Free CG 901 - West Virginia

IN THE CIRCUIT COURT OF _______________ COUNTY, WEST VIRGINIA
For Clerk's Use Only IN RE: ______________________________________________, AN ALLEGED PROTECTED PERSON DATE: __________________________________________ CASE NUMBER ___________ - G - __________

PETITION FOR THE APPOINTMENT OF A CONSERVATOR/GUARDIAN [West Virginia Code: § 44A-1-1, et seq.] INSTRUCTIONS TO APPLICANT A. B. C. All information must be printed or typed and be clearly readable. All information requested MUST be provided, if known. If unknown, you must state it is unknown. Any petition which does not provide the necessary information, or is unreadable, may be dismissed for incompleteness. Please be sure you read and answer all questions. In this document, the PROTECTED PERSON is the person for whom a conservator or guardian is sought. The person requesting the appointment is the PETITIONER. Answers to some questions may require more space than provided. If so, attach additional pages as needed and label each response on such page(s) with the number of the applicable question. Additional guidelines and instructions are contained on Page 7. Please read these instructions carefully since substantial delays may result from failure to perform all the requirements of law.

D.

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F.

PART I INFORMATION ABOUT THE PETITIONER
1. PETITIONER'S [your] FULL NAME: _____________________________________________________

2. PETITIONER'S [your] PLACE OF RESIDENCE: ___________________________________________________ 3. PETITIONER'S [your] POST OFFICE ADDRESS: ___________________________________________________ TELEPHONE NUMBER: WORK: ( ) _________________________HOME: ( ) _____________________

4. WHAT IS YOUR RELATIONSHIP TO THE PROTECTED PERSON: __________________________________

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PART II INFORMATION ABOUT THE PROTECTED PERSON
5. 6. 7. 8. 9. FULL NAME OF PROTECTED PERSON: ___________________________________________________________ PROTECTED PERSON'S DATE OF BIRTH: _________________________________________________________ PROTECTED PERSON'S RESIDENCE ADDRESS: ____________________________________________________ PROTECTED PERSON'S CURRENT LOCATION: ____________________________________________________ PROTECTED PERSON'S POST OFFICE ADDRESS: __________________________________________________

PART III INFORMATION ABOUT THE PROTECTED PERSON'S RELATIVES You are required to provide information about the Protected Person's nearest relatives. You must answer each question fully and completely. If additional space is needed, attach additional page(s) as necessary.
10. DOES THE PROTECTED PERSON HAVE A SPOUSE AND/OR CHILDREN? __________YES __________NO. If you have answered "YES," complete the following and then go to PART IV. If you have answered "NO," go to question 11. SPOUSE'S FULL NAME: _________________________________________________________________________ SPOUSE'S POST OFFICE ADDRESS: _______________________________________________________________ FULL NAME(S) AND POST OFFICE ADDRESSES OF EACH OF PROTECTED PERSON'S CHILDREN: ________________________________________________________________________________________ ________________________________________________________________________________________

11.

DOES THE PROTECTED PERSON HAVE PARENTS, BROTHERS AND/OR SISTERS? __________YES __________NO.
IMPORTANT NOTE: Complete this question ONLY if you answered "NO" to Question 10 above If you have answered "YES," complete the information requested below and go to PART IV. If you haveanswered "NO," go to question 12 below.

FULL NAME(S) AND POST OFFICE ADDRESSES OF EACH OF PROTECTED PERSON'S PARENTS AND BROTHERS AND SISTERS:

_______________________________________________________________________________________ _______________________________________________________________________________________.
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Petition for Appointment of Conservator/Guardian ­ Page 2 of 7 Pages

12. IMPORTANT NOTE: Provide the following information ONLY if you have answered "NO" to BOTH questions 10 and 11
above.LIST THE PROTECTED PERSON'S NEAREST KNOWN RELATIVES, AND THE POST OFFICE ADDRESS(ES) FOR EACH, WHO WOULD BE ENTITLED TO SUCCEED TO THE PROTECTED PERSON'S ESTATE BY INTESTATE SUCCESSION AS SET FORTH IN WEST VIRGINIA CODE: § 42-1-1, et seq. :

