Name of Person Filing Document: Address: City, State, Zip Code: Telephone Number: Attorney Bar Number (if applicable): Representing: Self (Without a Lawyer) or Attorney for Petitioner or Respondent FOR CLERK’S USE ONLY SUPERIOR COURT OF ARIZONA MARICOPA COUNTY In the Matter of the Guardianship of: Case Number PB: PETITION FOR PERMANENT APPOINTMENT OF GUARDIAN OF AN ADULT (Incapacitated Person) REQUIRED INFORMATION FROM PETITIONER, UNDER OATH: 1. INFORMATION ABOUT ME. I am called the Petitioner: Name: Address: Telephone: Date of Birth: My relationship to the person I say needs a guardian is: 2. INFORMATION ABOUT THE PERSON I SAY NEEDS A GUARDIAN. This person is called the proposed incapacitated person: Name: Address: Telephone: 3. Date of Birth: PERSONS WHO ARE ENTITLED TO NOTICE of the court matter under Arizona law, A.R.S. 145309 for guardians, and to whom I will give notice of this case: (See instructions) Name Address Relationship to Person Who I Say Needs a Guardian A. B. C. D. ©Superior Court of Arizona in Maricopa County January 29, 2009 ALL RIGHTS RESERVED Page 1 of 4 PBGA11f Use only most current version APE American LegalNet, Inc. www.FormsWorkflow.com Case No. 4. ASSETS OF PERSON WHOM I SAY NEEDS GUARDIAN: (check one box) The person who needs a guardian has no substantial assets or income. No bond by Petitioner is required; The person who needs a guardian has assets and/or annual income in the approximate amount of $ 5. Explain: PERSON TO BE APPOINTED GUARDIAN (complete this only if the person is a different person than Petitioner): Name: Address: Date of Birth: Telephone: My relationship to the person I say needs a guardian: 6. INFORMATION REGARDING GUARDIANSHIP. To the best of my knowledge, (check one box): No Guardian and/or Conservator has been appointed in any other court, and no court proceedings are pending for such appointment; OR Someone has been appointed Guardian and/or Conservator, or court proceedings are pending. Explain who, when, in what court, and if the appointee is guardian or conservator: 7. REASONS FOR GUARDIANSHIP: I believe that the person needs a guardian and is incapacitated as defined by Arizona Law, A.R.S. §14-5101(1) to the extent that he or she lacks sufficient understanding or capacity to make or communicate responsible decisions concerning his or her person because of (check one or more reasons that you think apply): Mental illness, mental deficiency, mental disorder; Physical illness or disability; Chronic use of drugs; Chronic intoxication; Other (explain): 8. REASONS FOR REQUESTED PERSON TO BE APPOINTED GUARDIAN: Either I or the person I request to be appointed in Paragraph 5 has priority for appointment under Arizona Law, A.R.S. § 145311, because (check one or more that you think apply about the relationship to the person you say is incapacitated): Appointee is the spouse of the incapacitated person; Appointee was selected by the incapacitated person to be the guardian; Appointee is an adult child of the incapacitated person; Appointee is the parent of the incapacitated person; Appointee is a relative of the incapacitated person and has lived with the person more than six months before filing this petition; Appointee was chosen to be the guardian by someone who is caring for the incapacitated person or is paying benefits for the incapacitated person; Appointee is a private fiduciary, a professional guardian, conservator, or the Arizona Department of Veterans' Services. ©Superior Court of Arizona in Maricopa County January 29, 2009 ALL RIGHTS RESERVED Page 2 of 4 PBGA11f Use only most current version APE American LegalNet, Inc. www.FormsWorkflow.com Case No. Other (explain): 9. REASONS I AM ASKING FOR A GUARDIANSHIP ORDER: The appointment of a guardian for the person I say is incapacitated is necessary or desirable to provide continuing care and supervision of the person, and is in his or her best interest. I am interested in the welfare of the person in need of protection because(explain): 10. INFORMATION FOR APPOINTMENT OF A PHYSICIAN: (You cannot ask the court for a guardianship unless the adult is examined by a physician and you file the physician’s written report with the court before the hearing. If authority to consent to inpatient mental health care is being sought, the report must be prepared by a licensed psychiatrist or psychologist. I have the name, address, and telephone number of a physician who will examine the person I say is incapacitated and whose written report I will file with the court. The physician will also indicate if the incapacitated person needs inpatient mental No. If yes, health care and treatment and/or whether driving privileges should be suspended. Yes or identify the name, address and telephone number of the physician. Name of Physician: Address: Telephone Number: 11. APPOINTMENT OF AN ATTORNEY (You cannot ask the court for a guardianship unless the adult has a lawyer appointed to represent him or her. See the instructions on how to do this.) (Check one box only and fill in the information requested): The person I say is incapacitated already has an attorney who will represent the person in court about this guardianship: NAME OF ATTORNEY: ADDRESS: TELEPHONE: OR 12. The incapacitated person is not represented by an attorney, and I request this Court to appoint an attorney. REQUIRED STATEMENTS TO THE COURT, UNDER OATH: (Note: you must check each box as true, and all these statements must be true, or you cannot file this Petition.) TRUE TRUE Venue (the court in which you are filing this Petition) is proper in this county because the person who is said to need a guardianship lives in or is present in this county. The person who is requesting to be the guardian has completed the required document called Affidavit of Person to be Appointed as Guardian of an Adult and is filing that Affidavit with this Petition as required by Arizona law, A.R.S. § 14-5106. ©Superior Court of Arizona in Maricopa County January 29, 2009 ALL RIGHTS RESERVED Page 3 of 4 PBGA11f Use only most current version APE American LegalNet, Inc. www.FormsWorkflow.com Case No. TRUE I or the person I request to be appointed in Paragraph 5 is a suitable and proper person to act as guardian and is entitled to consideration for appointment under Arizona Law, A.R.S. § 14-5106, 5311, and/or 5410. REQUEST TO THE COURT FOR AN ORDER, UNDER OATH: Petitioner asks the court to do the following: 1. 2. 3. 4. 5. 6. Schedule a hearing to determine if a guardianship is appropriate; Appoint a physician if one is not available to examine the person I say needs a guardian and a lawyer to represent the person. After the Petitioner gives notice of the hearing to all interested persons and to those required by law, hold a hearing to determine if the Court should order a guardianship; Make a finding that the person is incapacitated and needs a guardian, and if applicable make a finding that the incapacitated person requires inpatient mental health care. Please check box if you are requesting this authorization from the court. Pursuant to A.R.S. § 14-5312.01(B), authorize the guardian to give consent for the ward to receive inpatient mental health care including placement in a level one behavioral health facility licensed by the department of health services and medical, psychiatric and psychological treatment associated with that placement. Appoint a guardian of the proposed incapacitated person. Make any other orders the Court decides are in the best interests of the proposed incapacitated person. OATH OR AFFIRMATION AND VERIFICATION I swear or affirm that the information on this document is true and correct under penalty of perjury. Signature Date Sworn to or Affirmed before me this: by (date) My Commission Expires: Deputy Clerk or Notary Public ©Superior Court of Arizona in Maricopa County January 29, 2009 ALL RIGHTS RESERVED Page 4 of 4 PBGA11f Use only most current version APE American LegalNet, Inc. www.FormsWorkflow.com