Petition for Appointment of Guardian for Incapacitated Pursuant to

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Petition for Appointment of Guardian for Incapacitated Pursuant to Powered By Docstoc
					                                                              Docket No.                Commonwealth of Massachusetts
   PETITION FOR APPOINTMENT OF                                                                 The Trial Court
  GUARDIAN FOR AN INCAPACITATED                                                            Probate and Family Court
  PERSON PURSUANT TO G.L. c. 190B,
              §5-303
  In the Interests of:
                                                                                                                     Division
            First Name            Middle Name             Last Name


  Alleged Incapacitated Person/Respondent



  The Court shall encourage the development of maximum self-reliance and independence of the Incapacitated Person and
  make appointive and other orders only to the extent necessitated by the Incapacitated Person's limitations or other conditions
  warranting the procedure.
1. The Petitioner is
         A person or organization interested in the welfare of the Respondent.
    OR
         The Respondent.

2. This is a Petition for appointment of a (choose one):
         Limited Guardian
         State the powers being sought:




         Further power(s) being sought as specified in paragraphs 10 and/or 11
    OR
         General Guardian
         State the reasons why a Limited Guardianship is inappropriate:




         Further power(s) being sought as specified in paragraphs 10 and/or 11
3. Information about the Petitioner:
   An attachment to this petition provides information on co-petitioner(s).                                       click to add




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4. Information about Respondent:
Name:                                                                                                                             Age:
                       First Name                                 M.I.                                  Last Name

Primary Language:        English          Other                                                   Primary Phone #:
Principal Residence:
                                      (Address Line 1)                    (Apt, Unit, No. etc.)            (City/Town)             (State)         (Zip)

Date Residence was established:

Current Address:       Same as Above or                  the following address:

            (Address Line 1)                      (Apt, Unit, No. etc.)                   (City/Town)               (State)        (Zip)


If this appointment is made, Respondent will reside at                    Principal Residence             Current Address            the following address:

            (Address Line 1)                      (Apt, Unit, No. etc.)                   (City/Town)               (State)        (Zip)

5. List Respondent's spouse and children. If none, list parents and brothers and sisters or if none, list heirs apparent
    or presumptive. Indicate any person who is a minor or incapacitated.
1) Name:
                                    First Name                                         M.I.                                   Last Name


                          (Address Line 1)                        (Apt, Unit, No. etc.)                  (City/Town)             (State)        (Zip)

    Primary Phone #:                                                               Relationship to Respondent:
        This person is a minor who is                      years old.           This person is incapacitated.
2) Name:
                                    First Name                                         M.I.                                   Last Name


                          (Address Line 1)                        (Apt, Unit, No. etc.)                  (City/Town)             (State)        (Zip)

    Primary Phone #:                                                               Relationship to Respondent:
        This person is a minor who is                      years old.           This person is incapacitated.
3) Name:
                                    First Name                                         M.I.                                   Last Name


                          (Address Line 1)                        (Apt, Unit, No. etc.)                  (City/Town)             (State)        (Zip)

    Primary Phone #:                                                               Relationship to Respondent:

        This person is a minor who is                      years old.           This person is incapacitated.
    Name:
                                    First Name                                         M.I.                                   Last Name


                          (Address Line 1)                        (Apt, Unit, No. etc.)                  (City/Town)             (State)        (Zip)

    Primary Phone #:                                                               Relationship to Respondent:

        This person is a minor who is                      years old.           This person is incapacitated.

   An attachment to this petition provides additional information.                                                                           click to add
6. State the following information for any person who has had the care and custody of Respondent or with whom
   Respondent has resided during the 60 days (exclusive of hospitalization or institutionalization) preceding the filing
   of this petition:




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1) Name:
                                   First Name                                   M.I.                         Last Name


                            (Address Line 1)                 (Apt, Unit, No. etc.)          (City/Town)         (State)          (Zip)

      Primary Phone #:                                                      Relationship to Respondent:
      Date of        co-residency or            care and custody:

      Name:
                                   First Name                                   M.I.                         Last Name


                            (Address Line 1)                 (Apt, Unit, No. etc.)          (City/Town)         (State)          (Zip)

      Primary Phone #:                                                      Relationship to Respondent:

      Date of        co-residency or            care and custody:
      An attachment to this petition provides additional information.                                                         click to add

7. State the reason a guardianship is necessary:




8. Give a brief description of the nature and extent of Respondent's alleged incapacity:




9. Respondent             is          is not alleged to be mentally retarded.

10.       Petitioner seeks Court authorization:
            To treat Respondent with antipsychotic medication in accordance with the treatment plan;
            For the following treatment or action for which a substituted judgment determination may be required:




11.       Petitioner seeks Court authorization to admit Respondent to a nursing facility.

12. A Medical Certificate dated with an examination having taken place within 30 days of the filing of the petition or, if
    Respondent is alleged to be mentally retarded, a Clinical Team Report dated with an examination having taken place
    within 180 days of the filing of the petition:

            is filed with this Petition or is on file with the Court (Docket No.                                                    ) ; OR
            is not filed with this Petition and is not on file with this Court.
      If a Medical Certificate or Clinical Team Report is not filed or on file with this Court, you must immediately file with this petition
      and present a motion requesting that the Court waive or postpone the filing of the Medical Certificate or Clinical Team Report
      together with a supporting affidavit stating why it is impossible to obtain a Medical Certifcate or Clinical Team Report.

