SUPERIOR COURT OF THE DISTRICT OF COLUMBIA PROBATE DIVISION _________ INT _________ _________ IDD _________ In re ________________________________ Subject PETITION FOR A GENERAL PROCEEDING [ [ [ [ [ ] Appointment of a guardian of an incapacitated individual [ ] General [ ] Limited [ ] mental retardation [ ] mental retardation [ ] other [ ] other ] Appointment of successor guardian [ ] General [ ] Limited ] Appointment of a conservator of a protected individual [ ] General [ ] Limited ] Appointment of a special conservator of a protected individual ] Entry of a protective order 1. Petitioner a. Name: ______________________________________________________________ b. Address: ______________________________________________________________ ______________________________________________________________ 2. Subject a. Name: ______________________________________________________________ b. Age: ______________________________________________________________ c. Address: ______________________________________________________________ ______________________________________________________________ d. Telephone: ______________________________________________________________ e. Specific reasons why the subject is incapacitated (i.e., the diagnoses): ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ f. Alleged incapacity [ ] does [ ] does not arise from mental retardation. g. A comprehensive evaluation or habilitation plan [ ] does [ ] does not exist. 1 American LegalNet, Inc. www.FormsWorkFlow.com 3. Nominated guardian and/or conservator if not petitioner a. Name ______________________________________________________________ b. Address ______________________________________________________________ ______________________________________________________________ c. Entitled to serve because ______________________________________________________________ ______________________________________________________________ 4. The Court has jurisdiction because a. D.C. Code, sec. 21-2402.03 [ ] The District of Columbia is the subject’s home state as defined in D.C. Code, sec. 21-2402.01(a)(2). [ ] The District of Columbia is a significant connection state as defined in D.C. Code, sec. 21-2402.01(a)(3) and one of the following applies: 1. [ ] The subject does not have a home state. 2. [ ] The home state court has declined to exercise jurisdiction because the District of Columbia is the more appropriate forum. 3. [ ] No petition or order is pending before the home state or a significant connection state. [ ] The District of Columbia is not the home state or a significant connection state, but the home state and all significant connection states decline to exercise jurisdiction and jurisdiction in the District of Columbia is more appropriate and consistent with Title 11 and the Constitution. [ ] Special jurisdiction exists in accordance with D.C. Code, sec. 21-2402.04 for the following: [ ] Issuance of a protective order as to real or tangible personal property located in the District of Columbia [ ] Appointment of a guardian or conservator for whom a provisional order to transfer a proceeding from another state has been issued. b. Other basis for jurisdiction: _____________________________________________ _________________________________________________________________________ _________________________________________________________________________ 2 American LegalNet, Inc. www.FormsWorkFlow.com 5. No guardian or conservator has been appointed in any other jurisdiction and there are no pending proceedings in any other jurisdiction to do so except _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ 6. The subject’s ability to receive and evaluate information effectively or to communicate decisions is impaired to such an extent that the subject lacks the capacity to take actions necessary to [ ] obtain, administer, dispose of real and personal property, intangible property, business property, benefits, and income and/or [ ] provide health care, food, shelter, clothing, personal hygiene and other care without which serious physical injury or illness is more likely than not to occur and/or [ ] acquire and maintain those life skills that enable the subject to cope more effectively with the demands of the subject’s own person and environment and to raise the level of the subject’s physical, intellectual, social, emotional, and economic efficiency or meet all or some essential requirements for the subject’s therapeutic needs [ ] [ [ [ ] ] ] without court-ordered assistance or without the appointment of a guardian a conservator 7. Examiner (i.e., attending physician/doctor) familiar with the subject a. Name: ___________________________________________________________________ b. Address: ___________________________________________________________________ ___________________________________________________________________ c. Phone: ___________________________________________________________________ d. Report attached [ ] yes [ ] no e. [ ] Appoint this person as examiner. (Choose this only if: (1) you have discussed this appointment with the examiner and advised him/her of the duties of an examiner, including the need to attend the hearing to be scheduled regarding this petition and the right of the subject to cross examine the examiner in court, (2) he/she is willing to serve, and (3) if the alleged incapacity arises from mental retardation, he/she is a qualified mental retardation professional.) [ ] Appoint another examiner. [ ] Waive appointment of examiner. 3 American LegalNet, Inc. www.FormsWorkFlow.com 8. Visitor (i.e., social worker) familiar with the subject a. Name: ___________________________________________________________________ b. Address: ___________________________________________________________________ ___________________________________________________________________ c. Phone: ___________________________________________________________________ d. Report attached [ ] yes [ ] no e. [ ] Appoint this person as visitor. [ ] Appoint another visitor. [ ] Waive appointment of visitor. 