IN THE COURT OF CHANCERY OF THE STATE OF DELAWARE In the Matter of: C.M.# AN ALLEGED DISABLED PERSON PRO SE PETITION FOR THE APPOINTMENT OF GUARDIAN OF THE PERSON AND/OR PROPERTY Petitioner represents: your name 1. Information about Petitioner (You are the Petitioner): a. Current address: c. Social Security No.: b. Telephone No.: d. Relationship to alleged disabled person: 2. Information about the alleged disabled person whose name is: a. Age: c. Current address: d. b. Date of birth: Permanent address: e. Current mailing address, if different from above f. If the alleged disabled person is a patient/living at a hospital or an institution, i. Admission date ii. Admitted by iii. Reason(s) for admission: 3. Who is paying the alleged disabled person's expenses AND out of what funds? 4. The married status of the alleged disabled person is: (Check one) American LegalNet, Inc. www.FormsWorkFlow.com Single 5. Married RELATIONSHIP TO ALLEGED DISABLED PERSON ADDRESS OF NEXT OF KIN NEXT OF KIN’S AGE The alleged disabled person is believed to have made a Will that is located at in the custody of address where will can be found 7. Widowed The next of kin of the alleged disabled person are: [The next of kin is/are the person(s) who would be entitled to inherit the alleged disabled person's estate if the alleged disabled person died without having a will]: (Complete the table below with respect to next of kin.) NEXT OF KIN NAME 6. Divorce . possession of whom Has the alleged disabled person ever appointed a Power of Attorney? If "YES", name of the Power of Attorney: YES NO 8. Has the alleged disabled person been represented by a Delaware attorney within 2 years of filing this Petition? YES NO If "YES" briefly explain and include the years of service: 2 American LegalNet, Inc. www.FormsWorkFlow.com 9. Has the alleged disabled person ever been a member of the military? 10. In detailed information, explain why it is necessary for the Court to grant you Guardianship. 11. In the opinion of the Petitioner, will notifying the alleged disabled person that this Petition is being filed, likely result in harm to the alleged disabled person's health? (Check one) YES NO 12. List ALL alleged disabled person’s assets: (Attach additional pages if necessary.) PROPERTY ESTIMATED VALUE RETAIL VALUE YES NO IF OWNED JOINTLY NAME AND ADDRESS OF JOINT OWNER Cash Bank accounts Stocks Bonds Mutual funds Securities Options Annuities Home/real estate Other real estate Motor vehicles/automobile(s) Other vehicles Business Other valuable property (except ordinary household furnishings and clothes) Life insurance policy amount Other: _____________________________ Other: _____________________________ 3 American LegalNet, Inc. www.FormsWorkFlow.com 13. List ALL believed current sources of income for the alleged disabled person: (Attach additional sheets if necessary). BENEFIT OR SOURCE OF INCOME AMOUNT WHEN RECEIVED HOW OFTEN RECEIVED (one time or regular) Business, profession or self-employment Rent payments Interest Dividends from stocks or bonds Qualified and/or non-qualified pension and/or retirement plan Social security retirement Social security disability VA benefits Federal pension (CSRS or FERS) Disability or private disability Military pension IRA Any other annuity payments Bank account interest Gifts Other: ____________________________ Other: ____________________________ 14. List ALL debts and monthly expenses of the alleged disabled person: (Attach additional pages if necessary.) DESCRIPTION OF DEBTS AND MONTHLY EXPENSES, BILLS TOTAL DEBT MONTHLY PAYMENT Mortgage (taxes, insurance and escrow) or Rent Water Sewer Electric Gas Oil Garbage Cable television Telephone Household items Household maintenance and repairs (list) Item: ________________________________ Item: ________________________________ Groceries Clothing 4 American LegalNet, Inc. www.FormsWorkFlow.com DESCRIPTION OF DEBTS AND MONTHLY EXPENSES, BILLS (cont.) TOTAL DEBT (cont.) MONTHLY PAYMENT (cont.) Health insurance (COBRA) Medications Health care Other out-of-pocket medical and dental expenses for self Medical and dental expenses for dependents Laundry and dry cleaning Cosmetics and toiletries Hobbies Barber and hairdresser Newspaper, magazine subscriptions Charitable and/or religious donations Vacation Entertainment and miscellaneous Transportation other than automobile Automobile Monthly payment: Repairs and maintenance: Insurance: Gasoline: Life insurance payment Other: ____________________________ Other: ____________________________ 15. Check ONLY the statement(s) below that applies to your situation (the one that is true). If both statements are true, check both boxes. The alleged disabled person is UNABLE TO PROPERLY MANAGE AND CARE FOR HIS/HER PROPERTY and, as a consequence thereof, IS IN DANGER OF DISSIPATING OR LOSING SUCH PROPERTY by becoming the victim of designing person(s). The alleged disabled person is UNABLE TO PROPERLY MANAGE AND CARE FOR HIS/HER PERSON and, as a consequence thereof, IS IN DANGER OF SUBSTANTIALLY ENDANGERING HIS/HER OWN HEALTH or BECOMING SUBJECT TO ABUSE by other person(s). 16. ALL of the following statements must be true before the Court of Chancery will consider this Petition. Check ALL the following statements to acknowledge they are true: THERE IS CURRENTLY NO GUARDIAN for the Person OR the Property of the alleged disabled person. The alleged disabled person is domiciled in the State of Delaware. 5 American LegalNet, Inc. www.FormsWorkFlow.com ATTACHED is the medical report of: Name of attending doctor/physician of alleged disabled person: Doctor/physician’s office address: Doctor/physician’s telephone no.: Petitioner consents to the Register in Chancery of the Court being his/her agent for acceptance of service on behalf of the Petitioner as to any claim arising out of the Guardianship if, by reason of the Guardian’s absence from this State, he/she cannot be personally served. WHEREFORE, Petitioner respectfully requests that: a. This Court appoint him/her as Guardian of: (check all that apply): Guardian of the Property of the alleged disabled person. Guardian of the Person of the alleged disabled person. b. He/she be permitted to serve as Guardian without the necessity of posting surety on the bond. c. A Preliminary Order be entered to schedule a Hearing and to notify interested parties. Date Petitioner's Signature SWORN TO AND SUBSCRIBED before me on this date: Notary Public or Clerk of the Court 6 American LegalNet, Inc. www.FormsWorkFlow.com