IN THE SUPERIOR COURT FOR THE STATE OF ALASKA AT In the Matter of the Protective Proceeding of Respondent ) ) ) ) ) ) ) ) CASE NO. PETITION FOR APPOINTMENT OF A GUARDIAN CONSERVATOR (AS 13.26.105) (AS 13.26.180) FOR AN ADULT (Answer all questions on this form, including both the “Guardianship” and “Conservatorship” questions on pages 4 – 7.) 1. Petitioner asks the court to appoint the following for the above-named respondent: a guardian because the respondent is incapacitated as defined in Alaska Statute 13.26.005(4). [Respondent's ability to receive and evaluate information or to communicate decisions is impaired to the extent that he/she lacks the ability to provide the essential requirements for his/her physical health or safety without court-ordered assistance.] a conservator because the respondent is (1) unable to manage his/her property and affairs effectively and (2) has property that will be wasted or dissipated unless proper management is provided (or needs the management of a conservator in order to receive proper financial support). 2. Petitioner's Name Age Mailing Address (box or street number) Home Phone (city) (state) (ZIP) Work Phone Relationship to Respondent 3. Respondent's Name Date of Birth Mailing Address (box or street number) (city) (state) (city) (ZIP) (state) Residence Address (street address) Daytime Phone 4. Social Security No. Has a petition for appointment of a guardian for respondent been filed in any other state? No. Yes, in (court name & location) , by , case number (if known): (AS 13.27.170) Page 1 of 7 AS 13.26.005-.320 PG-100 (9/08)(cs) Probate Rules 14 - 19 PETITION FOR APPOINTMENT OF A GUARDIAN/CONSERVATOR FOR AN ADULT American LegalNet, Inc. www.FormsWorkflow.com 5. Respondent’s “home state” as defined in AS 13.27.180 is: Alaska because respondent was physically present in Alaska for the six consecutive months before the filing date of this petition (except for temporary absences). because 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 which state is respondent’s “home state.” Respondent has been physically present in the following states at the following times during the year prior to my filing this petition: Dates During the Past Year 6. a. Respondent lives Place (State & Address) Where Respondent Resided alone with b. Who takes care of respondent? Name of person or facility Address Phone c. Does respondent currently have a guardian? No Yes Guardian's name, No Yes Conservator's name, address and phone d. Does respondent currently have a conservator? address and phone e. Has respondent given a power of attorney to anyone? No Yes Name, address and phone f. Does respondent have a "representative payee" for social security or other benefits? No Yes Name, address and phone g. Are there any other restrictions on the legal capacity of the respondent to act in respondent's own behalf? No Yes If yes, describe the restrictions: h. Does respondent have a living will or a durable power of attorney for health care or any other document directing how health care decisions should be made if respondent is unable to make them? No I do not know Yes Describe (include 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 7 AS 13.26.005-.320 PG-100 (9/08)(cs) Probate Rules 14 - 19 PETITION FOR APPOINTMENT OF A GUARDIAN/CONSERVATOR FOR AN ADULT American LegalNet, Inc. www.FormsWorkflow.com 7. List the names, addresses and telephone numbers of the following relatives of the respondent: (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 respondent has none of the above relatives, list the name and address of respondent's nearest relative: 8. List names, addresses and telephone numbers of close friends of respondent who may have current information about respondent: 9. Respondent's Financial Information a. Monthly Income b. Monthly Expenses Wages, Pension, Retirement Social Security S.S.I. Public Assistance Longevity Bonus Interest and Dividends Veteran's Benefits Other monthly income: Food Rent or Mortgage Utilities Car Payment Credit Card Payment Insurance Medical (not covered by insurance) Other: TOTAL TOTAL c. Other Income Received During 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 Page 3 of 7 AS 13.26.005-.320 PG-100 (9/08)(cs) Probate Rules 14 - 19 PETITION FOR APPOINTMENT OF A GUARDIAN/CONSERVATOR FOR AN ADULT American LegalNet, Inc. www.FormsWorkflow.com Other: d. Assets e. Debts 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. 