Name of Person Filing: __________________________________________ Mailing Address: __________________________________________ City, State, Zip Code: __________________________________________ Daytime Phone Number: __________________________________________ Evening Phone Number: __________________________________________ ATLAS Number (if applicable)_________________________________________ Attorney Bar Number (if Applicable) ____________________________________ Self Petitioner Representing: Respondent FOR CLERK’S USE ONLY SUPERIOR COURT OF ARIZONA MOHAVE COUNTY In the Matter of the Guardianship and/or Conservatorship of: Case No:_________________________ PETITION FOR PERMANENT APPOINTMENT OF GUARDIAN AND/OR CONSERVATOR OF AN ADULT _____________________________________ An Adult NOTICE: The authority granted to the guardian may include the authority to withhold or withdraw life sustaining treatment, including artificial food and fluid. A.R.S. §14-5303(B) REQUIRED INFORMATION ABOUT PETITIONER, UNDER OATH OR AFFIRMATION: 1. INFORMATION ABOUT ME (the petitioner): Name: _______________________________________________________________________________ Street Address: ________________________________________________________________________ City, State, Zip Code:____________________________________________________________________ Telephone:__________________________________ Date of Birth: _____________________________ I am related by blood to the person who needs a guardian and/or conservator (“the incapacitated person and/or protected person”). My relationship to the person I say needs a guardian and/or conservator is: ________________________________ 2. INFORMATION ABOUT THE PERSON WHO NEEDS A GUARDIAN AND/OR CONSERVATOR. This person is called the proposed incapacitated person (for a guardianship) and proposed protected person (for a conservatorship): Name: _______________________________________________________________________________ Street Address: ________________________________________________________________________ City, State, Zip Code:____________________________________________________________________ Telephone:__________________________________ Date of Birth: ______________________________ 3. PERSON TO BE APPOINTED GUARDIAN AND/OR CONSERVATOR (Complete this section only if the person is a different person than petitioner): Name: _______________________________________________________________________________ Revised 12/3/2009 Page 1 of 6 American LegalNet, Inc. www.FormsWorkFlow.com Case No.________________________________ Street Address: ________________________________________________________________________ City, State, Zip Code:____________________________________________________________________ Telephone:_____________________________ Date of Birth: ______________________________ The person to be appointed guardian and/or conservator is related by blood to the person who needs a guardian and/or conservator. If “yes” above, HOW is the person to be appointed guardian and/or conservator related to the proposed incapacitated/proposed protected person? ______________________________________________________________________________ (Examples: grandmother, uncle, sister) 4. PERSON(S) ENTITLED TO NOTICE of this Court matter under Arizona law, A.R.S. 14-5309 for guardians, and 14-5405 for conservators, and to whom I will give notice of this case: (See instructions) A______________________/_______________________________________________ (Name) (Address) _______________________________________________ (Relationship to Person Who I Say needs a Guardian and/or Conservator) B______________________/_______________________________________________ (Name) (Address) _______________________________________________ (Relationship to Person Who I Say needs a Guardian and/or Conservator) C______________________/_______________________________________________ (Name) (Address) _______________________________________________ (Relationship to Person Who I Say needs a Guardian and/or Conservator) D______________________/_______________________________________________ (Name) (Address) _______________________________________________ (Relationship to Person Who I Say needs a Guardian and/or Conservator) 5. INFORMATION REGARDING GUARDIANSHIP AND/OR CONSERVATORSHIP to the best of my knowledge, (check one box): No guardian and/or conservator have been appointed by Will or by any Court Order, and no Court proceedings are pending for such appointment; 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 and/or conservator): ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 6. ASSETS OF PERSON WHOM I SAY NEEDS GUARDIAN AND/OR CONSERVATOR (check one box) The person who needs a guardian and/or conservator has no substantial assets or income. No bond by petitioner is required; OR, The person who needs a guardian and/or conservator has assets and/or annual income in the approximate amount of $___________________ Revised 12/3/2009 Page 2 of 6 American LegalNet, Inc. www.FormsWorkFlow.com Case No.________________________________ Explain: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ 7. REASONS FOR CONSERVATORSHIP: The person needs a conservator because he or she has property which will be wasted or used up unless proper management is provided, and (check one or both boxes that apply): He or she needs funds for his or her support, care and welfare; Funds are needed for the support, care and welfare of those entitled to be supported by the person. 8. REASONS PERSON CANNOT MANAGE HIS OR HER PROPERTY: (check one or more reasons that you think apply): Mental illness, mental deficiency, or mental disorder; Physical illness or disability; Chronic use of drugs; Chronic intoxication; Confinement; Detention by a foreign power; Disappearance. 9. 