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 [ ] intellectual disability [ ] intellectual disability [ ] 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. Relationship to subject: ______________________________________________________________ 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 intellectual disability. g. A comprehensive evaluation or habilitation plan [ ] does [ ] does not exist. 1 November 2015 � 926.10.v4 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: _____________________________________________ _________________________________________________________________________ _________________________________________________________________________ 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 2 November 2015 � 926.10.v4 American LegalNet, Inc. www.FormsWorkFlow.com 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 intellectual disability, he/she is a qualified intellectual disability professional.) [ ] Appoint another examiner. [ ] Waive appointment of examiner. 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 subjec