Free pc658.pmd - Michigan

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JIS CODE: PEG

STATE OF MICHIGAN PROBATE COURT COUNTY
CIRCUIT COURT - FAMILY DIVISION

PETITION FOR APPOINTMENT OF GUARDIAN, INDIVIDUAL WITH ALLEGED DEVELOPMENTAL DISABILITY

FILE NO.

A B

In the matter of 1. I,
Name (type or print) State your interest/relationship

, an individual with an alleged developmental disability , am interested in this matter and make this petition as .

C

2. An action within the jurisdiction of the family division of circuit court involving the family or family members of the individual has been previously filed in assigned to Judge Court, Case Number , and , is a resident of
Date County Name of person or center or facility City State Zip

, was is no longer pending. , at . XXX-XXLast four digits of SSN

remains

D

3. The individual named above, born Michigan, and presently lives with/at
Address

E

The individual is a citizen of the following foreign country: 4. His/her presumptive heirs are as follows: (Attach additional page if needed.)
NAME AGE RELATIONSHIP ADDRESS

F G

5. A report and evaluation required by law

accompanies

does not accompany

the petition.

6. The individual has a developmental disability described as a severe, chronic condition that meets all of the following: 1) it is attributable to a mental or physical impairment or a combination of mental and physical impairments; 2) it was manifested before the individual was 22 years old; 3) it is likely to continue indefinitely; and 4) it results in substantial functional limitations in the major life activities of (A minimum of three of the following options must apply and be checked.) self-care, receptive and expressive language, learning, mobility, self-direction, capacity for independent living, economic self-sufficiency, and it reflects the individual's need for a combination and sequence of special, interdisciplinary, or generic care, treatment, or other services that are of lifelong or extended duration and are individually planned and coordinated. 7. The specific nature and extent of the disability is:

H

(PLEASE SEE OTHER SIDE)
Do not write below this line - For court use only

MCL 330.1100a, MCL 330.1609 PC 658 (9/08)

PETITION FOR APPOINTMENT OF GUARDIAN, INDIVIDUAL WITH ALLEGED DEVELOPMENTAL DISABILITY

I

8. A guardian is needed to assist the individual with the following responsibilities and duties:

J

9. The estimated value of the individual's estate and income are: Real estate: Yearly income: I REQUEST THAT: 10. 11. If a report does not accompany this petition, the court order evaluations to be performed and a report to be prepared. The court determine that the individual requires guardianship as an individual with a developmental disability. The court determine and appoint
Address Name City State Zip

$ $

Personal property:

$

Source of yearly income:

K

12.

of
Telephone no.

or appoint some other suitable individual or entity as a. plenary (full) guardian of the b. partial guardian of the individual individual estate estate

with the following powers:

The proposed guardian is a current service provider. No other individual or agency is suitable to serve as guardian.

L

13.

The court authorize the guardian to execute an application for admission to located at
Address

Name of facility

.

M

14.

Pending the appointment of a guardian, the court appoint a temporary guardian or exercise its emergency powers because
Describe emergency situation

.

N

15.

The court appoint

Name

of

Address

as standby guardian. 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.
Signature of attorney Name (type or print) Address City, state, zip Telephone no. Bar no. Date Signature of petitioner Address City, state, zip Telephone no.

INSTRUCTIONS FOR COMPLETING "PETITION FOR APPOINTMENT OF GUARDIAN, INDIVIDUAL WITH ALLEGED DEVELOPMENTAL DISABILITY"
Please type or print neatly using black or blue ink.
Items A through N 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 C Enter the name of the individual whom you believe needs a guardian. Enter your name on 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 a personal protection, abuse or neglect, adoption, name change, or divorce or support action. If the individual is under the age of 19½, the individual may be the subject of a support order if the parents are divorced or a support order was entered. 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 the case. Place a check in the box indicating whether the case is still pending or not. Enter the date of birth of the individual on the first line, the name of the county the person resides in on the second line, and the name and address of the person, center or facility where the person is currently located. This address may or may not be the home of the individual. List the presumptive heirs of the individual. If the individual has a spouse or minor or adult children, list those individuals' names, addresses, ages, relationships and current addresses. If the individual does not have a spouse or children, list the parents of the individual and if there are no living parents, then the siblings of the individual, with their ages, relationship and current addresses. If the individual doesn't have any siblings, list any other presumptive heirs. If the individual has no presumptive heirs, you must notify the Attorney General by sending a copy of this form to: Attorney General, Public Administration, PO Box 30736, Lansing, MI 48909. Indicate whether a report and evaluation required by law accompanies or does not accompany the petition. Check the appropriate boxes under this item (not less than three). Indicate the specific nature and extent of the disability. Explain in detail, giving specific examples why a guardian is needed to assist the individual. For example, decision-making in all aspects of life, such as medical and residential aspects. Give an estimated value of the individual's estate and income. If the individual receives social security benefits or some other type of monthly benefit, calculate the yearly amount and indicate the source of the income. Enter on the first line the name of the person you are requesting be appointed guardian of the individual and the address of that person on the second line. Check the appropriate box indicating whether you are requesting a plenary (full) guardian or a partial guardian of the individual and/or the estate and list the powers you desire the guardian to have. A full guardian has custody of the individual and will make all decisions regarding the individual's person. A partial guardian does not have custody of the individual, which will allow the individual to make certain decisions on his/her own. Please note that unless the individual owns or has interest in real estate or substantial other personal property or has income from a source other than social security (unless the individual is the beneficiary of a trust), it is generally not necessary to appoint a guardian of the estate. Check the next box if the proposed guardian is a current service provider. A current service provider includes the owner of an adult foster care home where the individual resides and who is not related to the individual. L M N Check this box if it is necessary for the guardian to execute an application for admission to place the individual in a facility. Enter the name of the facility on the first line and the address of the facility on the second line. Check this box if an emergency exists and it is necessary to have a temporary guardian appointed. Indicate in detail the emergency situation on the provided lines. Check this box to request the appointment of a standby guardian. Enter the name of the person you want to be the standby guardian on the first line and the address of that person on the second line. The standby guardian cannot be the nominated guardian. Generally, a standby guardian should be requested unless the proposed guardian is an agency or corporation. A standby guardian will be able to step in to act as guardian in certain circumstances, such as if the guardian is unable to act or dies.

D

E

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