GEORGIA PROBATE COURT STANDARD FORM Petition for the Appointment of an Emergency Guardian and/or Conservator for a Proposed Ward INSTRUCTIONS I. Specific Instructions 1. This form is to be used for filing a Petition for the Appointment of an Emergency Guardian and/or Conservator for a Proposed Ward pursuant to O.C.G.A. §29-4-14 and/or §29-5-14. 2. Regarding the need for the pre-hearing appointment of an Emergency Guardian and/or Conservator, O.C.G.A. §29-4-15(c)(5) and 29-5-15 (c)(5) provide as follows: If the court determines that there is probable cause to believe that the proposed ward is in immediate need of an emergency guardian, the court shall appoint an emergency guardian to serve until the emergency hearing, with or without prior notice to the proposed ward, but only if the threatened risk is so immediate and the potential harm so irreparable that any delay is unreasonable and the existence of the threatened risk and potential for irreparable harm is certified by the affidavit of a physician licensed to practice medicine under Chapter 34 of Title 43, a psychologist licensed to practice under Chapter 39 of Title 43, or a licensed clinical social worker. If the court determines that there is probable cause to believe that the proposed ward is in immediate need of an emergency conservator, the court shall appoint an emergency conservator to serve until the emergency hearing, with or without prior notice to the proposed ward, but only if the threatened risk is so immediate and the potential harm so irreparable that any delay is unreasonable and the existence of the threatened risk and potential for irreparable harm is certified by the affidavit of a physician licensed to practice medicine under Chapter 34 of Title 43, a psychologist licensed to practice under Chapter 39 of Title 43, or licensed clinical social worker; provided, however, that, pending the emergency hearing, the court shall order that no withdrawals may be made from any account on the authority of the proposed ward´s signature without the court´s prior approval and that the emergency conservator shall not expend any funds of the proposed ward without prior court approval. 3. Further, if a pre-hearing emergency guardian and/or conservator is appointed to serve until the emergency hearing, then such guardian and/or conservator shall, prior to the issuance of Letters of Emergency Guardianship and/or Conservatorship, take an oath and post such bond as the court may require. Effective 7/09 GPCSF 11Petitioner American LegalNet, Inc. www.FormsWorkFlow.com 4. 5. In any case involving the appointment of a conservator when the proposed ward owns real property in Georgia, a certificate of creation of conservatorship will be completed by the clerk of the probate court and filed with the clerk of the superior court of each county in which the proposed ward owns real property. 6. II. The burden of proof is on the petitioner to prove by clear and convincing evidence that the proposed ward lacks sufficient capacity to make or communicate significant responsible decisions concerning his/her health or safety and is in need of a guardian AND there is an immediate, clear, and substantial risk of death or serious physical injury, illness, or disease unless an emergency guardian is appointed and/or that the proposed ward lacks sufficient capacity to make or communicate significant responsible decisions concerning the management of his/her property and is in need of a conservator AND there is an immediate, substantial risk of irreparable waste or dissipation of the estate unless an emergency conservator is appointed. According to Probate Court Rule 22 (A), unless the court specifically assumes the responsibility, it is the responsibility of the moving party to prepare the proper citation and deliver it properly so it can be served according to law. Pages after 13 which are labeled “Court” are to be completed by the moving party, unless otherwise directed by the court. General Instructions General instructions applicable to all Georgia probate court standard forms are available in each probate court. Effective 7/09 GPCSF 11Petitioner American LegalNet, Inc. www.FormsWorkFlow.com GEORGIA PROBATE COURT STANDARD FORM PROBATE COURT OF COUNTY STATE OF GEORGIA IN RE: , PROPOSED WARD ) ) ) ) ) ) ESTATE NO. PETITION FOR APPOINTMENT OF AN EMERGENCY GUARDIAN AND/OR EMERGENCY CONSERVATOR FOR A PROPOSED WARD TO THE HONORABLE JUDGE OF THE PROBATE COURT: [NOTE: Unless there are two or more petitioners, the affidavit on page 8 must be completed by a physician, psychologist, or licensed clinical social worker based upon an examination within 15 days prior to the filing of this petition.] 