District Court Denver Probate Court __________________________________ County, Colorado Court Address: In the Interests of: COURT USE ONLY Respondent Attorney or Party Without Attorney (name and address): Case Number: Phone Number: FAX Number: Division E-mail: Atty. Reg. #: Courtroom VERIFIED PETITION FOR APPOINTMENT OF CONSERVATOR FOR ADULT 1. The Petitioner is a person who would be adversely affected by lack of effective management of the Respondent’s property and business. a person who is interested in the estate, financial affairs, or welfare of the Respondent. the Respondent (the person to be protected.) This is a Petition for: Permanent Conservator. If you are seeking a Special Conservator, select one of the two boxes below: Special Conservator (emergency situation only to preserve and apply the property of the Respondent as may be required for the support of the Respondent or individuals who are in fact dependent upon the Respondent), pursuant to §15-14-406(7), C.R.S.) Special Conservator (to assist in the accomplishment of a protective arrangement or other authorized single transaction), pursuant to §15-14-412(3), C.R.S.) 2. Information about the Petitioner: Name: _______________________________________ Relationship to Respondent: ___________________ Address: _______________________________________________________________________________ City: ____________________ State: ___ Zip Code: ________ Email Address: ________________________ Home Phone #: ______________________________ Work Phone #: _______________________________ 3. Information about the Respondent: Name: ________________________________________ Age: _____ Date of Birth: ____________________ Address: _______________________________________________________________________________ City: ____________________ State: _____ Zip Code: _________County of Residence: _________________ If this appointment is made, the Respondent’s dwelling will change to: ____________________________________________________________________________________ JDF 876 4/08 PETITION FOR APPOINTMENT OF CONSERVATOR FOR ADULT Page 1 of 5 American LegalNet, Inc. www.FormsWorkflow.com 4. Information about the Respondent’s spouse or adult who has resided with the Respondent for more than six months in the last year: Name: ________________________________________ Relationship to Respondent: _________________ Address: _______________________________________________________________________________ City: ____________________ State: ___ Zip Code: ________ Email Address: ________________________ Home Phone #: ______________________________ Work Phone #: _______________________________ 5. Venue for this proceeding is proper in this county because the Respondent resides in this county. does not reside in this state, but has property in this county. 6. A Conservator is required because the Respondent is unable to manage property and business affairs because he/she is unable to effectively receive and evaluate information or both or to make or communicate decisions, even with the use of appropriate and reasonably available technological assistance due to the Physician’s Letter following alleged disabilities or impairments pursuant to §15-14-401(1)(b)(I), C.R.S: attached. _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ In addition pursuant to §15-14-401(1)(b)(II), C.R.S: the Respondent has property which will be wasted or dissipated unless proper management is provided. or the Respondent, or persons entitled to the Respondent’s support, require money for support, care, education, health, and welfare, and protection is necessary or desirable to obtain or provide money. 7. A Conservator is required to show by clear and convincing evidence that the Respondent is missing, detained, or unable to return to the United States, pursuant to §15-14-401(1)(b)(I) and (II), C.R.S. The nature of the Respondent’s disappearance or detention and any efforts to locate the respondent are as follows: _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ 8. If any Power of Attorney exists for financial or medical matters, attach a copy to the Petition, if available. List the agent(s) of the Power of Attorney: _______________________________________________________________________________________ _______________________________________________________________________________________ JDF 876 4/08 PETITION FOR APPOINTMENT OF CONSERVATOR FOR ADULT Page 2 of 5 American LegalNet, Inc. www.FormsWorkflow.com 9. Petitioner is requesting to be appointed as Conservator or Special Conservator. or Petitioner is requesting the following person to act as the Conservator or Special Conservator. Name: _______________________________________ Relationship to Respondent: _________________ Address: ______________________________________________________________________________ City: ___________________ State: ___ Zip Code: ________ Email Address: ________________________ Home Phone #: ____________________________ Work Phone #: ________________________________ Yes No If Yes, 10. Did the Respondent nominate a Conservator pursuant to §15-14-413, C.R.S.? identify: Name: __________________________________________ Phone #: ______________________________ Current Residence: _______________________________________________________________________ City: ____________________ State: ___ Zip Code: ________ Email Address: ________________________ The nominee is 21 years of age or older. State relationship to Respondent: nominated in writing by Respondent. spouse. parent. adult child. agent under power of attorney. adult with whom respondent has resided. other: ___________________________________________________________________________ The Court, whenever feasible, shall grant to a conservator only those powers necessary based on the protected person’s limitations and demonstrated needs and will issue orders that will encourage the development