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 GUARDIAN FOR ADULT 1. The Petitioner is an adult 21 years of age or older and is interested in the welfare of the Respondent. or the Respondent. This is a Petition for appointment of a: Permanent Guardian pursuant to §15-14-304(1) and (2), C.R.S. Emergency Guardian (not to exceed 60 days) pursuant to §15-14-312, C.R.S. 2. Information about the Petitioner: Name: _________________________________________ Relationship to Respondent: ________________ Address: _______________________________________________________________________________ City: ____________________ State: _____ Zip Code: _________ Home Phone #: ____________________ Email Address: _______________________________Work Phone #: ______________________________ 3. Information about the Respondent: Name: ___________________________________________Age: _____ Date of Birth: _________________ Address: _______________________________________________________________________________ City: ____________________ State: _____ Zip Code: _________County of Residence: _________________ Home Phone #: __________________________________ If this appointment is made, the Respondent’s residence will change to: ________________________________________________________________________________________ 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 #: _______________________________ JDF 841 4/08 VERIFIED PETITION FOR APPOINTMENT OF GUARDIAN FOR ADULT Page 1 of 5 American LegalNet, Inc. www.FormsWorkflow.com 5. Venue for this proceeding is proper because the Respondent resides in this county. is present in this county. Check this box only if requesting an Emergency Guardian pursuant to §15-14108(2), C.R.S. is admitted to an institution pursuant to an order of a court of competent jurisdiction sitting in this county. Attach copy of order. 6. An appointment of a guardian for the Respondent has been made. Attach copy of Order. 7. 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: _______________________________________________________________________________________ _______________________________________________________________________________________ 8. The Respondent is unable to effectively receive or evaluate information or both, make or communicate decisions to such an extent that the individual lacks the ability to satisfy essential requirements for physical health, safety, or self-care, even with appropriate and reasonably available technological assistance pursuant to §15-14-102(5), C.R.S. 9. The Respondent’s identified needs cannot be met by less restrictive means, including use of appropriate and reasonably available technological assistance. 10. Guardianship is necessary for the following reasons, include a brief description of the nature and extent of the Respondent’s alleged incapacity pursuant to §15-14-304(2)(g). C.R.S.: _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ Attach physician's letter or professional evaluation by qualified person pursuant to §15-14-306, C.R.S. JDF 841 4/08 VERIFIED PETITION FOR APPOINTMENT OF GUARDIAN FOR ADULT Page 2 of 5 American LegalNet, Inc. www.FormsWorkflow.com The Court, whenever feasible, shall grant to a guardian only those powers necessary based on the Respondent’s limitations and demonstrated needs and will issue orders that will encourage the development of the Respondent’s maximum self-reliance and independence. 11. Are you requesting the powers and duties to be unlimited/unrestricted or limited/with restrictions pursuant to §15-14-304(2)(h), C.R.S.? Provide information below to support your request. ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ Petitioner is requesting to be appointed as Guardian. 12. or Petitioner is requesting the following person to act as the Guardian. Name: ______________________________________ Address: _____________________________________________________________________________ City: __________________ State: ___ Zip Code: ________ Email Address: ________________________ Home Phone #: ___________________________ Work Phone #: ________________________________ He/She has priority for appointment as Guardian pursuant to §15-14-310, C.R.S. because: 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 currently resides other: ____________________________________________________________________________ 13. Did the Respondent nominate a Guardian pursuant to §15-14-304, C.R.S.? Yes No If Yes, identify: Name: ______________________________________________ Relationship: _______________________ Address: _______________________________________________________________________________ City: ____________________ State: ___ Zip Code: ________ Email Address: ________________________ Home Phone #: ______________________________ Work Phone #: _______________________________ 14. It is necessary to appoint an Emergency Guardian for the Respondent because complying with the normal procedures for the appointment of a guardian will likely result in substantial harm to the Respondent’s health, safety, or welfare and no other person appears to have authority and willingness to act in the circumstances, pursuant to §15-14-312, C.R.S. The nature of the emergency is: ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ JDF 841 4/08 VERIFIED PETITION FOR APPOINTMENT OF GUARDIAN FOR ADULT Page 3 of 5 American LegalNet, Inc. www.FormsWorkflow.com 15. Information on adult children and parents. None If None, list an adult relative, for example brother, 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 #: _______________________________ 16. Information on each person currently responsible for primary care and custody of the Respondent, None including the Respondent’s treating physician: Name of Treating Physician: ________________________________Phone #: ________________________ Address: _______________________________________________________________________________ City: ____________________ State: ___ Zip Code: ________ Email Address: ________________________ Name of Caregiver: _________________________________ Phone #:______________________________ Address: _______________________________________________________________________________ City: ____________________ State: ___ Zip Code: ________ Email Address: ________________________ 17. Does the Respondent’s have any legal representative(s) pursuant to §15-14-102(6), C.R.S. No If Yes, identify: Yes Name: __________________________________________ Phone #: ______________________________ Current Residence: _______________________________________________________________________ City: ____________________ State: ___ Zip Code: ________ Email Address: ________________________ Name: __________________________________________ Phone #: ______________________________ Current Residence: _______________________________________________________________________ City: ____________________ State: ___ Zip Code: ________ Email Address: ________________________ JDF 841 4/08 VERIFIED PETITION FOR APPOINTMENT OF GUARDIAN FOR ADULT Page 4 of 5 American LegalNet, Inc. www.FormsWorkflow.com If a conservatorship case exists or you are also filing a Petition for Conservatorship, do not complete sections 18 and 19. Please note that a guardianship case does not provide authority over substantial funds. 18. Does the Respondent have any assets, e.g. bank accounts, property? Yes Description of Assets, e.g. Bank Accounts, Property No If Yes, identify: Estimated Value of Property $ Total $ 19. Does the Respondent have any anticipated income, e.g. Social Security, interest? identify: Yes No If Yes, Description of Income e.g. Social Security, interest Amount of Anticipated Income or Receipts $ Total $ The Petitioner shall provide notice to the Respondent, spouse, if applicable, any nominees by the Respondent and persons listed in paragraphs 12 and 15 - 17 of the time and place for hearing on this Petition in accordance with Colorado Rules of Probate Procedures and pursuant to §15-14-309, C.R.S. and §15-14-113, C.R.S. Notice requirements may be different if this is an emergency guardianship. The Petitioner is interested in the welfare and best interests of the Respondent and requests that an appointment of a guardian be made after notice and hearing pursuant to §15-14-304, 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 841 4/08 ______________________________________ Notary Public/Clerk VERIFIED PETITION FOR APPOINTMENT OF GUARDIAN FOR ADULT Page 5 of 5 American LegalNet, Inc. www.FormsWorkflow.com