1. Petitioner, , is the (relationship) of the proposed ward, and is domiciled at (address) County of , State of number , telephone , and (Initial either a. or b. below): a. (Second Petitioner, if any) , is the (relationship) of the proposed ward, and is domiciled at (address) County of , telephone number , State of , show that: or b. attached hereto as page 8 and made a part of this petition is the completed affidavit of ,a physician, psychologist or licensed clinical social worker licensed to practice in Georgia, who has examined the proposed ward within fifteen days prior to the filing of this petition, show that: Effective 7/09 GPCSF 11Petitioner -1- American LegalNet, Inc. www.FormsWorkFlow.com 2. The proposed ward, age security no. , date of birth , social , is domiciled at (address) County, State of , and is presently located at , which is a (type of facility, if applicable) and can be contacted at (telephone number): . (initial if applicable) It is anticipated that the proposed ward will be moved within the next 3 days to the following address: , telephone number . The proposed ward is a citizen of a foreign country, being (if a guardianship or conservatorship is granted, pursuant to The Vienna Convention, the Probate Court must notify the consul). 3. The proposed ward is in need of an emergency guardian and/or conservator by reason of the following incapacity: to the extent that the proposed ward: (initial all applicable) a. (for emergency guardianship:) lacks sufficient capacity to make or communicate significant responsible decisions concerning his/her health or safety , and there is an immediate, and substantial risk of death or serious physical injury, illness, or disease unless an emergency guardian is appointed, b. (for emergency conservatorship:) lacks sufficient capacity to make or communicate significant responsible decisions concerning the management of his/her property and there is an immediate, substantial risk of irreparable waste or dissipation of the estate unless an emergency conservator is appointed. The facts which support the claim of the need for an emergency guardian and/or conservator are as follows: (NOTE: pursuant to O.C.G.A. §29-4-15(b) and 29-5-14(b), the Court shall dismiss the petition if the petitioner does not allege facts which cause the Court to believe that the proposed ward is in need of an emergency guardian and/or conservator as stated above. The Petition cannot be granted unless sufficient facts are presented which support the claim for the need for the appointment of an emergency guardian and/or conservator. While an attached physician’s/psychologist’s/social worker’s affidavit is permissible, the Petitioner(s) MUST specifically allege sufficient facts to support the granting of this Petition.) Effective 7/09 GPCSF 11Petitioner -2- American LegalNet, Inc. www.FormsWorkFlow.com 4. It is in the best interest of the proposed ward that be appointed emergency guardian and appointed emergency conservator. 5. (Initial if applicable) a. In addition to the appointment of an emergency guardian after notice and a hearing, the Court immediately should appoint a pre-hearing emergency guardian for the following reasons: Note: the court cannot appoint a pre-hearing emergency guardian unless the petition alleges sufficient specific facts showing that any delay is unreasonable and the existence of the threatened risk and potential for irreparable harm is certified by an affidavit of a physician, psychologist, or social worker. and, the pre-hearing guardian should be granted the following specific powers and duties which do not exceed those absolutely necessary to respond to the immediate threatened risk(s) described above: b. In addition to the appointment of an emergency conservator after notice and a hearing, the Court immediately should appoint a pre-hearing emergency conservator for the following reasons: Note: the court cannot appoint a pre-hearing emergency conservator unless the petition alleges sufficient specific facts showing that any delay is unreasonable and the existence of the threatened risk and potential for irreparable harm is certified by an affidavit of a physician, psychologist, or social worker. and, the pre-hearing conservator should be granted the following specific powers and duties which do not exceed those absolutely necessary to respond to the immediate threatened risk(s) described above: Effective 7/09 GPCSF 11Petitioner -3- American LegalNet, Inc. www.FormsWorkFlow.com 6. The reason(s) why the procedures for the appointment of a non-emergency (permanent) guardianship and/or conservatorship are inadequate to protect the proposed ward and/or his/her property is/are: (Initial if applicable) A Petition for permanent guardianship/conservatorship was/is being/will be filed in conjunction with this Petition. No Petition for permanent guardianship/conservatorship has been/will be filed, and a summary description of all known assets, income, other sources of funds, liabilities, and expenses of the proposed ward is shown on page 10. 