Free STATE OF MINNESOTA - Minnesota

M.S. § 524.5-311 M.S. § 524.5-406(f)/412

State of Minnesota
Select County County of ___________________

District Court Probate Division Judicial District: ______________ Court File No. _________________ Case Type: 14, Conservatorship

Guardianship of In Re: Emergency Agent/Conservatorship of ______________________________

Petition for Emergency Appointment of Guardian Agent/Conservator

TO THE HONORABLE JUDGE OF THE DISTRICT COURT: 1. Petitioner's: Name: ______________________________________ Address: ______________________________________ Telephone number: ______________________________________ Interest in this matter: ______________________________________. 2. Respondent's: Name: ______________________________________ Address: ______________________________________ Telephone number: ______________________________________ Age/Date of birth: ______________________________________. and if the petition is granted, Respondent will be moved to: _____________________ _____________________________________________________________________ 3. The names and addresses of the Respondent's spouse and kindred are: Relationship Name Address a) Spouse (include an adult with whom Respondent has resided for six months or more):

b) Kindred: (adult children, parents and adult brothers and sisters; if none of these, then list the nearest adult kin; See M.S. § 524.5-303(b)(3) and 524.5-102 subd. 7)

GAC 17-U State

ENG

Rev 12/03

www.courts.state.mn.us/forms

Page 1 of 5

M.S. § 524.5-311 M.S. § 524.5-406(f)/412

c) Administrator (if Respondent is in a hospital, VA, unit, nursing home, home care agency or other institution):

d) Legal Representative (guardian/conservator, representative payee, trustee or custodian of property):

e) Persons nominated, proposed, or confirmed by prior order, as guardian or conservator (file applicable document with petition including a prior order, health care directive or related document):

4.

5.

An emergency appointment of a Guardian of Respondent should be made because: A. A petition for appointment of a general guardian for Respondent has been filed, or will be filed in the immediate future with this court; B. Compliance with the procedures for appointment of a general guardian will likely result in substantial harm to the Respondent's health, safety, or welfare, and no other person appears to have the authority and the willingness to act on Respondent's behalf; C. The Respondent's needs for health, safety, or welfare are at risk because: (Describe behavior and circumstances supporting this allegation): __________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ ___________________________________________________________; and D. no alternative less restrictive of civil rights and liberties exists, including the use of appropriate technological assistance. The following powers are needed for an Emergency Guardian to protect and supervise the person of the Respondent: All of the rights and powers on behalf of the Ward under M.S. § 524.5-313 subd.(c) paragraphs 1, 2, 3, 4, 5, 6 and 7. (If the Guardian is granted limited powers and duties, specify which powers and duties are vested in the Guardian by this Order.) Have custody of the Ward and establish the place of abode for the Ward within or without the State, M.S. § 524.5-313 (c)(1); Provide for the Ward's care, comfort and maintenance needs, M.S. § 524.5313 (c)(2); Take reasonable care of the Ward's clothing, furniture, vehicles and other personal effects, M.S. § 524.5-313 (c)(3);

GAC 17-U State

ENG

Rev 12/03

www.courts.state.mn.us/forms

Page 2 of 5

M.S. § 524.5-311 M.S. § 524.5-406(f)/412

6.

7.

