APPLICATION/GUARDIANSHIP OF PERSON WITH INTELLECTUAL DISABILITY PC-700 REV. 7/12 Page 1 of 2 STATE OF CONNECTICUT RECORDED(CONFIDENTIAL VOLUME): COURT OF PROBATE [Type or print in black ink.] TO: COURT OF PROBATE, DISTRICT NO. IN THE MATTER OF RESPONDENT'S DATE OF BIRTH Hereinafter referred to as the respondent. PRESENT ADDRESS OF RESPONDENT [If institutionalized, give name and address of institution.] PETITIONER [Name, address, zip code, and telephone number] RESPONDENT'S TOWN OF DOMICILE RELATIONSHIP OF PETITIONER TO RESPONDENT PERSONS TO WHOM NOTICE SHOULD BE GIVEN: RESPONDENT, SPOUSE, AND PARENTS [if any, and provided they are not the applicants], CHILDREN [if any], SIBLINGS OR THEIR REPRESENTATIVES [if any and only if respondent has no living parents], DEPARTMENT OF DEVELOPMENTAL SERVICES REGIONAL DIRECTOR, PERSON IN CHARGE OF THE INSTITUTION WHERE THE RESPONDENT CURRENTLY RESIDES, ATTORNEY FOR THE RESPONDENT [if any], and ANY OTHER PERSONS HAVING AN INTEREST IN THE RESPONDENT. [Give names, addresses, zip codes, and relationships to respondent. If attorney for respondent, list juris number.] C.G.S. §45a-670. Additional data [on Second Sheet, PC-180] if any, is made a part hereof. THE PETITIONER REPRESENTS that: The respondent There is is not able to attend a hearing at the court. is is not a plenary guardian, limited guardian or conservator for the respondent in any jurisdiction. [If so, list status, location, court and date of decree in the space below.] APPLICATION/GUARDIANSHIP OF PERSON WITH INTELLECTUAL DISABILITY PC-700 American LegalNet, Inc. www.FormsWorkFlow.com APPLICATION/GUARDIANSHIP OF PERSON WITH INTELLECTUAL DISABILITY PC-700 REV. 7/12 Page 2 of 2 STATE OF CONNECTICUT RECORDED(CONFIDENTIAL VOLUME): COURT OF PROBATE [Type or print in black ink .] The respondent, by reason of the severity of his or her intellectual disability, is able to do some, but not all, of the tasks necessary to meet essential requirements for his or her physical health or safety or to make some, but not all, informed decisions about matters related to his or her care. (LIMITED GUARDIANSHIP) The respondent, by reason of the severity of his or her intellectual disability, is totally unable to meet essential requirements for his or her physical health or safety and totally unable to make informed decisions about matters related to his or her care. (PLENARY GUARDIANSHIP) Please list the specific areas of protection and assistance required for the respondent by checking the appropriate boxes below. The probate court may give a guardian the power to assure and/or consent to the following: residence outside the natural family home; routine, elective and emergency medical and dental care; specifically designed educational, vocational, or behavioral programs; other specific limited services necessary to develop or regain to the maximum extent possible the ward's capacity to meet essential requirements. the release of clinical records and photographs; A plenary guardian will be given all of the above powers; a limited guardian will be given only those powers deemed necessary by the court. C.G.S. § 45a-677. Plenary and limited guardians also have a duty to assure the care and comfort of the ward* within the scope of their appointment and within the limitations of the resources available to the ward, either through his or her own estate or by reason of public or private assistance. * A respondent is referred to as a "ward" after the appointment of a guardian. WHEREFORE THE PETITIONER REQUESTS that this court appoint a limited plenary standby guardian(s) of the person. The representations contained herein are made under the penalties of false statement. .................................................................................. Petitioner: DATE: IF APPOINTED, I WILL ACCEPT THE POSITION OF TRUST AS DETERMINED BY THE COURT. Proposed LIMITED PLENARY Guardian Proposed Standby Guardian Signed............................................................................... Signed............................................................................... Type Name: Type Name: Address and Zip Code: Address and Zip Code: Telephone Number: Telephone Number: Proposed LIMITED PLENARY Guardian Proposed Standby Guardian Signed............................................................................... Signed............................................................................... Type Name: Type Name: Address and Zip Code: Telephone Number: Address and Zip Code: Telephone Number: APPLICATION/GUARDIANSHIP OF PERSON WITH INTELLECTUAL DISABILITY PC-700 American LegalNet, Inc. www.FormsWorkFlow.com