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 PARTIAL GUARDIAN FOR AN ADULT [Partial guardianship is a legal arrangement where the court appoints a person or institution as a partial guardian to make decisions on limited issues stated in the court order such as housing, medical care, legal issues, finances, or services. This is different from a full guardianship when a full guardian makes decisions on all of those issues. If you wish for full guardianship, use form PG-100. For a conservatorship (financial management only), use form PG-104.] 1. Petitioner asks the court to appoint a partial guardian for the respondent named above 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 to communicate decisions is so impaired that the person cannot provide for their physical health or safety without court-ordered help (including health care, food, shelter, clothing, personal hygiene, and protection).] I request the partial guardian be granted the following powers and duties: How long will this appointment need to last? 2. Petitioner's Name Mailing Address Age (box or street number) (city) (state) (ZIP) E-mail Address Home Phone Relationship to Respondent 3. Respondent's Name Mailing Address Work Phone Cell Phone Date of Birth (city) (city) (state) (state) (ZIP) (box or street number) Residence Address (street address) Daytime Phone Social Security No. AS 13.26.005-.580 Probate Rules 14 - 19 American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 7 PG-103 (3/17)(cs) PETITION FOR APPOINTMENT OF A PARTIAL GUARDIAN FOR AN ADULT 4. Has anyone filed a petition for appointment of a guardian for the respondent in any other state? No. Yes, in (court name & location) , by , case number [AS 13.27.170] Has anyone filed a petition to protect the respondent from financial abuse? No Yes. Case Number: Respondent's "home state" as defined in AS 13.27.180 is: Alaska, because respondent was physically present here 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 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 5. 6. 7. a. Respondent lives alone with b. Who takes care of respondent? Name of person or facility Address c. Does respondent currently have a guardian? No Yes Guardian's name, address and phone d. Does respondent currently have a conservator? Conservator's name, address and phone No Phone Yes e. Has respondent given a power of attorney to anyone? Name, address and phone f. No Yes 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 respondent's legal capacity to act on his or her 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 AS 13.26.005-.580 Probate Rules 14 - 19 American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 7 PG-103 (3/17)(cs) PETITION FOR APPOINTMENT OF A PARTIAL GUARDIAN FOR AN ADULT 8. List the names, addresses and telephone numbers of the following relatives of the respondent: (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 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 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: b. Monthly Expenses Food Rent or Mortgage Utilities Car Payment Credit Card Payment Insurance Medical (not covered by insurance) Other: TOTAL TOTAL Page 3 of 7 PG-103 (3/17)(cs) PETITION FOR APPOINTMENT OF A PARTIAL GUARDIAN FOR AN ADULT AS 13.26.005-.580 Probate Rules 14 - 19 American LegalNet, Inc. www.FormsWorkFlow.com 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 Other: d. Assets e. Debts Cash on hand or in savings Mortgages or checking account Stocks, bonds, CDs, Loans mutual funds Home Credit card balance Other land or buildings Other: Vehicles Businesses Insurance Other Property TOTAL ASSETS TOTAL DEBTS f. Additional 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 or investment accounts: g. 11. 12. Petitioner has no knowledge of the respondent's financial situation. Is the respondent a veteran entitled to the payment of money from the U.S. Department of Veterans Affairs? Yes No Describe the respondent's mental or physical state that makes you to think he or she cannot take care of all of his or her living responsibilities: Page 4 of 7 PG-103 (3/17)(cs) PETITION FOR APPOINTMENT OF A PARTIAL GUARDIAN FOR AN ADULT AS 13.26.005-.580 Probate Rules 14 - 19 American LegalNet, Inc. www.FormsWorkFlow.com 13. List examples that show how the respondent's limitations have, or may, lead to physical injury or illness and the need for a guardian: 14. If you believe a conservator (someone to manage the respondent's money) should be appointed, explain why you think