7. The foreseeable duration of the proposed ward’s incapacity will be: and the Court should grant the emergency guardian/conservator the following powers and duties which do not exceed those absolutely necessary to respond to the immediate threatened risk(s) described above: . 8. (initial one:) a. b. No other person has authority to act in the circumstances, whether under a power of attorney, trust, or otherwise. The following individual(s) with the authority to act under a power of attorney, trust, or otherwise, appear(s) unwilling or unable to act: (name, address, and telephone number): 9. Additional Data: Where full particulars are lacking, state here the reasons for any such omission. Effective 7/09 GPCSF 11Petitioner -4- American LegalNet, Inc. www.FormsWorkFlow.com WHEREFORE, petitioner(s) pray(s): 1. 2. 3. 4. 5. that service be perfected as required by law; that the court appoint legal counsel and an evaluator for the proposed ward and order an evaluation as required by law; that the court order an emergency hearing to be conducted not sooner than 3 days nor later than 5 days after the filing of this petition; that an emergency guardian and/or conservator be appointed for the proposed ward; and that, if requested, the Court immediately appoint a pre-hearing emergency guardian and/or conservator with such powers and duties as the Court shall direct. Signature of first petitioner Signature of second petitioner, if any Printed Name Printed Name Address Address Telephone Number Telephone Number Signature of Attorney: Typed/printed name of Attorney: Address: Telephone: State Bar # Effective 7/09 GPCSF 11Petitioner -5- American LegalNet, Inc. www.FormsWorkFlow.com VERIFICATION GEORGIA, COUNTY Personally appeared before me the undersigned petitioner(s) who on oath state(s) that the facts set forth in the foregoing petition are true. Sworn to and subscribed before me this day of , 20 . First Petitioner NOTARY/CLERK OF PROBATE COURT My Commission Expires Printed Name -------------------------------------------------------------------------------------------------------------------------------Sworn to and subscribed before me this day of , 20 . Second Petitioner, if any NOTARY/CLERK OF PROBATE COURT My Commission Expires Printed Name Effective 7/09 GPCSF 11Petitioner -6- American LegalNet, Inc. www.FormsWorkFlow.com CONSENT TO SERVE AS EMERGENCY GUARDIAN AND/OR CONSERVATOR RE: Petition for the appointment of an emergency guardian and/or conservator for , a proposed ward. I/We, , having been nominated as emergency guardian(s) and I/we, , having been nominated as emergency conservator(s)of the above-named proposed ward, do hereby consent to serve as emergency guardian(s)/conservator(s) and pre-hearing emergency guardian(s)/conservator(s) if so appointed. Proposed Emergency Guardian/Conservator Proposed Emergency Guardian/Conservator Print Name Print Name Address Address Telephone Telephone Proposed Emergency Guardian/Conservator Print Name Address Telephone Effective 7/09 GPCSF 11Petitioner -7- American LegalNet, Inc. www.FormsWorkFlow.com STATE OF GEORGIA COUNTY OF PROBATE COURT OF RE: COUNTY Petition for appointment of an emergency guardian and/or conservator for . AFFIDAVIT OF PHYSICIAN, PSYCHOLOGIST, OR CLINICAL SOCIAL WORKER FOR EMERGENCY GUARDIANSHIP/CONSERVATORSHIP I, being first duly sworn, depose and say that I am a physician licensed to practice under Chapter 34 of Title 43 of the Official Code of Georgia Annotated or a psychologist licensed to practice under Chapter 39 of Title 43 of the Official Code of Georgia Annotated, or a licensed clinical social worker; that my office address is , Georgia, and that I have examined the above-named proposed ward on the day of , 20 . NOTE: The examination on which this affidavit is based must occur WITHIN FIFTEEN DAYS prior to the filing of the petition. I found