10. Mortgages Loans Credit card balance Other Debts TOTAL DEBTS Petitioner has no knowledge of respondent's financial situation. Is respondent a veteran entitled to the payment of money from the U.S. Department of Yes No Veterans Affairs? Guardianship (Answer all questions.) 11. Describe the nature and degree of respondent's incapacity (the limitations on his/her ability to understand or communicate that endanger his/her physical health or safety): 12. List the facts that support your allegations of incapacity and the need for appointment of a guardian (examples that show how the respondent's limitations have, or may, lead to physical injury or illness). Page 4 of 7 AS 13.26.005-.320 PG-100 (9/08)(cs) Probate Rules 14 - 19 PETITION FOR APPOINTMENT OF A GUARDIAN/CONSERVATOR FOR AN ADULT American LegalNet, Inc. www.FormsWorkflow.com 13. a. Type of appointment sought: Full guardianship with all the powers described in AS 13.26.150(c), including the powers of a conservator to manage and control respondent’s financial affairs (almost all the powers and duties a parent has with respect to a minor child). [Answer all the questions on this form, including the “Conservatorship” questions on pages 6 -7.] Partial guardianship with the following specific powers and duties: (List any powers and duties you want the court to grant. Examples: to have custody and decide where respondent will live; to arrange for medical care and consent to medical treatment; to apply for benefits for respondent; to receive money due to respondent and apply it to provide support, care or education for respondent.) [Answer all the questions on this form, including the “Conservatorship” questions on pages 6 -7.] b. How long will this appointment need to last? 14. List people you know who have knowledge that might help the court determine the capacity and needs of the respondent. Name Phone Address a. Doctors: b. Counselors and Social Workers: c. Case Managers and Care Coordinators: d. Others (Teachers, Clergy, etc.): 15. Who do you think should be appointed guardian? Name Address This person's relationship to the respondent is This person's priority for appointment under AS 13.26.145 is Phone Page 5 of 7 AS 13.26.005-.320 PG-100 (9/08)(cs) Probate Rules 14 - 19 PETITION FOR APPOINTMENT OF A GUARDIAN/CONSERVATOR FOR AN ADULT American LegalNet, Inc. www.FormsWorkflow.com Names and addresses of persons with higher priority are: Conservatorship (Answer all questions.) 16. State petitioner's interest in this matter: 17. Explain why a conservator should be appointed: 18. Who do you think should be appointed conservator? Name: Address: Phone This person's priority for appointment under AS 13.26.210 is Names and addresses of persons with higher priority are: 19. List people you know who have knowledge that might help the court determine the respondent's ability to manage his/her property and affairs. Name Phone Address a. Doctors: b. Counselors and Social Workers: c. Case Managers and Care Coordinators: d. Others (Landlords, Clergy, etc.): Page 6 of 7 AS 13.26.005-.320 PG-100 (9/08)(cs) Probate Rules 14 - 19 PETITION FOR APPOINTMENT OF A GUARDIAN/CONSERVATOR FOR AN ADULT American LegalNet, Inc. www.FormsWorkflow.com Date Signature of Petitioner or Petitioner's Attorney If attorney, print name and bar number: Verification I state on oath or affirm that I have read this petition and that all statements made in it are true to the best of my knowledge and belief. Date Subscribed and sworn to or affirmed before me at on . (date) (SEAL) Petitioner's Signature , Alaska Clerk of Court, Notary Public, or other person authorized to administer oaths. My commission expires: Page 7 of 7 AS 13.26.005-.320 PG-100 (9/08)(cs) Probate Rules 14 - 19 PETITION FOR APPOINTMENT OF A GUARDIAN/CONSERVATOR FOR AN ADULT American LegalNet, Inc. www.FormsWorkflow.com