AS 13.26.005-.0Probate Rules 14 - 19 Page 1 of 7 PG-100 ((cs)PETITION FOR APPOINTMENT OF A FULL GUARDIAN FOR AN ADULT IN THE SUPERIOR COURT FOR THE STATE OF ALASKA AT In the Matter of the Protective Proceeding of ) ) ) ) ) ) CASE NO. Respondent (person who needs a guardian) ) ) PETITION FOR APPOINTMENT OF A FULL GUARDIAN FOR AN ADULT [Full guardianship is a legal arrangement where the court appoints a person or institution to make all decisions on issues such as housing, medical care, legal issues, finances, and services. If you only wish for limited guardianship, use form PG-103 . For a conservatorship (financial management only), use form PG-104 .] 1.Petitioner asks the court to appoint a full guardian for the above-named respondent because the respondent is incapacitated as defined in Alaska Statute 13.26.005(5).[Someone is incapacitated if his or her ability to receive and evaluate information or tocommunicate decisions is so impaired that the person cannot provide for their physicalhealth or safety without court-ordered help (including health care, food, shelter,clothing, personal hygiene, and protection).] How long will this appointment need to last? 2.Petitioner's NameAge Mailing Address (box or street number) (city) (state) (ZIP) E-mail Address Home Phone Work Phone Cell Phone Relationship to the Respondent 3.Respondent's NameDate of Birth Mailing Address (box or street number) (city) (state) (ZIP) Residence Address (street address) (city) (state) Daytime Phone Social Security No. 4.Has anyone filed a petition for appointment of a guardian for the respondent in anyother state? No. Yes, in (court name & location), by , case number (if known): (AS 13.27.170) 5.Has anyone filed a petition to protect the respondent from financial abuse? No Yes. Case Number: American LegalNet, Inc. www.FormsWorkFlow.com AS 13.26.005-.Probate Rules 14 - 19 Page 2 of 7 PG-100 ((cs)PETITION FOR APPOINTMENT OF A FULL GUARDIAN FOR AN ADULT 6.The r 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). 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 AddressPhone c.Does the respondent currently have a guardian? No Yes If yes, guardian's name, address and phone d.Does the respondent currently have a conservator? No Yes If yes, conservator's name, address and phone e.Has the respondent given a power of attorney to anyone? No Yes If yes, name, address and phone f.Does respondent have a "representative payee" for social security or other benefits? No Yes If yes, name, address and phone g.her own behalf? No Yes If yes, describe the restrictions: h.Does the respondent have a living will or a durable power of attorney for health careor any other document directing how health care decisions should be made if therespondent is unable to make them? No I do not know Yes Describe (include name of any agent authorized to make health care decisions forthe respondent): i.Is a no-code (Do Not Resuscitate) provision in place for the respondent? No I do not know Yes American LegalNet, Inc. www.FormsWorkFlow.com AS 13.26.005-.0Probate Rules 14 - 19 Page 3 of 7 PG-100 ((cs)PETITION FOR APPOINTMENT OF A FULL GUARDIAN FOR AN ADULT 8.List the names, addresses and telephone numbers of the following relatives of therespondent: (If 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 Phone Address a.Spouse: b.Children: c.Parents: d.Brothers and Sisters: e.If the respondent has none of the above relatives, list the name and address of therespondent's nearest relative: 9.List names, addresses and telephone numbers of close friends whomay have current information about the respondent: 10.Respondent's Financial Information a.Monthly Incomeb.Monthly Expenses Wages, Pension, RetirementFood Social SecurityRent or Mortgage S.S.I.Utilities Public AssistanceCar Payment Longevity BonusCredit Card Payment Interest and DividendsInsurance Veteran's BenefitsMedical (not covered Other monthly income:by insurance) Other: TOTAL TOTAL American LegalNet, Inc. www.FormsWorkFlow.com AS 13.26.005-.0Probate Rules 14 - 19 Page 4 of 7 PG-100 ((cs)PETITION FOR APPOINTMENT OF A FULL GUARDIAN FOR AN ADULT c.Other Income Received During Last 12 Months Permanent Fund Dividends (PFD) received in last 12 months Native/Other Corporation Dividends not listed above Value of gifts or inheritances received in last 12 months Other: d.Assetse.Debts Cash on hand or in savingsMortgages or checking account Stocks, bonds, CDs,Loans mutual funds HomeCredit card balance Other land or buildingsOther: Vehicles Businesses Insurance Other Property TOTAL ASSETSTOTAL DEBTS f.Additional Financial Information Does the respondent have a trust? No g. Petitioner has no knowledge of the respondent's financial situation. 11.Is the respondent a veteran entitled to the payment of money from the U.S. Departmentof Veterans Affairs? Yes No 12.Describe the or shecannot take care of all of his or her living responsibilities: Yes. Name of Financial Institution and trustee: Does the respondent belong to a Native Corporation? No Yes. Name of Native Corporation: Please list the institutions where the respondent has savings, checking or investment accounts: American LegalNet, Inc. www.FormsWorkFlow.com AS 13.26.005-.0Probate Rules 14 - 19 Page 5 of 7 PG-100 ((cs)PETITION FOR APPOINTMENT OF A FULL GUARDIAN FOR AN ADULT 13.List examples that show how the respondent's limitations have, or may, lead to physicalinjury or illness and the need for a guardian: 14.List people you know who have knowledge that might help the court determine thecapacity and needs of the respondent including the respondent's ability to manage his orher property and affairs. Name Phone Address a.Doctors: b.Counselors and Social Workers: c.Case Managers and Care Coordinators: d.Others (Teachers, Clergy, etc.): 15.Letters or Evaluations: Attached to this petition are letters or evaluations from a doctor, ANP, neuropsychologist, psychologist, or psychiatrist considered decisions regarding his or her affairs. I do not have any letters or evaluations to attach. 16.Who do you think the court should appoint guardian? Name Address Phone This person's relationship to the respondent is: American LegalNet, Inc. www.FormsWorkFlow.com AS 13.26.005-.0Probate Rules 14 - 19 Page 6 of 7 PG-100 ((cs)PETITION FOR APPOINTMENT OF A FULL GUARDIAN FOR AN ADULT This person has priority to be appointed under AS 13.26. because he or she is: (1) nominated by the respondent. (2) (3) (4) rent. (5) months during the year before filing this petition. (6) (7) a private professional conservator. (8) the public guardian. If there are unchecked boxes above the one you checked, list the names and addresses of persons who could check those boxes. (For example, if you checked number (3), you respondent, if any.) Names and Addresses: 17. Who do you think the court should appoint conservator? (Can be same as guardian.)Name:Address: PhoneThis person's relationship to the respondent is:This person has priority to be appointed under AS 13.26. because he or she is: (1) nominated by the respondent. (2) (3) (4) (5) months during the year before filing this petition. (6) relative or friend who has shown a sincere and longstanding (7) a private professional conservator. (8) the public guardian. If there are unchecked boxes above the one you checked, list the names and addresses of persons who could check those boxes. (For example, if you checked number (3), you would fill in the respondent, if any.) Names and Addresses: American LegalNet, Inc. www.FormsWorkFlow.com AS 13.26.005-.0Probate Rules 14 - 19 Page 7 of 7 PG-100 ((cs)PETITION FOR APPOINTMENT OF A FULL GUARDIAN FOR AN ADULT Date