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INSTRUCTIONS FOR COMPLETING "PETITION FOR APPOINTMENT OF GUARDIAN OF INCAPACITATED INDIVIDUAL"
Please type or print neatly using black or blue ink. Items A through Q must be read and filled in (when required) before your petition can be filed with the court. Please read the instruction for each item. Then fill in the correct information for that item on the form. A B Enter the name of the individual who you believe needs a guardian. Enter the date of birth, race, and sex of the individual named in A . Enter the address where the individual is currently located. This address may or may not be the home of the individual. For example, if the individual is currently in the hospital, enter the address of the hospital. Enter your name in the first line and your relationship to the individual (or your interest) on the second line. Check this box if there is or has been a case in the family division of the circuit court involving the individual in A . Examples of a family division case are personal protection, abuse or neglect, or a name change. If you have checked this box, enter the name of the court, the case number of the action, the name of the judge assigned to that case. Then place a check in the box indicating whether that case is still pending or not. Enter the city, village, or township and county and state the individual is a resident of and the full home address of the individual. Check the boxes that apply and provide the name(s) and address(es). If the individual has a patient advocate and you believe there is a problem, check only the boxes that apply. Check the boxes that you believe apply to the individual. Explain in as much detail as possible specific examples of the individual's conduct that lead you to believe he or she needs a guardian. Give specific examples of his or her conduct that supports what you checked in H and that demonstrate the need for a guardian. This information is extremely important for the court in making a decision about the need to appoint a guardian. Use additional sheets of paper if needed. Enter the name, address, and telephone number of the person or agency who currently has care and custody of the individual. If there is no one, leave blank. Check whether the individual is or is not entitled to receive Veterans Administration benefits. If you checked that the individual is entitled to benefits, enter his or her VA claimant number.

C D

E F G H I

J

K

L - M Check all the boxes that apply and enter the names, relationships, addresses and telephone numbers of each relative of the individual. If any of the adults named in L are under legal incapacity, enter the names in M . If you check the last box in L (item 10), you must notify the Attorney General by sending a copy of this form to: Attorney General, Public Administration, PO Box 30736, Lansing, Michigan 48909. N Enter the name, address, and telephone number of the person you want to be appointed as guardian of the individual. Enter the relationship, if any, that this person has to the individual. Check the box for either a full guardian or a limited guardian. Check the box if there is an emergency requiring the appointment of a temporary guardian before the hearing on this petition is held. Enter today's date, sign your name, and enter your address and telephone number. If the individual wants to nominate someone to be his/her guardian, check the box and enter the name, address, and telephone number of the person the individual is nominating. The individual must sign and date the form.

O

P Q

Approved, SCAO

JIS CODE: PEG

STATE OF MICHIGAN PROBATE COURT COUNTY
CIRCUIT COURT - FAMILY DIVISION

PETITION FOR APPOINTMENT OF GUARDIAN OF INCAPACITATED INDIVIDUAL

FILE NO.

A B C

In the matter of
Date of birth

XXX-XXAlleged incapacitated individual Race Sex Last four digits of SSN Address of alleged incapacitated individual where now found

1. I,

Name (type or print) State interest/relationship

, am interested in this matter .

and make this petition as

D

2. An action within the jurisdiction of the family division of circuit court involving the family or family members of the above named person has been previously filed in assigned to Judge Court, Case Number , and
City, village, or township Address City

, was is no longer pending.
State State Zip

remains ,
County

E

3. The adult is a resident of

and has a home address of

.

F

The individual is a citizen of the following foreign country: 4. The adult has: a patient advocate/power of attorney for health care (specify name and address below): a power of attorney (specify name and address below): a conservator (specify name and address below):
Name and address

G

5.

The patient advocate designation was not executed in compliance with MCL 700.5506. The patient advocate is not complying with the terms of the designation or of MCL 700.5506 to 700.5512. The patient advocate is not acting consistent with the ward's best interests.

H

6. The adult lacks sufficient understanding or capacity to make or communicate informed decisions due to the following conditions: mental illness mental deficiency physical illness or disability chronic intoxication chronic drug use 7. Following are specific facts about the adult's recent condition or conduct that lead me to believe the adult needs a guardian:
(Attach a separate sheet if more space is needed.)

I

J

8. The name, address, and telephone number of the person/agency (if any) who currently has care and custody of the adult are: SEE SECOND PAGE
Do not write below this line - For court use only

MCL 700.1105(a), MCL 700.5303, MCR 5.125(C)(22), MCR 5.402(A) PC 625 (1/08)

PETITION FOR APPOINTMENT OF GUARDIAN OF INCAPACITATED INDIVIDUAL

K L

9. The adult is is not claimant number is:

entitled to receive Veterans Administration benefits. The Veterans Administration

10. The alleged incapacitated individual has: a spouse whose name and address are listed below. adult child(ren) whose name(s) and address(es) are listed below. living parent(s) whose name(s) and address(es) are listed below. no spouse, child(ren), or parent(s). The names and addresses of presumptive heirs are listed below. none of the above (must notify Attorney General - see instructions for the address of the Attorney General).
NAME RELATIONSHIP ADDRESS AND TELEPHONE NO.

M

11. None of the above named adults is under any legal incapacity except:
Give name, legal incapacity, and representative of the person, if any

N

12. I REQUEST that the court determine the adult is an incapacitated individual and appoint
Address City Priority relationship State Zip

Name

Telephone no.

, who has priority as

,

full guardian with all powers provided by statute. limited guardian with the following powers:

O

13. No other person appears to have authority to act in the circumstances. I request that a temporary guardian be appointed pending a hearing on this petition because of the following emergency:

I declare under the penalties of perjury that this petition has been examined by me and that its contents are true to the best of my information, knowledge, and belief.

P

Date Petitioner signature

Petitioner address City, state, zip Telephone no.

Attorney signature Attorney name (type or print) Bar no.

Attorney address City, state, zip Telephone no.

Q

14. NOMINATION BY THE ALLEGED INCAPACITATED INDIVIDUAL In the event the court finds that I require a guardian, I nominate:
Name, address, and telephone no.

Date

Signature of alleged incapacitated individual