him/her to be incapacitated by reason of : to the extent that said proposed ward (initial all applicable): a. (re: emergency guardianship:) lacks sufficient capacity to make or communicate significant responsible decisions concerning his/her health or safety and there is an immediate and substantial risk of death or serious physical injury, illness, or disease unless an emergency guardian is appointed, and (if applicable) i. the threatened risk is so immediate and the potential harm so irreparable that any delay is unreasonable and a pre-hearing guardian should be appointed. b. (re: emergency conservatorship:) lacks sufficient capacity to make or communicate significant, responsible decisions concerning the management of his/her property and there is an immediate, substantial risk of irreparable waste or dissipation of the estate unless an emergency conservator is appointed, and (if applicable) i. the threatened risk is so immediate and the potential harm so irreparable that any delay is unreasonable and a pre-hearing conservator should be appointed. The following facts support my opinion of incapacity and the existence of immediate threat(s) or risk(s) to the proposed ward: Effective 7/09 GPCSF 11Petitioner -8- American LegalNet, Inc. www.FormsWorkFlow.com The foreseeable limits on the duration of such incapacity are: Based on available data, the proposed ward should retain the following rights which would be lost with the appointment of a guardian/conservator: (initial all applicable) a. b. c. d. e. f. g. h. i. j. contract marriage make, modify, or terminate other contracts consent to medical treatment establish a residence or dwelling place change domicile revoke a revocable trust established by the ward bring or defend any action at law or equity, except an action relating to the guardianship/conservatorship buy sell, or otherwise dispose of or encumber property enter into or conduct other business or commercial transactions none of the above Optional: Affiant’s opinions as to any other limitations on the emergency guardianship/conservatorship are: WITNESS MY HAND AND SEAL this day of , 20 Sworn to and subscribed before me this me this day of , 20 . Signature of Physician/Psychologist/Social Worker Notary Public My commission expires on the of , 20 (NOTARIAL SEAL AFFIXED) Printed Name of Evaluator day . Effective 7/09 GPCSF 11Petitioner -9- American LegalNet, Inc. www.FormsWorkFlow.com . NOTE: If the appointment of an emergency conservator is sought and no petition for permanent conservatorship is being filed simultaneously, this form must be completed ASSETS, INCOME, OTHER SOURCES OF FUNDS, LIABILITIES, AND EXPENSES OF PROPOSED WARD PROPOSED WARD: REAL PROPERTY (Indicate if property is jointly owned and with whom) Description County State Parcel 1 Approximate equity $ Parcel 2 $ Parcel 3 $ INCOME FROM ALL SOURCES Social Security per year Yearly Total $ SSI (Supplemental Security Income) per year $ Retirement benefits per year $ VA benefits per year $ Other income per year, including, e.g., alimony, annuity, or trust distributions $ Interest, dividend, or investment income $ YEARLY TOTAL OF ALL INCOME $ PERSONAL AND INTANGIBLE PROPERTY (Indicate if property is jointly owned and with whom) Approximate Current Value 1. Checking/Savings/Money Market/Certificates of Deposit/Liquid Accounts: Bank/Financial Institution/Broker Acct. No. Joint Owner (if any) $ $ $ $ Effective 7/09 GPCSF 11Petitioner -10- American LegalNet, Inc. www.FormsWorkFlow.com 2. Stocks/Bonds/Investments (including retirement and profit-sharing accounts): a. Held by brokers: Brokerage Firm or Institution Acct. No. Joint Owner (if any) $ $ $ $ $ b. Privately held: Company/Issuer No. of Shares Joint Owner (if any) $ $ 3. Automobiles: Year/Make/Model V.I.N. Joint owner (if any) $ $ 4. Other assets of significant value: Description Joint owner (if any) $ $ $ TOTAL VALUE OF PERSONAL AND INTANGIBLE PROPERTY Effective 7/09 $ GPCSF 11Petitioner -11- American LegalNet, Inc. www.FormsWorkFlow.com DEBTS AND OTHER LIABILITIES The proposed ward owes the following debts/liabilities: 1. Secured debts: Obligor/Payee Collateral Solely/Jointly Owed Approx. Current Balance $ $ $ 2. Unsecured debts: Obligor/Payee Acct. No. Solely/Jointly Owed Approx. Current Balance $ $ $ TOTAL DEBTS AND OTHER LIABILITIES OF PROPOSED WARD $ AVERAGE MONTHLY LIABILITIES AND EXPENSES Household: Care Facility/Rent/Mortgage payments: $ Property taxes/Insurance $ Utilities/Lawn Care/Pest Control $ Miscellaneous household food $ Total credit