Give any necessary consent to enable, or to withhold consent for, the Ward to receive necessary medical or other professional care, counsel, treatment or service, M.S. § 524.5-313 (c)(4); Approve or withhold approval of any contract, except for necessities, which the Ward may make or wish to make (only given if no conservator is appointed), M.S. § 524.5-313 (c)(5); Exercise supervision authority over the Ward, M.S. § 524.5-313 (c)(6); Apply on behalf of the Ward for any assistance, services, or benefits available to the Ward through any unit of government, M.S. § 524.5-313 (c)(7); (other)________________________________________________________. All other powers, duties and responsibilities conferred on the Guardian under applicable law. An emergency appointment of an agent or Conservator of Respondent is needed because: A. A petition for appointment of a general conservator of the estate for Respondent has been filed, or will be filed in the immediate future with this court; B. Compliance with the procedures for appointment of a general conservator will likely result in harm to the Respondent's health, safety, or welfare; or property is needed for support of the Respondent or for individuals who are in fact dependent upon the Respondent for support; and no other person appears to have the authority and the willingness to act on Respondent's behalf; C. The Respondent's needs for health, safety, or welfare are at risk, or the Respondent's assets must be immediately preserved, because: (Describe behavior and circumstances supporting this allegation): __________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ ___________________________________________________________; and no alternative less restrictive of civil rights and liberties exists, including the D. use of appropriate technological assistance. The following powers are needed for an emergency agent or Conservator to protect and supervise the estate of the Respondent: All of the rights and powers under M.S. § 524.5-417 subd. (c) paragraphs 1, 2, 3, 4, 5 and 6.. (If the Conservator is granted limited powers and duties, specify which powers and duties are vested in the Conservator by this Order.) Pay reasonable charges for the support, maintenance, and education of the Protected Person in a manner suitable to the Protected Person's station in life and the value of the Protected Person's estate, M.S. § 524.5-417 (c)(1); Pay out of the Protected Person's estate all lawful debts of the Protected Person, M.S. § 524.5-417 (c)(2); Possess and manage the estate of the Protected Person, collect all debts and claims in favor of the Protected Person, or with the approval of the court compromise them, institute suit on behalf of the Protected Person and represent the Protected Person in court proceedings, and invest pursuant to M.S. § 48A.

GAC 17-U State

ENG

Rev 12/03

www.courts.state.mn.us/forms

Page 3 of 5

M.S. § 524.5-311 M.S. § 524.5-406(f)/412

8.

9. 10.

07(6) and 501B.151 all funds not currently needed for debts, charges, and management of the estate, M.S. § 524.5-417 (c)(3); Exchange or sell an undivided interest in real property, M.S. § 524.5-417 (c)(4); Approve or withhold approval of any contract, except for necessities, which the Protected Person may make or wish to make, M.S. § 524.5-417 (c)(5); Apply on behalf of the Protected Person for any assistance, services, or benefits available to the Protected Person through any unit of government, M.S. § 524.5-417 (c)(6); and (other)____________________________________________________; All other powers, duties and responsibilities conferred on the Conservator under applicable law. The probable value and the general character of the assets of the Respondent are: Homestead: $_____________________________ Other Real Estate: $_____________________________ Money: $_____________________________ Investments: $_____________________________ Personal Property: $_____________________________ Other: $_____________________________ TOTAL: $_____________________________ The probable amount of the debts of the Respondent is $_______________________. The name, age, address, and phone number of each proposed: Guardian is: Name, age ___________________________ Address: ___________________________ ___________________________ Telephone number: ___________________________; ___________________________ ___________________________ ___________________________ Telephone number: ___________________________. Each proposed Guardian and Conservator is the most suitable and best qualified among those available and willing to discharge the trust and is not excluded from appointment pursuant to M.S. § 524.5-309(c) or 524.5-413(d). Conservator is: Name, age Address:

11.

WHEREFORE, your Petitioner respectfully requests the Court, without notice to interested persons, schedule a time and place for a preliminary hearing on this petition and, after the appointing _____________________________ Guardian of hearing, issue an order an Respondent with the powers and duties described in allegations numbered 5 above and order appointing ___________________________________ as Agent/Conservator of Respondent, or as a limited agent of Respondent, with the powers and duties described in allegations numbered 7 above.

GAC 17-U State

ENG

Rev 12/03

www.courts.state.mn.us/forms

Page 4 of 5

M.S. § 524.5-311 M.S. § 524.5-406(f)/412

FURTHER, under penalties for perjury for deliberate falsification therein, I declare or affirm that I have read the foregoing petition and, to the best of my knowledge or information, its representations are true, correct and complete.

Dated:_________________

__________________________________ Petitioner Name of Petitioner's Attorney: Name: ___________________________ License No.: ___________________________ Address: ___________________________ ___________________________ City/State/Zip: ___________________________

GAC 17-U State

ENG

Rev 12/03

www.courts.state.mn.us/forms

Page 5 of 5