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 of the boxes if applicable): Mental Illness, mental deficiency, mental disorder; Physical illness or disability; Chronic use of drugs; Chronic intoxication; Other (explain): _____________________________________________________________________________ 10. REASONS FOR REQUESTED PERSON TO BE APPOINTED GUARDIAN AND/OR CONSERVATOR: (Check one or more of the boxes that you think apply about the relationship of the proposed guardian and/or conservator to the person you say requires a guardian and/or conservator): Proposed appointee is the spouse of the incapacitated/protected person; Proposed appointee was selected by the incapacitated/ protected person; Proposed appointee is the adult child of the incapacitated/protected person; Proposed appointee is the parent of the incapacitated/protected person; Proposed appointee is a relative of the incapacitated/protected person and has lived with the person more than six months before filing this petition; Proposed appointee was chosen to be the guardian and/or conservator by someone who is caring for the incapacitated/protected person or is paying benefits for the incapacitated or protected person. Other (explain): __________________________________________________________________ Revised 12/3/2009 Page 3 of 6 American LegalNet, Inc. www.FormsWorkFlow.com Case No.________________________________ 11. REASONS I AM ASKING FOR A GUARDIANSHIP AND/OR CONSERVATORSHIP ORDER: The appointment of a guardian and/or conservator for the person I say is incapacitated or protected is necessary or desirable to provide continuing care and supervision of the person, and is in his or her best interests. I am interested in the welfare of the person in need of protection because (explain): _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ 12. THE TYPE OF GUARDIANSHIP REQUESTED IS: A general guardianship. Other alternatives have been explored and a limited guardianship is not appropriate because: ______________________________________________________________________________ ______________________________________________________________________________ A limited guardianship. The specific powers requested are (See instructions): ______________________________________________________________________________. These powers are necessary because: ______________________________________________________________________________ ______________________________________________________________________________. 13. INFORMATION FOR APPOINTMENT OF A PHYSICIAN: I have the name, address, and telephone number of a physician who will examine the person I say is incapacitated, whose written report I will file with the court. The physician will also indicate if the incapacitated person’s driving privileges should be suspended. NAME OF PHYSICIAN: ___________________________________________________________ ADDRESS: __________________________________________________________________ TELEPHONE: __________________________________________________________________ 14. APPOINTMENT OF AN ATTORNEY (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: __________________________________________________________________ The incapacitated person has no attorney to represent him or her in Court. A lawyer should be appointed by the Court. Revised 12/3/2009 Page 4 of 6 American LegalNet, Inc. www.FormsWorkFlow.com Case No.______________________________ REQUIRED STATEMENTS TO THE COURT, UNDER OATH OR AFFIRMATION: (Note: All of these statements must be true and you must check the box for each statement to indicate to the Court that each statement is true, or you cannot file this Petition.) 15. 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 and/or conservatorship lives in or is present in this county. 16. TRUE I have completed the required document called Affidavit of Person to be Appointed as Guardian and/or Conservator of an Adult and am filing that Affidavit with this Petition as required by Arizona Law, A.R.S. §14-5106. 17. TRUE I will give notice to the proposed incapacitated/protected person and his or her attorney by personal service of the Petition and Order, as well as all filed reports and affidavits within the time frame the court directs which will not be in excess of seventy-two hours following entry of the order of appointment. 18. TRUE I have filed a report from a physician or psychiatrist detailing the need for guardianship. REQUEST TO THE COURT FOR AN ORDER, UNDER OATH: Petitioner asks the Court to do the following: FOR GUARDIANSHIP: 1. 2. Appoint a physician to examine the person I say needs a guardian; Make a finding that the person is incapacitated, needs a guardian, and that the proposed ward’s needs cannot be met by less restrictive means, including the use of appropriate technological assistance; FOR CONSERVATORSHIP: 3. Make a finding that the person needs protection under law including a conservator; FOR EITHER OR BOTH GUARDIANSHIP AND/OR CONSERVATORSHIP: 4. 5. 6. 7. Appoint an investigator to interview the person, and a lawyer to represent the person. After 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 and/or conservatorship; Appoint a guardian and/or conservator of the proposed incapacitated and protected person; Make any other orders the Court decides are in the best interests of the proposed incapacitated and/or protected person. Revised 12/3/2009 Page 5 of 6 American LegalNet, Inc. www.FormsWorkFlow.com Case No._______________________________ OATH OR AFFIRMATION STATE OF ARIZONA County of Mohave ) ) ss. ) I, the Petitioner, declare under penalty of perjury, that I have read this Petition. All the statements in the Petition are true and correct and complete to the best of my knowledge and belief. SIGNATURE:___________________________________ DATE:___________________________ Sworn to or affirmed before me this ____________ day of _____________, _______ by ____________________________________________. My Commission Expires:_____________________ Revised 12/3/2009 ______________________________________ Notary Public / Deputy Clerk Page 6 of 6 American LegalNet, Inc. www.FormsWorkFlow.com