account and other debt payments $ Other (specify) $ Automotive/Transportation Fuel and Repairs $ Tags and license fees, Insurance $ Bus/Train/Taxi fares $ Minors or Other Dependents of the Proposed Ward Child Care $ School Tuition/Supplies/Expenses/Lunches $ Clothing/Diapers /Grooming/Hygiene $ Medical/Dental/Prescription $ Entertainment/Activities $ Effective 7/09 GPCSF 11Petitioner -12- American LegalNet, Inc. www.FormsWorkFlow.com Other Insurance Health $ Life/Disability $ Other (specify) $ Proposed Ward’s Other Expenses Laundry/Clothing/Grooming/Hygiene $ Medical/Dental/Prescriptions/Medications $ Entertainment/Vacations/Subscriptions/Dues $ Personal Caretakers/Cleaning personnel $ Other (specify) $ Total Expenses $ Payments to Creditors: Is the proposed ward behind in any debt payments? (yes) (no) If so, payee and amount: SUMMARY 1. Average Monthly Income $ 2. Average Monthly Expenses GPCSF 11Petitioner -13- American LegalNet, Inc. www.FormsWorkFlow.com Petition for the Appointment of an Emergency Guardian and/or Conservator for a Proposed Ward NOTICE: THE FOLLOWING PAGES ARE TO BE COMPLETED BY THE PETITIONER (MOVING PARTY) UNLESS OTHERWISE DIRECTED BY THE COURT. SEE PROBATE COURT RULE 22 (A). American LegalNet, Inc. www.FormsWorkFlow.com GEORGIA PROBATE COURT STANDARD FORM PROBATE COURT OF COUNTY STATE OF GEORGIA IN RE: , PROPOSED WARD ) ) ) ) ) ) ESTATE NUMBER PETITION FOR APPOINTMENT OF AN EMERGENCY GUARDIAN AND/OR CONSERVATOR FOR A PROPOSED WARD ORDER FOR EVALUATION, APPOINTMENT OF COUNSEL, APPOINTMENT OF SPECIAL PROCESS SERVER, AND NOTICE OF HEARING The above petition having been read and considered, and it appearing that there is probable cause to believe that the proposed ward is in need of an emergency guardian and/or emergency conservator within the meaning of O.C.G.A. §29-4-14 and/or §29-5-14, it is hereby ordered that , (physician) (psychologist) (licensed clinical social worker), is appointed to evaluate the above-named proposed ward at on o’clock .M., at (location) , telephone number . In compliance with Georgia law and federal law, including HIPAA, healthcare providers shall permit the above evaluator to have access to the proposed ward’s medical records. IT IS FURTHER ORDERED that is hereby appointed special agent to serve , proposed ward, with a copy of the petition for appointment of emergency guardian and/or conservator and this Order/Notice. IT IS FURTHER ORDERED that the above-named proposed ward shall submit to an evaluation at the time and place stated above and that a written report shall be furnished to the Court and made available to the parties within 72 hours after this order being issued; American LegalNet, Inc. www.FormsWorkFlow.com IT IS FURTHER ORDERED that an emergency hearing shall be conducted (in the Probate Court of County, courtroom , (address) , Georgia) (at the following location: ) at o’clock .M., on (which is not sooner than three days nor later than five days after the filing of the petition); IT IS FURTHER ORDERED that the evaluator shall explain the purpose of the evaluation to the proposed ward; IT IS FURTHER ORDERED that at law, telephone number , attorney is hereby appointed to represent the proposed ward; IT IS FURTHER ORDERED that the Clerk /Deputy Clerk shall mail by first-class mail copies of the petition and this order to all interested individuals identified in paragraph 8 of the Petition, if any. a. IT IS FURTHER ORDERED that, based on the affidavit filed with the Petition, it appears that the threatened risk of death or serious physical injury, illness, or disease of the proposed ward is so immediate and the potential harm so irreparable that any delay is unreasonable, and is named as pre-hearing emergency guardian of the proposed ward, to serve pending the hearing as scheduled above. Emergency Letters of Guardianship shall issued upon said emergency guardian taking the oath. b. IT IS FURTHER ORDERED that, based on the affidavit filed with the Petition, it appears that the threatened risk of waste or dissipation of the proposed ward’s property is so immediate and the potential harm so irreparable that any delay is unreasonable, and is named as pre-hearing emergency conservator of the proposed ward, to serve pending the hearing as scheduled above. Emergency Letters of Conservatorship shall issued upon said emergency conservator posting a surety bond in the amount of $ and taking the oath. Effective 7/09 GPCSF 11Court American LegalNet, Inc. www.FormsWorkFlow.com (initial if applicable) (i) IT IS FURTHER ORDERED