEA/SPGO Form 001, February 2017
Rule 58M-2.001, FAC
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