IN THE PROBATE DIVISION, CIRCUIT COURT, ST. LOUIS COUNTY, MISSOURI In the matter of __________________________________________ Respondent No._____________________ PETITION FOR APPOINTMENT OF A GUARDIAN AND/OR CONSERVATOR Comes now ____________________________________________________________________, who is / are the ___________________________________of the above named respondent, a is domiciled in St. Louis County, Missouri, and states that the following is the respondent's: Present residence and post office address: ________________________________________________________________ Most recent addresses for the three (3) years prior to the filing of this petition*: 1. ______________________________________________________________________________________________ 2. ______________________________________________________________________________________________ 3. ______________________________________________________________________________________________ *If unknown, please provide an explanation as to the efforts made to ascertain them. Petitioner(s) further state(s) that respondent is unable by reason of _____________________________________ ________________________________, as evidenced by the attached Physician's Answers to Interrogatories which are incorporated herein by this reference as Exhibit F: To receive and evaluate information or to communicate decisions to such an extent that respondent lacks capacity to meet essential requirements for food, clothing, shelter, safety or other care such that serious physical injury, illness or disease is likely to occur. To receive and evaluate information to communicate decisions to such an extent that respondent lacks the ability to manage his / her financial resources. To meet respondent's essential daily needs of living and/or to manage his financial resources without supervision and that there are no less intrusive alternatives to a full / limited guardianship and/or a full / limited conservatorship available to provide for respondent's care and financial needs. If respondent is alleged to be only partially incapacitated and/or disabled, the nature and extent of the respondent's partial incapacity / disability is: ____________________________________________________________. The nature, extent and estimated value of the respondent's assets located in St. Louis County, State of Missouri, and any assets located outside the State of Missouri as far as is known to petitioner(s) is set forth in Exhibit A ­ Financial Statement attached hereto and incorporated herein by this reference. For Court's Use Only: KALGC - Ptn Appt Gdn Consvr Adult KALGD - Ptn Appt Gdn Adult KALCN - Ptn Appt Consvr Adult person, age _______, who 1 American LegalNet, Inc. www.FormsWorkFlow.com The respondent is the grantor, a qualified beneficiary or is / was the trustee or co-trustee of any trust for which the purpose is: ______________________________________________________________________________________ ____________________________________________________. The name(s) and address(es) of the presently acting trustee(s) is / are set forth in Exhibit B attached hereto and incorporated herein by this reference. The respondent has executed a durable power of attorney for the purpose of ______________________________ ________________________________________________. The name(s) and address(es) of any agent appointed in said durable power of attorney is / are set forth in Exhibit B attached hereto and incorporated herein by this reference. The reasons why the appointment of a full / limited guardian(s) and/or a full / limited conservator(s) is sought are:______________________________________________________________________________________________ __________________________________________________________________________________________. Petitioner(s) request(s) that letters of guardianship and/or conservatorship be granted to: Name(s) __________________________________________________________________________________________ Address(es) ________________________________________________________________________________________ The following information is set forth in Exhibit B attached hereto and incorporated herein by this reference: The names and addresses of the respondent's parents; and if one or both of them are deceased, their date of death; The respondent is married / widowed; the name and address of the spouse; and if deceased, their date of death; The respondent has living children and their names, ages and addresses; The names, relationships, and addresses of respondent's closest known relatives; The names and relationship, if known, of any adults living with respondent; The respondent has no spouse, living adult child or parent; the names and addresses of respondent's siblings - if any of them are deceased, their date of death; the names and addresses of the children of deceased siblings; The respondent has a guardian and/or conservator appointed in this state or any other state; their name(s) and address(es); The name and address of the person having custody of the respondent; The names and addresses of any others that the petitioner(s) is / are guardian and/or conservator. Attached hereto and incorporated herein by this reference as Exhibit C is the consent of the proposed guardian(s) and/or conservator(s) to act if appointed. If the proposed guardian(s) and/or conservator(s) is / are a non-resident of Missouri, attached hereto and incorporated herein by this reference as Exhibit D is the proposed guardian(s) and/or conservator(s) designation of resident agent and the agent's consent to act. Attached hereto and incorporated herein by this reference as Exhibit E is a list of the names and addresses of the witnesses who may be called to testify in support of this petition. 2 American LegalNet, Inc. www.FormsWorkFlow.com WHEREFORE, petitioner(s) pray(s) that a hearing and inquiry be held and the court appoint ________________________________________________________________________________________ Full / Limited Guardian(s) of the Person and Full / Limited Conservator(s) of the Estate for the respondent. Petitioner(s) state(s) that the foregoing is made on this _____ day of __________________, ______, under oath or affirmation, and its representations are true and correct to the best of petitioner's knowledge and belief, subject to penalties of making a false affidavit or declaration. _______________________________________ Petitioner's Signature ______