THAT, pending the emergency hearing, the court hereby orders that no withdrawals may be made from any account on the authority of the proposed ward´s signature without the court´s prior approval and that the emergency conservator shall not expend any funds of the proposed ward without prior court approval. NOTICE TO PROPOSED WARD: This is to notify you of a proceeding initiated in this court by seeking to appoint (initial one or both) a. an emergency guardian for your person b. an emergency conservator for your property BY THIS ORDER, THE COURT HAS APPOINTED AN ATTORNEY TO REPRESENT YOU AND HAS SCHEDULED A HEARING. YOU AND YOUR ATTORNEY HAVE THE RIGHT TO ATTEND ANY HEARING HELD ON THIS MATTER. IF A GUARDIAN IS APPOINTED FOR YOU, YOU MAY LOSE IMPORTANT RIGHTS TO CONTROL AND MANAGE YOUR PERSON. IF A CONSERVATOR IS APPOINTED FOR YOU, YOU MAY LOSE IMPORTANT RIGHTS TO CONTROL AND MANAGE YOUR PROPERTY. ALTHOUGH YOU MUST ATTEND THE EVALUATION, YOU DO NOT HAVE TO RESPOND TO QUESTIONS. So ordered this day of , 20 . Probate Judge Effective 7/09 GPCSF 11Court American LegalNet, Inc. www.FormsWorkFlow.com CERTIFICATE OF MAILING OF ORDER FOR EVALUATION; APPOINTMENT OF COUNSEL; APPOINTMENT OF SPECIAL PROCESS SERVER; AND NOTICE OF HEARING ESTATE NO. This is to certify that I have this day served the persons named in paragraph 8 of the petition, who were ordered to be served by first-class mail, with a copy of the foregoing petition and order, by placing a copy of same in an envelope addressed to each and depositing same in the U.S. Mail, first-class, with adequate postage thereon. DATE PROBATE CLERK/DEPUTY CLERK CERTIFICATE OF MAILING OF ORDER OF DISMISSAL ESTATE NO. This is to certify that I have this day served the proposed ward with a copy of the (petition, the medical affidavit, and)* order for dismissal by placing a copy of same in an envelope addressed to the proposed ward and depositing same in the U.S. Mail, first-class, with adequate postage thereon. I have also served a copy of the order for dismissal in the same manner upon the persons required in said order to be so served. DATE PROBATE CLERK/DEPUTY CLERK * not necessary if dismissal is after evaluation. Effective 7/09 GPCSF 11Court American LegalNet, Inc. www.FormsWorkFlow.com PROBATE COURT OF COUNTY STATE OF GEORGIA IN RE: , PROPOSED WARD ) ) ) ) ) ) ESTATE NO. PETITION FOR APPOINTMENT OF AN EMERGENCY GUARDIAN AND/OR CONSERVATOR FOR A PROPOSED WARD ORDER FOR DISMISSAL The above and foregoing petition having been read and considered pursuant to O.C.G.A. §29-415 and/or O.C.G.A. §29-5-15, and based on the petition and prior to the court-ordered evaluation, it appears that there is not probable cause to believe that the proposed ward is in need of an emergency guardian and/or conservator, therefore, it is hereby ORDERED that the petition is dismissed. IT IS FURTHER ORDERED that a copy of the Petition, the affidavit, if any, and this order be served on the proposed ward by first-class mail, and a copy of this order be served in the same manner upon the petitioner(s) or his/her/their attorney, if any. SO ORDERED this day of , 20 . Probate Judge Effective 7/09 GPCSF 11Court American LegalNet, Inc. www.FormsWorkFlow.com PROBATE COURT OF COUNTY STATE OF GEORGIA IN RE: , PROPOSED WARD ) ) ) ) ) ) ESTATE NUMBER PETITION FOR APPOINTMENT OF AN EMERGENCY GUARDIAN AND/OR CONSERVATOR FOR A PROPOSED WARD RETURN OF SHERIFF/SPECIAL AGENT I have this day served the proposed ward, , personally with a copy of the petition for appointment of emergency guardian and/or conservator and Order for Evaluation, Appointment of Counsel, Appointment of Special Process Server, and Notice of Hearing. This day of , 20 Deputy Sheriff . County, Georgia Special Agent Print Name (If return is by special agent:) Sworn to and subscribed before me, this day of , 20 . Notary Public/Clerk, Probate Court My commission expires . Effective 7/09 GPCSF 11Court American LegalNet, Inc. www.FormsWorkFlow.com EVALUATOR’S REPORT AND RETURN OF SPECIAL AGENT, IF APPLICABLE EMERGENCY GUARDIANSHIP AND/OR CONSERVATORSHIP PROCEEDINGS ESTATE NO. PETITIONER(S) PROPOSED WARD In compliance with the Order of the Probate Court of County dated proposed ward on 20 , I performed an evaluation of the above-named 20 . This evaluation took place at beginning at . The evaluation continued for the evaluation to the proposed ward. minutes. I explained the purpose of The following questions and tests were utilized in the evaluation: Below is a list of all persons and other sources of information