9. A Guardian ad litem is a person appointed by the court at the beginning of an intervention proceeding to help the subject determine the subject’s interest in this proceeding or to make that determination for the subject if the subject is unconscious or otherwise wholly incapable of making such a determination, even with assistance. Petitioner asks the court to [ ] Appoint a Guardian ad litem [ ] Not appoint a Guardian ad litem 10. Persons to whom notice will be sent pursuant to D.C. Code, secs. 21-2042 and 212402.08 and SCR-PD 325, including name, address, and telephone number: a. Spouse. (If none, adult children. If none, parents. If none, at least one of the nearest adult relatives of the subject.): Name: _____________________________________________ Address: _____________________________________________ _____________________________________________ Phone: _____________________________________________ Name: _____________________________________________ Address: _____________________________________________ _____________________________________________ Phone: _____________________________________________ b. Counsel to the subject: Name: _____________________________________________ Address: _____________________________________________ _____________________________________________ Phone: _____________________________________________ c. Attorney in fact nominated in durable power of attorney as guardian and/or conservator and any previously appointed guardian and/or conservator and the custodian of the subject: Name: _____________________________________________ Address: _____________________________________________ _____________________________________________ Phone: _____________________________________________ d. All persons entitled to notice if this petition had been filed in the subject’s home state: Name: _____________________________________________ Address: _____________________________________________ _____________________________________________ Phone: _____________________________________________ 4 American LegalNet, Inc. www.FormsWorkFlow.com 11. [ ] [ ] [ ] Appointment of a guardian is requested and is necessary to provide continuing care and supervision to the subject and/or A protective order should be entered or A conservator should be appointed because [ ] the subject has property that will be wasted or dissipated unless property management is provided, and/or [ ] money is needed for the support, care, and welfare of the subject, and/or [ ] money is needed for those entitled to the subject’s support, and protection is necessary or desirable to obtain and provide money. The names and addresses of those persons are as follows: _____________ ________________________________________________________ ________________________________________________________ 12. If a protective order or conservator is requested, describe the subject’s property with an estimate of the value of that property including any income, insurance, pension, or allowance to which the subject is entitled: _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ 13. Bond [ ] [ ] [ ] Not required Covering all assets of the subject plus one year’s income): $_________________ Reduced bond. $_____________________ List all assets not covered. Those assets cannot be sold, transferred, or encumbered without prior court order. 14. Petitioner asks for temporary relief in accordance with D.C. Code, sec. 21-2044(d) or D.C. Code, sec. 21-2055(b)(1). State exactly what is requested and why. _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ 15. Petitioner asks for the following relief: [ ] A protective order as follows: _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ 5 American LegalNet, Inc. www.FormsWorkFlow.com [ ] Appointment of a [ ] Guardian with [ ] Statutory powers [ ] Greater powers. Specify power sought and legal authority by which court may grant such power. __________________________________________________ __________________________________________________ __________________________________________________ [ ] Lesser powers [ ] Conservator with [ ] Statutory powers [ ] Greater powers. Specify power sought and legal authority by which court may grant such power. __________________________________________________ __________________________________________________ __________________________________________________ [ ] Lesser powers. Note: This box must be checked if petitioner is asking that bond not include real estate or securities. ________________________________ Signature of petitioner ________________________________ Telephone number VERIFICATION I ____________________________, being first duly sworn, on oath, depose and say that that I have read the foregoing pleadings by me subscribed and that the facts therein stated are true to the best of my knowledge, information, and belief. _________________________________ Signature of petitioner Subscribed and sworn to before me this ____ day of _________________, 20__. _________________________________ Notary Public/Deputy ACCEPTANCE OF APPOINTMENT AND CONSENT TO PERSONAL JURISDICTION I hereby accept the duties of the office of [ ] guardian [ ] conservator of _________________________________ (subject) and consent to personal jurisdiction in any action begun in the District of Columbia by any interested person against me as guardian and/or conservator arising from the duties of my office and, if I am a non-resident, I do hereby irrevocably appoint the Register of Wills and successors in office as the person upon whom all notice and process issued by a competent court in the District of Columbia may be served with the same effect as personal service in relation to all suits or matters 6 American LegalNet, Inc. www.FormsWorkFlow.com pertaining to the proceeding in which Letters of guardianship and/or conservatorship shall issue. _____________________________________ Signature of petitioner if seeking appointment _____________________________________ Telephone number CERTIFICATE OF SERVICE I hereby certify that within three (3) days of the filing of the foregoing petition, a copy was served by first class mail, postage prepaid, on the following parties (list names and addresses of all parties): _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ _______________________________ ____________________________________ Signature __________________________________ Signature of Attorney __________________________________ Attorney Name __________________________________ Bar No. __________________________________ Address (Actual address/Not Post Office Box) _______________________________________ Telephone No. June 2009 7 American LegalNet, Inc. www.FormsWorkFlow.com