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AOC-740 Rev. 5-04 Page 1 of 2

Doc. Code: PDD
01/9/2007 11:45 am
Ver. 1.01

Case No. Court PETITION TO DETERMINE IF DISABLED County

Commonwealth of Kentucky Court of Justice www.kycourts.net KRS 387.530 COMMONWEALTH OF KENTUCKY VS.

PETITIONER RESPONDENT

__________________________________________________________________ has reasonable grounds or knowledge to lead him/her to believe Respondent appears to be unable to provide for his/her physical health and safety and/or manage his/her financial resources effectively and submits to the Court the following facts upon which he/she supports this belief: 1. Name of Petitioner: Address: __________________________________________________________________________

___________________________________________________________________________________

______________________________________________________________________________________________ ______________________________________________________________________________________________ Telephone Number: ________________________ ____________________________________________________________ Petitioner's relationship to Respondent:

2. Name of Respondent: ___________________________________________________________________________ Address: ______________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Respondent's Date of Birth (if known): ____________________ 3. The nature of Respondent's disability and the facts or reasons supporting the need for determination of disability are: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ 4. Respondent owns the following estate, including government benefits, insurance entitlements, and anticipated yearly income (state none or unknown): ESTATE Real Property Personal Property Yearly Income Source of Yearly Income VALUE $____________________ $____________________ $____________________ ______________________________________________________________________

_____________________________________________________________________________________________ 5. Name of Person having custody of Respondent: ____________________________________________________ Address: _____________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________

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AOC-740 Rev. 5-03 Page 2 of 2 6. Respondent's [ ] Durable Power of Attorney OR [ ] Health Care Surrogate is: Name: _______________________________________________________________________________________ Address: _____________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ 7. Respondent's next of kin: Name: _______________________________________________________________________________________ Address: _____________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Relationship to Respondent: ________________________________________________________________ Name: _______________________________________________________________________________________ Address: _____________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Relationship to Respondent: ________________________________________________________________

WHEREFORE, Petitioner requests the Court inquire into Respondent's ability to care for himself/herself and to manage his/her financial resources. Petitioner attaches an Application for Appointment of Fiduciary and further requests: 1. Trial by jury; 2. Counsel to represent the Respondent; and 3. Court appointment of a physician, psychologist and social worker to evaluate Respondent as provided by law unless the evaluation report is filed with this Petition. Date: ___________________, 2______ ___________________________________________ Signature of Petitioner

Subscribed and before me on________________, 2_____. My commission expires: _________________, 2____. ______________________________________________ Name/Title

To be completed if Applicant is represented by counsel: Attorney's Name _________________________________________________________________________________ Address _______________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ Telephone Number ______________________________ ____________________________________________ Attorney Signature

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