consulted in evaluating the proposed ward: The following is a description of the proposed ward’s mental and physical state and condition, including all observed facts considered by me: The following is a description of the overall social condition of the proposed ward, including support, care, education, and well-being, and the functional capabilities of the proposed ward, if determined by the evaluator: Effective 7/09 GPCSF 11Court -1- American LegalNet, Inc. www.FormsWorkFlow.com The following are my findings as to the needs of the proposed ward and their foreseeable duration: (initial all applicable) a. I find the proposed ward to be incapacitated by reason of to the extent that said proposed ward (initial all applicable): (i) (for emergency guardianship:) lacks sufficient capacity to make or communicate significant responsible decisions concerning his/her health or safety and there is an immediate, clear, and substantial risk of death or serious physical injury, illness, or disease unless an emergency guardian is appointed, (ii) (for emergency conservatorship:) lacks sufficient capacity to make or communicate significant responsible decisions concerning the management of his/her property and there is an immediate, substantial risk of irreparable waste or dissipation of the proposed ward’s estate unless an emergency conservator is appointed, b. I do not find that the proposed ward meets the standards for emergency guardianship set out in a. (i) above. c. I do not find that the proposed ward meets the standards for emergency conservator set out in a. (ii) above. Physician licensed under Chapter 34 of Title 43 of the Official Code of Georgia Annotated or Psychologist licensed under Chapter 39 of Title 43 of the Official Code of Georgia Annotated or Licensed Clinical Social Worker Sworn to and subscribed before me this day of ,20 . Notary Public/Clerk, Probate Court My Commission Expires NOTE: This report must be filed with the Probate Court no later than 72 hours after this order being issued. Effective 7/09 GPCSF 11Court -2- American LegalNet, Inc. www.FormsWorkFlow.com STIPULATION AND WAIVER BY PROPOSED WARD’S ATTORNEY GEORGIA, COUNTY ESTATE NO. TO THE PROBATE COURT OF SAID STATE AND COUNTY IN RE: PETITION FOR THE APPOINTMENT OF AN EMERGENCY GUARDIAN AND/OR CONSERVATOR FOR , PROPOSED WARD The undersigned, as the attorney representing the above-named proposed ward in these proceedings, (initial all applicable:) a. does hereby stipulate into evidence the affidavit prepared by (name of affiant evaluator) , being the evaluation report Ordered by the Court in this matter, and hereby waives the appearance of such affiant at any hearing concerning the said petition b. c. This does hereby stipulate into evidence the affidavit(s) prepared by (name of affiant evaluator) , which is the affidavit referred to in Paragraph 1(b) of the petition, and hereby waives the appearance of such affiant at any hearing concerning the said petition. does further waive the appearance of my client the proposed ward at said hearing. day of , 20 . Attorney Typed/printed name of Attorney: Address: Telephone: Effective 7/09 State Bar # GPCSF 11Court American LegalNet, Inc. www.FormsWorkFlow.com PROBATE COURT OF COUNTY STATE OF GEORGIA IN RE: ) ) , ) ) ) ) PROPOSED WARD ESTATE NO. PETITION FOR APPOINTMENT OF AN EMERGENCY GUARDIAN AND/OR CONSERVATOR FOR A PROPOSED WARD FINAL ORDER A hearing was held on the above-referenced petition on 20 , and after considering the pleadings, the evaluation report and the evidence taken at the hearing, the Court makes the following: FINDINGS OF FACT 1. All procedural requirements of O.C.G.A. §29-4-14 and/or O.C.G.A. §29-5-15 have been met. 2. The above-named proposed ward is in need of a guardian/conservator by reason of . Such need appears to be (permanent)(limited to the following number of days: ). 