PP-105 001 (Rev. 5-1-98) STATE OF MAINE County Probate Court Docket No. In Re: JOINED PETITIONS: Minor Appointment of Conservator and Guardian of Minor 1. Name, address and telephone number of petitioner: 2. Name and address of nominee to become guardian. (If same as item 1, enter 223same224.) State qualifications of the nominee and why said appointment would be in the best interest of the minor. 3. Date of birth of persons listed in item 2, and relationship of such person to the minor: 4. Name and legal residence of minor1: 5. Date of birth of minor: 6. Current location of the minor (if same as item 4, enter 223same224): 7. Name and addresses of all persons who must be notified and the relationship of each to the minor2: (Indicate of waivers of notice have been or are to be filed.) NAME ADDRESS RELATIONSHIP WAIVERS 8. Any person listed in item 7, other than the minor, may wave notice and hearing and agree to this appointment by signing here. This waiver does not apply to subsequent proceedings. American LegalNet, Inc. www.FormsWorkFlow.com 001 PP-105 (Rev. 5-1-98) Page 2 of 5 9. I, , being 14 years of age or older do hereby nominate to be my Guardian and consent to his/her appointment as such without the necessity of hearing.3 Dated: (signature of minor) 10. Is a temporary guardian required? YES NO . If yes, state here the reasons why and the name and address of the suggested temporary guardian.4 11. State here the issues to be heard and indicate who may take a position contrary to that of petitioner. 12. Is appointment of an attorney for the indigent non-consenting parent or legal custodian required? YES NO If yes, state the reasons why.5 13. Has the nominee attached a child custody affidavit as required by 19-A MRSA 247 17106? YES NO . If no, state when it will be filed. 14. Has the nominee attached an acceptance of appointment? YESNO If no, state when it will be filed. 15. State here the circumstances leading to this petition: (check where applicable) (a) Both parents have died making no testamentary appointment. (Copies of death certificates are attached). (b) Parental rights of custody have been terminated by a prior court order.7 (A certified copy of said order is attached). (c) Parental rights of custody have been suspended by circumstances:7 Explain. (d) A surviving parent(s) (has) (have) been adjudged incapacitated.8 Explain. (e) A living situation has been created that is at least temporarily intolerable for the minor as follows9: The proposed guardian will provide a living situation that is in the best interest of the minor. (A guardianship plan may be required.) (f) Other, explain: American LegalNet, Inc. www.FormsWorkFlow.com PP - 105 (Rev. 5-1-98) Page 3 of 5 001 16. (a) Does the petition believe a limited guardianship is sufficient in this case? YES NO . If yes, explain in detail including a statement of proposed powers of guardian and the parental rights and responsibilities retained by the parent(s) of the minor:10 (b) Does petitioner believe that the conservator's powers should be limited or expanded in any way? YES NO . If yes, include a statement of facts demonstrating why these specific powers are warranted.11 17. Name, address, qualifications and priority of nominee to be conservator12 (if same as item 1, so state): 18. Has nominee attached an acceptance of appointment as conservator? YES NO If no, state when it will be filed. 19. Has the nominee attached a conservatorship plan?13 YES NO 20. Is a bond attached? YES NO . If no, explain why not. If no, explain why not. If a Court order is sought with respect to the type or amount of bond, state here all the particulars of the order sought and reasons therefore.14 21. Set forth a general description of the assets of the protected person, including estimated values and location by county. Include any benefits paid or anticipated from any governmental agency: American LegalNet, Inc. www.FormsWorkFlow.com PP-105 (Rev. 5-1-98) Page 4 of 5 001 22. Is an interim Court order sought pursuant to 18-A MRSA 247 5-408? YES NO . If yes, set forth in detail the order sought and the reasons therefor. Attach a proposed order. 23. Is a temporary conservator required? YES NO . If yes, state here the reason why and the name and address of the suggested temporary conservator. An affidavit setting forth the factual basis for the emergency and the specific powers requested is required.15 24. Is appointment of a (visitor/guardian ad litem/attorney) required? YES NO . If yes, state here the reasons why:16 The petitioner believes that the appointment of a guardian and conservator for the above-named minor is necessary and desirable and is in the best interest of said minor. Petitioner requests that the Court determine that said minor is a person for whom appointment of a guardian and conservator is proper, make the appointments prayed for, and let letters of appointment issue to the guardian/conservator. Date Petitioner or Attorney "Every pleading of a party represented by an attorney shall be signed by at least one attorney of record in his individual name." See Rule 11. Name, address and telephone of attorney for petitioner, Attorneys appearing for other parties if any Name of Attorney Name of Party Date filed Hearing set in this Court for at , and notice sent or notice forms given to petitioner for service.17 Dated Register of Probate American LegalNet, Inc. www.FormsWorkFlow.com 001 PP-105 (Rev. 5-1-98) Page 5 of 5 The Court hereby appoints of Temporary Guardian of (name and address of minor) to serve until (not more than six months from appointment), and the reasons for this appointment are: Dated Judge of Probate The Court hereby appoints of Temporary Conservator of (name and address of minor) to serve until (not more than six months from appointment), and the reasons for this appointment are: Dated Judge of Probate Interim order or protective arrangement granted on separate order date Register of Probate NOTE: A guardian may institute proceedings to compel the performance by any person of a duty to support the ward or to pay same for the welfare of the ward. See 18-A MRSA 5-209(b). 1 The address listed here or in item 6 must be in this county to establish venue. See 18-A MRSA 247 5-205. 2 The following must be notified: (a) The minor if 14 or over who has not otherwise consented or waived notice; (b) The person who has had principal care and custody of the minor during 60 days immediately preceding date of petition; (c) Any living parent of minor; (d) The director or chief executive officer of the institution where the minor may be present. See Rule 4(d)(l)(D) of the MRPP. (e) Any governmental agency paying or planning to pay benefits to the minor. (i.e. Social Security Administration, Veteran's 3Admionistration, etc.) See 18-A MRSA 247 5-406. See 18-A MRSA 247 5-206. 4 See 18-A MRSA 247 5-207(c). 5 See18-A MRSA 247 5-204 (c). In such a proceeding, the non-consenting parent or legal custodian is entitled to 223court appointed224 counsel if he does not consent to the petition and is indigent. (An affidavit if indigency must be filed.) 6 See 19-A MRSA 247 1710. 7 See 18-A MRSA 247 5-204. 8 See 18-A MRSA 247 5-202. 9 See 18-A MRSA 247 5-204(c). 10 See 18-A MRSA 247 5-105. 11 See 18-A MRSA 247 5-426. 12 See18-A MRSA 247 5-410. 13 See 18-A 247 5-407(b). The plan must be filed at least 10 days before the hearing. See 18-A MRSA 247 5-407(d). 14 See 18-A MRSA 247 5-411 and 247 5-412. 15 See 18-A MRSA 247 5-408-16A(a). 16 See 18-A MRSA 247 5-207(d), 247 1-403(4) and 247 5-408-A(a-1). 17 If all persons who must be notified either sign the petition or waive notice of the proceedings, no notices will be required. Otherwise, notice shall be served as required by statute or by Rule 4 of the MRPP. See 18-A MRSA 247 5-405. Persons wishing to waive notice to all subsequent proceedings should file Form N-107. 18 See 18-A MRSA 247 5-408-A(a). MARP American LegalNet, Inc. www.FormsWorkFlow.com