of the protected person’s maximum self-reliance and independence. unlimited/unrestricted or limited/with 11. Are you requesting the powers and duties to be restrictions? Provide information below to support your request. List the property to be placed under the Conservator’s control and identify limitations/restrictions on the Conservator’s powers and duties, as appropriate. _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ 12. Sections a and b below identify assets and the source and amount of anticipated income or receipts (public benefits, income, houses, real property, proceeds from insurance policy as beneficiary, proceeds from pension as beneficiary, etc.), together with an estimate of the value, including any insurance or pension, pursuant to §15-14-403(2)(g), C.R.S. Yes No a. Does the Respondent have any assets, e.g. bank accounts, property? Description of Assets, e.g. Bank Accounts, Property Bank Account Balance or Estimated Value of Property $ Total JDF 876 4/08 $ PETITION FOR APPOINTMENT OF CONSERVATOR FOR ADULT Page 3 of 5 American LegalNet, Inc. www.FormsWorkflow.com b. Does the Respondent have any anticipated income, e.g. Social Security, interest? Yes No Description of Income e.g. Social Security, interest, insurance proceeds Amount Anticipated or Receipts $ Total $ 13. Does the Respondent currently have a guardian? Yes No of Income If Yes, identify: Name: ______________________________________ Relationship to Respondent: ____________________ Current Residence: _______________________________________________________________________ City: ____________________ State: ___ Zip Code: ________ Email Address: ________________________ Home Phone #: ______________________________ Work Phone #: _______________________________ None If None, list an adult relative, for example brother, 14. Information on adult children and parents. sister, aunt, uncle that can be found with reasonable efforts: Name: ______________________________________________ Relationship: Adult Child or Parent Address: _______________________________________________________________________________ City: ____________________ State: ___ Zip Code: ________ Email Address: ________________________ Home Phone #: ______________________________ Work Phone #: _______________________________ Name: ______________________________________________ Relationship: Adult Child or Parent Address: _______________________________________________________________________________ City: ____________________ State: ___ Zip Code: ________ Email Address: ________________________ Home Phone #: ______________________________ Work Phone #: _______________________________ Name: _________________________________________________ Relationship: _____________________ Address: _______________________________________________________________________________ City: ____________________ State: ___ Zip Code: ________ Email Address: ________________________ Home Phone #: ______________________________ Work Phone #: _______________________________ Name: ______________________________________________ Relationship: _______________________ Address: _______________________________________________________________________________ City: ____________________ State: ___ Zip Code: ________ Email Address: ________________________ Home Phone #: ______________________________ Work Phone #: _______________________________ JDF 876 4/08 PETITION FOR APPOINTMENT OF CONSERVATOR FOR ADULT Page 4 of 5 American LegalNet, Inc. www.FormsWorkflow.com 15. Did the Respondent have a person who had primary care and custody during the 60 days prior to the filing of this Petition? Yes No If Yes, identify: Name: ______________________________________ Relationship to Respondent: ____________________ Current Residence: _______________________________________________________________________ City: ____________________ State: ___ Zip Code: ________ Email Address: ________________________ Home Phone #: ______________________________ Work Phone #: _______________________________ 16. Does the Respondent have any legal representative(s)? Yes No If Yes, identify: Name: __________________________________________ Phone #: ______________________________ Current Residence: _______________________________________________________________________ City: ____________________ State: ___ Zip Code: ________ Email Address: ________________________ Name: __________________________________________ Phone #: ______________________________ Current Residence: _______________________________________________________________________ City: ____________________ State: ___ Zip Code: ________ Email Address: ________________________ The Petitioner shall provide the persons listed in paragraphs 4, 9, 10 and 13 – 16 (Respondent’s spouse, nominee, current Guardian or Conservator, parents, adult children or an adult relative, person who had primary care and control of the Respondent and any legal representatives, if applicable) with notice of the time and place for hearing on this Petition in accordance with Colorado Rules of Probate Procedures and pursuant to §15-14-404, C.R.S. In addition, I request that the Court: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ VERIFICATION AND ACKNOWLEDGMENT I swear/affirm under oath that I have read the foregoing Petition and that the statements set forth therein are true and correct to the best of my knowledge. Date: __________________________ ___________________________________________ Signature of Petitioner Subscribed and affirmed, or sworn to before me in the County of _________________________, State of ________________, this ___________ day of _______________, 20 _______. My Commission Expires: ____________________ JDF 876 4/08 _____________________________________ Notary Public/Clerk PETITION FOR APPOINTMENT OF CONSERVATOR FOR ADULT Page 5 of 5 American LegalNet, Inc. www.FormsWorkflow.com