_______________________________________________________________________________________ ______________________________________________________________________________________. PART IV
OTHER REQUIRED INFORMATION
13. LIST ANY INDIVIDUAL AND/OR FACILITY, INCLUDING ANY PERSON ACTING AS A DE FACTO CONSERVATOR , DE FACTO GUARDIAN, MEDICAL POWER OF ATTORNEY REPRESENTATIVE OR APPOINTED SURROGATE, THAT IS RESPONSIBLE FOR THE PROTECTED PERSON'S CARE OR CUSTODY. NAME OF THE INDIVIDUAL OR FACILITY: _______________________________________________________________ INDIVIDUAL'S OR FACILITY'S PLACE OF RESIDENCE OR LOCATION: ______________________________________ INDIVIDUAL'S OR FACILITY'S POST OFFICE ADDRESS: ___________________________________________________

IMPORTANT NOTE: If you nave named any individual and/or facility in this question, you MUST provide a detailed listing of the acts performed by any and all such persons and/or facilities on behalf of the protected person on a separate sheet which MUST be attached to this petition.
14. HAS ANY PERSON BEEN DESIGNATED AS A SURROGATE DECISION MAKER FOR THE PROTECTED PERSON? A "surrogate decision maker" is an adult individual or individuals who are reasonably available, are willing to make health care decisions on behalf of an incapacitated person, and are identified as such by the person's attending physician in accordance with West Virginia Code: § 16-30B-3(p). __________YES __________NO.

If "YES," provide information requested below. If "NO," go to Question 15. NAME(S) OF THE SURROGATE DECISION MAKER(S):_____________________________________________________ SURROGATE(S) PLACE OF RESIDENCE(S): ______________________________________________________________ SURROGATE(S) POST OFFICE ADDRESS(ES): ____________________________________________________________ 15. DOES THE PROTECTED PERSON HAVE A REPRESENTATIVE OR REPRESENTATIVES DULY APPOINTED UNDER A DURABLE POWER OF ATTORNEY, MEDICAL POWER OF ATTORNEY AND/OR A LIVING WILL?

__________YES __________NO.

If "YES," complete the information requested below AND attach a

copy of any such document with this petition. If "NO," go to Question 16. SCA-CG 901-3 / 6-00
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NAME(S) OF REPRESENTATIVE(S):

_________________________________________________________ _______________________________

REPRESENTATIVE(S) PLACE OF RESIDENCE OR LOCATION: REPRESENTATIVE(S) POST OFFICE ADDRESS(ES): 16.

___________________________________________

WILL THE PROTECTED PERSON'S INCAPACITY PREVENT THE PROTECTED PERSON FROM ATTENDING THE HEARING ON THIS PETITION?__________ YES__________ NO. If "YES," provide the reason(s) in the space below.

REASON(S): _________________________________________________________________________________________ ______________________________________________________________________________________________________. [IMPORTANT NOTE: The Court cannot conduct a hearing on the merits of this petition without the presence of the protected person unless one of the following is submitted to the Court at the beginning of the hearing: (1) a physician's affidavit (Form 902A), (2) qualified expert testimony or, (3) evidence that the person refuses to appear. SEE: West Virginia Code: § 44A-29(c).]

17.

WHAT TYPE OF GUARDIANSHIP OR CONSERVATORSHIP IS BEING REQUESTED? Check all appropriate spaces: __________ TEMPORARY GUARDIANSHIP __________ LIMITED GUARDIANSHIP __________ GUARDIANSHIP __________ TEMPORARY CONSERVATORSHIP __________ LIMITED CONSERVATORSHIP __________ CONSERVATORSHIP

LIST THE REASON OR REASONS SUPPORTING THE TYPE OR TYPES OF GUARDIANSHIP OR CONSERVATORSHIP REQUESTED: ___________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ _______________________________________________________________________________________________________. 18. IF A LIMITED GUARDIANSHIP IS BEING REQUESTED, INDICATE THE SPECIFIC AREAS OF PROTECTION AND ASSISTANCE TO BE INCLUDED IN THE ORDER OF APPOINTMENT: ________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________. 19. IF A LIMITED CONSERVATORSHIP IS BEING REQUESTED, INDICATE THE SPECIFIC AREAS OF MANAGEMENT AND ASSISTANCE TO BE INCLUDED IN THE ORDER OF APPOINTMENT: _____________________________________

______________________________________________________________________________________ ______________________________________________________________________________________.

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20.

NAME OF THE PROPOSED GUARDIAN: PROPOSED GUARDIAN: POST OFFICE ADDRESS: _______________________________________________________________________________ _______________________________________________________________________________

IF AN INDIVIDUAL IS BEING PROPOSED, PROVIDE THE FOLLOWING INFORMATION ABOUT THE INDIVIDUAL: AGE: _________________ OCCUPATION: ________________________________________________________________

RELATIONSHIP TO PROTECTED PERSON: ________________________________________________________________

21.

NAME OF THE PROPOSED CONSERVATOR: PROPOSED CONSERVATOR: ____________________________________________________________________________ POST OFFICE ADDRESS: ______________________________________________________________________________

IF AN INDIVIDUAL IS BEING PROPOSED, PROVIDE THE FOLLOWING INFORMATION ABOUT THE INDIVIDUAL: AGE: _________________ OCCUPATION: _______________________________________________________________

RELATIONSHIP TO PROTECTED PERSON: _______________________________________________________________

22. HAS THE PROTECTED PERSON NOMINATED A GUARDIAN OR CONSERVATOR DIFFERENT FROM THE PROPOSED GUARDIAN OR CONSERVATOR? __________YES __________NO. If "YES," complete the following:

NOMINATED GUARDIAN: ___________________________________________________________________________ POST OFFICE ADDRESS: ____________________________________________________________________________ IF AN INDIVIDUAL, PROVIDE THE FOLLOWING INFORMATION ABOUT THE INDIVIDUAL: AGE: _________________ OCCUPATION: ________________________________________________________ ________________________________________________________

RELATIONSHIP TO PROTECTED PERSON:

NOMINATED CONSERVATOR: ______________________________________________________________________ POST OFFICE ADDRESS: _______________________________________________________________________

IF AN INDIVIDUAL, PROVIDE THE FOLLOWING INFORMATION ABOUT THE INDIVIDUAL: AGE: _________________ OCCUPATION: __________________________________________________ ________________________________________________________

RELATIONSHIP TO PROTECTED PERSON:

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23. PROVIDE THE NAME(S) AND ADDRESS(ES) OF ANY GUARDIAN OR CONSERVATOR CURRENTLY ACTING ON BEHALF OF THE PROTECTED PERSON IN WEST VIRGINIA OR ELSEWHERE: ACTING GUARDIAN: ____________________________________________________________________________________ POST OFFICE ADDRES: __________________________________________________________________________________ ACTING CONSERVATOR:________________________________________________________________________________ POST OFFICE ADDRESS: ________________________________________________________________________________

24. HAS ANY INDIVIDUAL PROPOSED, NOMINATED OR ACTING CONSERVATOR OR GUARDIAN, WHOSE NAME IS LISTED IN ANY OF THE ANSWERS TO QUESTIONS 20 THROUGH 23, EVER BEEN CONVICTED OF A CRIMINAL OFFENSE OTHER THAN A TRAFFIC OFFENSE? [check one] __________ YES __________ NO. If the answer to this question Is "Yes," list the name of each such individual AND provide the CRIMINAL HISTORY of that individual: ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________

I, the Petitioner named in the foregoing Petition for the Appointment of a Conservator/Guardian hereby respectfully request that the Circuit Court set this matter for hearing and, following such hearing, appoint a guardian and/or conservator for the protected person named herein as requested and petitioned. Given under my hand this ________ day of ________________________________, 20_______.

__________________________________________________________________ PETITIONER'S SIGNATURE

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ALL PETITIONERS MUST NOTE THE FOLLOWING MATTERS ABOUT FILING THIS PETITION:

1.

This petition must be filed in the Office of the Clerk of the Circuit Court of the County in West Virginia where the Protected Person resides, OR the County where the Protected Person has been admitted to a health care or correctional facility OR, in the case of a missing person (a person who is absent from his or her usual place of residence in West Virginia and whose whereabouts are unknown for a period of six months or more), the county in which the missing person last resided . If this is not the case, ask for assistance from the Circuit Court Clerk. You are required to pay a filing fee of $ 90.00 to the Clerk of the Circuit Court upon filing of this petition. As the Petitioner, you are responsible for the payment of this fee and any other fees required for service of process, court costs, and for copies of court documents and transcripts. Once a guardian or conservator has been appointed, such fees may be reimbursed by the Protected Person's estate, but only if an appointment is made and only if funds are available for reimbursement. West Virginia Code: §§ 44A-2-1(c), 59-1-1, et seq., and 51-2-1, et seq., provide that if you are pecuniarily unable to advance these fees, you will not be required to pay the fees and costs. Ask the Court Clerk for assistance if you are unable to advance these fees and costs. You are required to submit additional documents with this petition. Unless the Court, for good cause shown, has waived it, you MUST file an EVALUATION REPORT, form SCA-CG 902, which is a required evaluation and report on the condition of the Protected Person which must be completed by a licensed psychologist or physician. If you do not have this report, you may obtain a blank form from the Circuit Court Clerk. It is your responsibility to arrange for an examination and completion of this form prior to filing. You may also be required to file a PHYSICIAN'S AFFIDAVIT. See the note to Question 16. In addition to the evaluation report, if the Protected Person has executed a durable power of attorney, a medical power of attorney or a living will, you must attach copies of each with this petition as directed by Question 15.

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4.

Upon proper and complete filing of the Petition, the Court will issue a NOTICE OF HEARING fixing the date, hour and location of the hearing on the Petition. It is the PETITIONER'S responsibility to insure that the following parties are served with a copies of court documents as follows: (a) The Protected Person must be served by Personal Service of Process not later than fourteen (14) days prior to the date of the hearing. The documents which must be served upon the Protected Person are: 1. The Notice of Hearing, and 2. This Petition, and 3. The Evaluation report. Upon request and payment of the appropriate fee, the Court Clerk can arrange to have this accomplished by the County Sheriff. As an alternative, you may employ a private process server to effect service, provided that service is made as required by law. You must also serve every individual who has reached the age of seven (7) years or older, and every entity whose names and post office addresses appear in the Petition. The documents required to be served upon these individuals/entities are: 1. The Notice of Hearing, and 2. This Petition. This service is made by sending each Notice and Petition by certified mail, return receipt requested, at least fourteen (14) days before the hearing. You are further required to submit the certified mail return receipts to the Court Clerk for filing on or before the hearing date.

(b)

IMPORTANT NOTE: A failure by the Petitioner to properly serve the Protected Person and/or other individuals as required by law will likely result in delay of the hearing or, possibly, dismissal of the petition. Make sure ALL parties are served as required. The Protected Person cannot waive this requirement. If you have questions, consult an attorney for advice. 5. Under West Virginia Code: § 44A-2-7, the Circuit Court is required to appoint an attorney to represent the Protected Person. You have the right to retain an attorney of your choosing to represent you in this matter, which is not mandatory, but is mentioned merely to insure that you understand that you have the right to be represented by an attorney at this hearing. If you are seeking the appointment of a conservator, you MUST file a "Statement of Financial Resources" with the Court any time prior to the hearing. The Circuit Clerk has a blank form which you may obtain for completion before the hearing. If you are unsure about any matter contained in these instructions, ask the Circuit Court Clerk for assistance. If you need legal advice, you should contact an attorney. The Court and Court Clerk are prohibited from providing legal advice. Petition for Appointment of Conservator/Guardian ­ Page 7 of 7 Pages

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