In the matter of First, middle, and last name , alleged incapacitated individual þ 1. þ I have been appointed by the court as guardian ad litem, and I accept this appointment. 2. þ I have performed the duties required by statute (see reverse side for list of duties). 3. þ I visited the alleged incapacitated individual on en-USDateen-US at en-USLocationen-US þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ appointment and otherwise complied with each provision of MCL 700.5305(1). 4. þ I report to the court as follows: þ þ a. þ the alleged incapacitated individual wishes to: þ þ þ þ þ þ þ þ þ do-not-resuscitate order. þ en-US POST (physician orders for scope of treatment) form. þ en-US other. þ þ þ contest the petition. þ þ object to the appointment of the nominated guardian. þ þ have an attorney appointed. þ þ b. þ There is a disagreement or dispute related to the guardianship, namely en-US þ en-US þ I believe it þ might þ will not þ be resolved through court-ordered mediation. þ þ c. þ There is one or more appropriate alternative to a full guardianship, namely: þ þ 1) þ appointment of a limited guardian with the following powers: en-US þ en-US en-US . þ þ 2) þ appointment of a conservator or a written protective order. þ þ 3) þ the alleged legally incapacitated individual executing one of the following: þ þ a patient advocate designation. þ en-US a do-not-resuscitate declaration. þ þ a durable power of attorney. þ en-US a physician orders for scope of treatment (POST) form. þ þ d. þ The alleged incapacitated individual wishes to be present at the hearing. þ þ e. þ I believe it is in the best interests of the individual to have legal counsel because en-US þ en-US en-US . þ þ The individual will retain legal counsel. þ en-US I recommend the court appoint legal counsel. þ 5. þ None of the items in item 4a above is demanded. My report to the court and recommendations are attached. en-USDate en-USSignature þ en-USAddress en-USName (type or print) þ en-USCity, state, zip Telephone no. American LegalNet, Inc. www.FormsWorkFlow.com DUTIES OF GUARDIAN AD LITEMYour duties as guardian ad litem include all the following: 1. Visit the individual alleged to be incapacitated. 3. Give the individual form PC 626 that outlines the rights in MCL 700.5306a(1). 4. Inform the individual that if a guardian is appointed, the guardian may have the power to execute a do-not-resuscitate order and/or physician orders for scope of treatment (POST) form on behalf of the individual. limited to: a. the right to contest the petition. order and/or a physician orders for scope of treatment (POST) form on behalf of the individual. c. the right to object to a particular person being appointed guardian. d. the right to be present at the hearing. e. the right to be represented by legal counsel and that legal counsel will be appointed for the person if s/he is unable to 6. Inform the individual of the name of any person known to be seeking appointment as guardian. 7. Ask the individual and the petitioner about the amount of cash and property readily convertible into cash that is in the 8. Make determinations and inform the court of those determinations, on all the following: a. whether the individual alleged to be incapacitated wishes to be present at the hearing. b. whether the individual alleged to be incapacitated wishes to contest the petition. d. whether the individual alleged to be incapacitated objec ts to having a do-not-resuscitate order and/or physician orders for scope of treament (POST) form executed on his or her behalf. e. whether the individual alleged to be incapacitated objects to a particular person being appointed guardian. f. whether there is one or more appropriate alternatives to the appointment of a full guardian or whether other action should be taken in addition to the appointment of a guardian after considering: litem believes appropriate. ii. appointment of a conservator or another protective order under 700.5401 et seq. iii. execution of a patient advocate designation, do-not-resuscitate declaration, physician orders for scope of treatment form, or durable power of attorney with or without limitations on purpose, authority, or duration. iv. available support from family members. Family members may often take responsibility for the care of an individual. Also, if the individual should be diagnosed as having a reduced life expectancy because of an advanced illness, the individual receiving, continuing, discontinuing and refusing medical treatment and may choose palliative treatment and adequate and appropriate pain and symptom management. In the report informing the court of the determinations, include an estimate of the amount of cash and property readily g. whether a disagreement or dispute related to the guardianship petition might be resolved through court-ordered mediation. American LegalNet, Inc. www.FormsWorkFlow.com