13. Petitioner is requesting:
          to be appointed            that some suitable person be appointed              the following person be appointed:




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Name:
                             First Name                                 M.I.                              Last Name


                    (Address Line 1)                (Apt, Unit, No. etc.)             (City/Town)           (State)             (Zip)

Primary Phone #:
        He or she has priority of appointment because the nominee is (choose one):
        Nominated in a durable power of attorney by Respondent;
        Respondent's spouse or a spousal nominee;
        Respondent's parent or a parental nominee; OR
        None of the above.

State the reason the proposed guardian(s) should be appointed:




   An attachment to this petition provides additional information.                                                                click to add

14. Respondent:
        Does           does not        have a current Guardian in the Commonwealth or elsewhere or                    Uncertain.
        A Petition for Guardianship was filed but has not been allowed (Court & Docket No.                                                       )

   Information about the Guardian:
   Name:
                                 First Name                                    M.I.                           Last Name


                         (Address Line 1)                 (Apt, Unit, No. etc.)             (City/Town)               (State)           (Zip)

            Primary Phone #:
   A copy of the Guardian's order of appointment is             attached              unavailable.
        If this Petition is allowed, a dismissal of the above guardianship will be sought.

15. Respondent:
        Does           does not        have a current Conservator in the Commonwealth or elsewhere or                   Uncertain.
        A Petition for Conservatorship was filed but has not been allowed (Court & Docket No.                                                        )
   Information about the Conservator:
   Name:
                                 First Name                                    M.I.                           Last Name


                         (Address Line 1)                 (Apt, Unit, No. etc.)             (City/Town)               (State)           (Zip)

            Primary Phone #:
   A copy of the Conservator's order of appointment is             attached           unavailable.




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16. Respondent:
       Has            has not       nominated a Guardian in the Commonwealth or elsewhere or                            Uncertain.
   Information about the nominated Guardian:
   Name:
                                First Name                                  M.I.                               Last Name


                        (Address Line 1)                 (Apt, Unit, No. etc.)             (City/Town)             (State)           (Zip)

           Primary Phone #:
   A copy of the nominating instrument is         attached             unavailable.
17. Respondent:
       Does           does not      have a Health Care Agent in the Commonwealth or elsewhere or                     Uncertain.
   Information about the Health Care Agent:
   Name:
                                First Name                                  M.I.                               Last Name


                        (Address Line 1)                 (Apt, Unit, No. etc.)             (City/Town)             (State)           (Zip)

           Primary Phone #:
   A copy of the Health Care Proxy is         attached           unavailable.
18. Respondent:
       Does           does not      have a Durable Power of Attorney/Agent in the Commonwealth or elsewhere or                       Uncertain.
   Information about the Durable Power of Attorney/Agent:
   Name:
                                First Name                                  M.I.                               Last Name


                        (Address Line 1)                 (Apt, Unit, No. etc.)             (City/Town)             (State)           (Zip)

           Primary Phone #:
   A copy of the Durable Power of Attorney is         attached              unavailable.

19. Respondent:
       Does           does not      have a Representative Payee in the Commonwealth or elsewhere or                     Uncertain.
   Information about the Representative Payee:
   Name:
                                First Name                                  M.I.                               Last Name


                        (Address Line 1)                 (Apt, Unit, No. etc.)             (City/Town)             (State)           (Zip)

           Primary Phone #:

20. Respondent            is       is not    entitled to benefits from the Department of Veterans Affairs or                 Uncertain.

21. Does Respondent have any assets, e.g. bank accounts, property?                     Yes           No        Uncertain. If Yes, identify:

     Description of Assets, e.g. Bank Accounts, Property, Insurance, Pensions
                                                                                                         Estimated Value of Property
      DO NOT INCLUDE NAMES OF INSTITUTIONS OR ACCOUNT NUMBERS




                                                                                             Total

   An attachment to this petition provides additional information.                                                                Click to add
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22. Does Respondent have any anticipated income?                            Yes           No        Uncertain. If Yes, identify:

                Description of Income, e.g. Social Security, Interest                            Amount of Anticipated
        DO NOT INCLUDE NAMES OF INSTITUTIONS OR ACCOUNT NUMBERS                                Monthly Income or Receipts




                                                                                  Total

   An attachment to this Petition provides additional information.                                                    Click to add


WHEREFORE, PETITIONER REQUESTS THAT THIS HONORABLE COURT:

   Appoint
                                 First Name                          M.I.                          Last Name

         or       Some suitable person.                                                                               click to add
   as     limited guardian(s)         general guardian(s) of Respondent.

   Petitioner seeks specific court authorization:
             to admit Respondent to a nursing facility;
             to treat Respondent with antipsychotic medication in accordance with a treatment plan;
             for the following treatment or action for which a substituted judgment determination may be required:




             to revoke the Health Care Proxy of Respondent;
             to apply for health insurance benefits including MassHealth on behalf of Respondent;

   I request the Court waive sureties on the Bond for the following reasons:




   In addition, I request that the Court:




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                         SIGNED UNDER THE PENALTIES OF PERJURY
I affirm or swear under oath that I have read the foregoing Petition and that the statements set forth therein are true and correct to
the best of my knowledge.

Date:
                                                                         Signature of Petitioner

Date:
                                                                         Signature of Co-petitioner (if applicable)
  I assent to the foregoing Petition:
                                        Print Name                                   Signature

Date
Date
Date
Date



Date:
                                                                                             Signature of Attorney for Petitioner


                                                                                                  (Print name)


                                                                                (Address line1)                                    (Apt, Unit, No. etc.)


                                                                               (City/Town)                               (State)               (Zip)

                                                             Primary Phone:
                                                             B.B.O. #




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