In the matter of Alleged incapacitated individual Last four digits of SSN þ en-USDate of birthen-USRaceen-USSexen-USAddress of alleged incapacitated individual where now found þ 1. þ I, en-USName (type or print)en-US , am interested in this matter þ and make this petition as en-USState interest/relationshipen-US . þ þ 2. þ An action within the jurisdiction of the family division of circuit court involving the family or family members of the person þ named above has been previously filed in en-US en-US Court, Case Number en-US en-US , was þ assigned to Judge en-US , and þ remains þ is no longer þ pending. þ þ 3. þ The adult is a resident of en-USCity, village, or townshipen-US , en-USCounty Stateen-US þ and has a home address and telephone number of en-USAddress þ en-USCity State Zip Telephone no. . þ þ þ þ þ The individual is a citizen of the following foreign country: en-US þ þ 4. þ The adult has þ en-US a patient advocate/power of attorney for health care.en-US (Specify name and address below.) þ en-US a power of attorney. en-US(Specify name and address below.) þ en-US a conservator. en-US(Specify name and address below.) þ en-USName and address þ þ þ þ 5. þ þ The patient advocate designation was not executed in compliance with MCL 700.5506. þ þ The patient advocate is not complying with the terms of the designation or of MCL 700.5506 to MCL 700.5512. þ þ The patient advocate is not acting consistent with the ward's best interests. þ 6. þ The adult lacks sufficient understanding or capacity to make or communicate informed decisions because of þ þ þ mental illness. þ mental deficiency. þ þ physical illness or disability. þ þ chronic intoxication. þ þ chronic drug use. þ þ en-US . þ þ 7. þ Specific facts about the adult's recent condition or conduct that lead me to believe the adult needs a guardian are þ en-US(Attach a separate sheet if more space is needed.) þ en-US þ en-US þ 8. þ The name, address, and telephone number of the person/agency (if any) who currently has care and custody of the adult þ are en-US en-US .en-USB C D E F G H I J American LegalNet, Inc. www.FormsWorkFlow.com File No. þ 9. þ þ The adult þ en-US is þ is not þ entitled to receive Veterans Administration benefits. The Veterans Administration þ þ claimant number is en-US en-US . þ 10. þ The alleged incapacitated individual has þ þ a spouse whose name and address are listed below. þ þ adult child(ren) whose name(s) and address(es) are listed below. þ þ living parent(s) whose name(s) and address(es) are listed below. þ þ no spouse, adult child(ren), or parent(s). The names and addresses of presumptive heirs are listed below. þ þ none of the above (must notify Attorney General - see instructions for the address of the Attorney General). en-USNAMEen-USRELATIONSHIPen-USADDRESS AND TELEPHONE NUMBERen-USStreet addressen-USCityen-USStateen-USZipen-USTelephone No.en-USStreet addressen-USCityen-USStateen-USZipen-USTelephone No.en-USStreet addressen-USCityen-USStateen-USZipen-USTelephone No. þ 11. þ None of the adults named above is under any legal incapacity except en-US þ en-USGive name, legal incapacity, and representative of the person, if anyen-US . þ þ 12. en-USI REQUESTen-US that the court determine the adult is an incapacitated individual and appoint en-USName þ en-US en-US en-USAddress þ en-USCity State Zip Telephone no.en-US , who has priority as þ en-USPriority relationship , þ þ full guardian with all powers provided by statute. þ þ limited guardian with the following powers: þ en-US en-US . þ þ 13. þ No other person appears to have authority to act in the circumstances. I request that a temporary guardian be þ þ appointed pending a hearing on this petition because of the following emergency: þ þ en-US þ I declare under the penalties of perjury that this petition has been examined by me and that its contents are true to the best þ of my information, knowledge, and belief. þ þ en-USAttorney signature þ en-USDate þ en-USAttorney name (type or print) Bar no. þ en-USPetitioner signature þ en-USAttorney address þ en-USPetitioner address þ en-USCity, state, zip Telephone no. þ en-USCity, state, zip Telephone no. þ þ 14. en-USNOMINATION BY THE ALLEGED INCAPACITATED INDIVIDUALen-US In the event the court finds that I require a þ guardian, I nominate: en-USName, address, and telephone no. þ en-USDate þ en-USSignature of alleged incapacitated individual þ en-USN K M L O P Q American LegalNet, Inc. www.FormsWorkFlow.com en-USINSTRUCTIONS FOR COMPLETINGen-US"PETITION FOR APPOINTMENT OF GUARDIAN OF INCAPACITATED INDIVIDUAL"en-USPlease type or print neatly using black or blue ink.en-USItems A through Q must be read and filled in (when required) before your petition can be filed with the court. Please read the en-USinstruction for each item. Then fill in the correct information for that item on the form.en-USA þ Enter the name of the individual who you believe needs a guardian. en-USB þ Enter the date of birth, race, and sex of the individual named in en-USA . Enter the address where the individual is currently þ located. This address may or may not be the home of the individual. For example, if the individual is currently in the þ hospital, enter the address of the hospital. en-USC þ Enter your name in the first line and your relationship to the individual (or your interest) on the second line. en-USD þ Check this box if there is or has been a case in the family division of the circuit court involving the individual in þ en-USA . Examples of a family division case are personal protection, abuse or neglect, or a name change. If you þ have checked this box, enter the name of the court, the case number of the action, the name of the judge þ assigned to that case. Then place a check in the box indicating whether that case is still pending or not. en-USE þ Enter the city, village, or township and county and state the individual is a resident of and the full home address and þ telephone number of the individual. en-USF þ Check the boxes that apply and provide the name(s) and address(es). en-USG þ If the individual has a patient advocate and you believe there is a problem, check only the boxes that apply. en-USH þ Check the boxes that you believe apply to the individual. en-USI þ en-USExplain inen-US as much en-USdetail as possible specific examples of the individual's conduct that lead you to believe he or she þ þ needs a guardian. Give specific examples of his or her conduct that supports what you checked in en-USH and that þ demonstrate the need for a guardian. en-USThis information is extremely important for the court in making a decision þ about the need to appoint a guardian. en-US Use additional sheets of paper if needed.en-USJ þ Enter the name, address, and telephone number of the person or agency who currently has care and custody of the þ individual. If there is no one, leave blank. en-USK þ Check whether the individual is or is not entitled to receive Veterans Administration benefits. If you checked that the þ individual is entitled to benefits, enter his or her VA claimant number. en-USL - en-USM þ Check all the boxes that apply and enter the names, relationships, addresses and telephone numbers of each þ relative of the individual. Presumptive heirs includes minor children, if any. If any of the adults named in en-USL þ are under legal incapacity, enter the names in en-USM . If you check the last box in en-USL (item 10), you must notify þ the Attorney General by sending a copy of this form to: Attorney General, Public Administration, PO Box 30755, þ þ Lansing, Michigan 48909. en-USN þ Enter the name, address, and telephone number of the person you want to be appointed as guardian of the individual. þ Enter the relationship, if any, that this person has to the individual. Check the box for either a full guardian or a limited þ guardian. en-USO þ Check the box if there is an emergency requiring the appointment of a temporary guardian before the hearing on this þ petition is held. en-USP þ Enter today's date, sign your name, and enter your address and telephone number. en-USQ þ If the individual wants to nominate someone to be his/her guardian, check the box and enter the na