3. The current value of the personal property of the proposed ward is approximately $ . The proposed ward has an interest in real property in the following locations: a. County, (state) ; b. County, (state) ; c. County, (state) . The proposed ward has outstanding debts of $ $ and average expenditures of per month. Effective 7/09 GPCSF 11Court -1- American LegalNet, Inc. www.FormsWorkFlow.com 4. Petitioner(s) moved the Court to appoint as emergency guardian and as emergency conservator asserting those individual(s) should serve because . (initial if applicable:) a. Another individual, being was nominated/designated by the proposed ward to serve as guardian, (i) and no good cause was shown to override such preference. (ii) but good cause was shown not to appoint said individual, being: . b. Another individual with higher preference, being was nominated/designated to serve as guardian by someone other than the proposed ward, and/but it (is) (is not) in the best interest of the proposed ward to appoint him/her guardian because . c. Another individual, being was nominated/designated by the proposed ward to serve as conservator, (i) and no good cause was shown to override such preference. (ii) but good cause was shown not to appoint said individual, being: . d. Another individual with higher preference, being was nominated/designated to serve as conservator by someone other than the proposed ward, and/but it (is) (is not) in the best interest of the proposed ward to appoint him/her conservator because . Effective 7/09 GPCSF 11Court -2- American LegalNet, Inc. www.FormsWorkFlow.com 5. The Petitioner asserted that the following additional powers pursuant to O.C.G.A. §29-4-23 (b) and O.C.G.A. §29-5-23(c) were absolutely necessary to respond to the immediate and threatened risks alleged in the petition: for the emergency guardian: for the emergency conservator: CONCLUSIONS OF LAW The Court finds, by clear and convincing evidence, that the above-named proposed ward (hereinafter referred to as "the ward") is in need of: a. an emergency guardian because the ward lacks sufficient capacity to make or communicate significant responsible decisions concerning his/her health or safety and there is an immediate and substantial risk of death or serious physical injury, illness, or disease unless an emergency guardian is appointed . b. an emergency conservator because the ward lacks sufficient capacity to make or communicate significant responsible decisions concerning the management of his/her property and there is an immediate, substantial risk of irreparable waste or dissipation of the ward’s property unless an emergency conservator is appointed. The duration of the emergency guardianship/ conservatorship is for: (initial one) a. 60 days, or until the effective date of the appointment of permanent guardianship/conservatorship, or until the emergency guardian(s) and/or conservator(s) are removed, or the dismissal of a petition for the appointment of a guardian and/or conservator, whichever occurs first. b. a date certain prior to the time identified in (a) above, being , 20 Therefore it is ORDERED that should be, and hereby is/are, appointed emergency guardian(s) and should be, and hereby is/are, appointed emergency conservator(s) of the ward. Letters of emergency guardianship and/or emergency conservatorship shall Effective 7/09 GPCSF 11Court -3- American LegalNet, Inc. www.FormsWorkFlow.com . issue to such guardian(s) and/or conservator(s) upon taking the required oath and upon the emergency conservator’s(s’) posting bond in the amount of $ . The appointed emergency guardian(s)/conservator(s) shall have no authority to act on behalf of the ward until Letters of Emergency Guardianship/Conservatorship have issued. IT IS FURTHER ORDERED that the emergency guardian(s) shall have only the following powers and duties determined by the Court to be absolutely necessary to respond to the immediate threatened risk: IT IS FURTHER ORDERED that the emergency conservator(s) shall have only the following powers and duties determined by the Court to be absolutely necessary to respond to the immediate threatened risk: IT IS FURTHER ORDERED that the emergency guardian(s) shall file the following reports with the Court: IT IS FURTHER ORDERED that the emergency conservator(s) shall file the following reports with the Court: IT IS FURTHER ORDERED that a copy of this Order shall be hand delivered or mailed by first class mail to the ward, the ward’s attorney; the guardian ad litem, if any; the guardian and/or conservator, the petitioner(s), and his/her/their attorney(s), if any. IT IS FURTHER ORDERED that the ward’s legal counsel shall make reasonable efforts to explain to the ward this Order and the ward’s rights under this Order. IT IS FURTHER ORDERED that, within 30 days of the date hereof, the clerk/deputy clerk shall file the certificate of creation of conservatorship in accordance with O.C.G.A. §29-5-13(d) with the Clerk of Superior Court of each county in this state in which the ward owns real property. SO ORDERED this day of , 20 . Probate Judge/Hearing Officer exercising the jurisdiction of the Probate Court pursuant to O.C.G.A. §29-4-12(d)(7) and/or §29-5-12(d)(7) