SUPERIOR COURT OF THE DISTRICT OF COLUMBIA PROBATE DIVISION _________ INT _________ _________ IDD _________ In re: ________________________________ An Adult PETITION FOR APPOINTMENT OF TEMPORARY GUARDIAN [ [ [ [ ] Emergency guardian for up to 21 days based on a life-threatening situation or situation involving emergency care when no other person appears to have authority to act under the circumstances. ] Health care guardian for up to 90 days when there is no guardian, there are two certifications of incapacity under D.C. Code, sec. 21-2204, and no other person appears to have authority to act under the circumstances. ] Provisional guardian for up to six months based on a finding that any guardian is not effectively performing said guardian's duties and the welfare of the ward requires immediate action. ] Extension of appointment [ ] Emergency guardian to serve as health care guardian [ ] Health care guardian to serve an additional 90 days. 1. Petitioner's name ______________________________________________________________ 2. Subject a. Name: ______________________________________________________________ b. Age: ______________________________________________________________ c. Address: ______________________________________________________________ ______________________________________________________________ d. Telephone: ______________________________________________________________ e. Specific reasons why the subject is incapacitated (i.e., the diagnoses): ______________________________________________________________ ______________________________________________________________ 3. Nominated guardian and/or conservator if not petitioner a. Name ______________________________________________________________ b. Address ______________________________________________________________ ______________________________________________________________ April 2014 ­ 927.10.v4 American LegalNet, Inc. www.FormsWorkFlow.com 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: _____________________________________________ _________________________________________________________________________ _________________________________________________________________________ 5. Appointment of the following is necessary because [ ] Emergency guardian for up to 21 days [ ] There is no guardian and no other person with authority to act under the circumstances, and there is [ ] A life-threatening situation. State the nature of such situation: ______________________________________________________________ ______________________________________________________________ ____________________________________________or [ ] A situation involving emergency care. State the nature of such situation. (This relief should be requested only when immediate treatment, including diagnostic treatment, is needed in response to a sudden, acute, and unanticipated medical crisis to avoid injury, extreme pain, impairment, or death.) _______________________________________________________ ______________________________________________________________ [ ] Health care guardian for up to 90 days [ ] There is no guardian and no other person with authority to act under the circumstances, and April 2014 ­ 927.10.v4 American LegalNet, Inc. www.FormsWorkFlow.com [ ] The incapacity of the subject has been certified pursuant to D.C. Code, sec. 212204 by two professionals, one of whom is a physician and one of whom is a qualified psychologist or psychiatrist and one of whom examined the subject within 1 day preceding the certification. [ ] Provisional guardian for up to 6 months [ ] The existing guardian is not effectively performing the duties of a guardian and the welfare of the ward requires immediate action. [ ] The name, address, and telephone number of the existing guardian are ___________________________________________________________________ [ ] The length of time for which the provisional guardian should be appointed is ___________________________________________________ [ ] Extension of appointment [ ] Emergency guardian be allowed to serve as health care guardian. [ ] Health care guardian be appointed for an additional 90 days (1) because of the continued incapacity of the subject and the continued need to provide substituted consent in accordance with D.C. Code, sec. 21-2210 for any health care service, treatment, or procedure or (2) because a petition for appointment of a limited or general guardian was filed before the current appointment of a health care guardian expired but has not yet been heard by the Court. 6. For requests for an emergency guardian or health care guardian, petitioner has [ ] Attached two certifications of incapacity in accordance with D.C. Code, sec. 212204 and asks that the appointment of an examiner be waived. [ ] Has not attached two certifications of incapacity, so an examiner must be appointed. [ ] Has attached two certifications of incapacity and requests appointment of an examiner. 7. 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 the proceeding or to ma