IN THE SUPERIOR COURT FOR THE STATE OF ALASKA AT In the Matter of the Protective Proceeding of ) ) ) ) ) ) CASE NO. ) ) PETITION FOR APPOINTMENT OF A CONSERVATOR FOR AN ADULT Respondent (person who needs a conservator) [A conservatorship should be used if the respondent: (1) is unable to manage his or her property and affairs effectively, and (2) has property that will be wasted or used up unless properly managed. For a full guardianship, use court form PG-100. For a partial guardianship, use court form PG-103.] 1. The petitioner asks the court to appoint a conservator for the respondent named above because the respondent: (1) is unable to manage his or her property and affairs effectively, and (2) has property that will be wasted or used up unless properly managed. Petitioner's Name Mailing Address Age (box or street number) (city) (state) (ZIP) 2. E-mail Address Home Phone Relationship to Respondent 3. Respondent's Name Mailing Address Residence Address Daytime Phone 4. Work Phone Cell Phone Date of Birth (city) (state) (ZIP) (box or street number) (street address) (city) Social Security No. (state) Has a petition for appointment of a guardian or a conservator for the respondent been No Yes filed in any other state? If yes, name and location of court Person who filed Case number (if known) [AS 13.27.170] Has a petition to protect the respondent from financial abuse been filed? No Yes. Case Number: 5. Page 1 of 6 PG-104 (3/17)(cs) PETITION FOR APPOINTMENT OF A CONSERVATOR FOR AN ADULT AS 13.26.005-.580 Probate Rules 14 - 19 American LegalNet, Inc. www.FormsWorkFlow.com 6. Respondent's "home state" as defined in AS 13.27.180 is: Alaska because the respondent was physically present in Alaska for the six consecutive months before the filing date of this petition (except for temporary absences). because the respondent was physically present in that state for the six consecutive months before the filing date of this petition (except for temporary absences). I do not know the respondent's "home state." The respondent was in the following states during the year before I filed this petition: Dates During the Past Year Place (State & Address) Where Respondent Lived 7. a. The respondent lives alone. with b. Who takes care of the respondent? Name of person or facility Address c. Does the respondent currently have a guardian? address and phone d. Does the respondent currently have a conservator? name, address and phone No Phone Yes, guardian's name, No Yes, conservator's No Yes, name, e. Has the respondent given a power of attorney to anyone? address and phone f. Does the respondent have a representative payee for social security or other No Yes, name, address and phone benefits? g. Are there any other restrictions on the respondent's legal capacity to act on his or No Yes, describe the restrictions: her own behalf? h. Does the respondent have a living will, durable power of attorney for health care, or any other document directing how health care decisions should be made if No I do not know Yes respondent is unable to make them? If yes, describe (include the name of any agent authorized to make health care decisions for the respondent): i. Is a no-code (do not resuscitate) provision in place for the respondent? No I do not know Yes Page 2 of 6 PG-104 (3/17)(cs) PETITION FOR APPOINTMENT OF A CONSERVATOR FOR AN ADULT AS 13.26.005-.580 Probate Rules 14 - 19 American LegalNet, Inc. www.FormsWorkFlow.com 8. List the names, addresses and telephone numbers of the following: [If the respondent has no such relative, write "none" on that line. Attach additional pages if necessary. Do not write on the back of any page.] Name a. Respondent's Spouse: b. Respondent's Children: Phone Address c. Respondent's Parents: d. Respondent's Brothers and Sisters: e. If the respondent has none of the above relatives, list the name and address of the respondent's nearest relative: 9. List names, addresses and telephone numbers of the respondent's close friends who may have current information about the respondent: 10. Respondent's Financial Information a. Monthly Income Wages, Pension, Retirement Social Security S.S.I. Public Assistance Longevity Bonus Interest and Dividends Veteran's Benefits Other monthly income: TOTAL b. Monthly Expenses Food Rent or Mortgage Utilities Car Payment Credit Card Payment Insurance Medical (not covered by insurance) Other: TOTAL AS 13.26.005-.580 Probate Rules 14 - 19 American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 6 PG-104 (3/17)(cs) PETITION FOR APPOINTMENT OF A CONSERVATOR FOR AN ADULT c. Other Income Received During the Last 12 Months Permanent Fund Dividends received in last 12 months Native/Other Corporation Dividends not listed above Value of gifts or inheritances received in last 12 months Other: d. Assets Cash on hand or in savings or checking account Stocks, bonds, CDs, mutual funds Home Other land or buildings Vehicles Businesses Insurance Other Property TOTAL ASSETS f. Other Financial Information Does the respondent have a trust? No. Yes. Name of financial institution and trustee: Does the respondent belong to a Native Corporation? No. Yes. Name of Native Corporation: List the institutions where respondent has savings, checking, investment accounts: e. Debts Mortgages Loans Credit card balance Other TOTAL DEBTS g. 11. 12. Petitioner has no knowledge of the respondent's financial situation. Is the respondent a veteran who is entitled to the payment of money from the U.S. Yes No Department of Veterans Affairs? Why are you interested in this matter? 13. Explain why a conservator should be appointed (list examples that show how the respondent cannot manage his or her own property and affairs): Page 4 of 6 PG-104 (3/17)(cs) PETITION FOR APPOINTMENT OF A CONSERVATOR FOR AN ADULT AS 13.26.005-.580 Probate Rules 14 - 19 American LegalNet, Inc. www.FormsWorkFlow.com 14. List people you know who have knowledge that might help the court determine the respondent's ability to manage his or her property and affairs. a. Doctors: Name Phone Address b. Counselors and Social Workers: c. Case Managers and Care Coordinators: d. Others (Landlords, Clergy, etc.): 15. Who do you think should be appointed conservator? Name: Address: Phone This person's relationship to the respondent is: This person has priority to be appointed under AS 13.26.465 because he or she is: (1) nominated by the respondent. (2) the respondent's spouse. (3) the respondent's adult child. (4) the respondent's