AOC-795 Rev. 8-99 Page 1 of 2
Doc. Code: PRMT
Case No.______________________ Court_________________________
Commonwealth of Kentucky Court of Justice KRS 387.620
PETITION FOR RELIEF, MODIFICATION OR TERMINATION
) ) ) ) ) )
County_______________________
COMMONWEALTH OF KENTUCKY Petitioner VS. _____________________________________________ Respondent
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Comes the Petitioner and requests the Court to u terminate u modify as follows:
u
The order of u partial disability u disability entered on __________________________________________ be
u terminated u modified as follows: u u
1.
___________________________________________________________
________________________________________________________________________________________ To remove the present fiduciary and replace with _________________________________________________. To renew the appointment of the present fiduciary for a period of ____________________________________.
In support of this request, Petitioner states: The Respondent's address: ______________________________________________________________________ In custody of: __________________________________________________________________________________ 2. Respondent's present fiduciary: ___________________________________________________________________ Address: _____________________________________________________________________________________ Appointed on: _________________________________________________________________________________ As:
u u
Limited Guardian Guardian
u u
Limited Conservator Conservator
3.
The Respondent's u Durable Power of Attorney u Health Care Surrogate is: _____________________________________________ Address _____________________________________________ _____________________________________________
_____________________________________________ Name
4.
Respondent's next of kin are: Name Address ______________________________ ______________________________ _______________________________ Relationship _____________________________ _____________________________ _____________________________
______________________________ ______________________________ ______________________________ 5.
The facts and reasons supporting this request: ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________
AOC-795 Rev. 8-99 Page 2 of 2
Doc. Code: PRMT
WHEREFORE, the Petitioner requests that this court conduct a hearing within thirty (30) days of the filing of this petition. If the foregoing petition is for a renewal of the appointment of a limited guardian or conservator, it shall be accompanied by verified affidavits of a physician, a psychologist, or a social worker in support of same pursuant to KRS 387.610.
_____________________________________________ Petitioner _____________________________________________ Address _____________________________________________ Relationship to Respondent
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SUBSCRIBED and SWORN to before me this ___________ day of _____________________________, ________.
_____________________________________________ Name/Title _____________________________________________ County, Kentucky
To be completed if Petitioner is represented by counsel:
_____________________________________________ Signature of Attorney _____________________________________________ Address of Attorney _____________________________________________ Telephone Number
An attested copy of this Petition was mailed this date to the Respondent, the attorney of record, the county attorney and all persons named in the Petition.
_________________________________________ Date
_____________________________________________ Signature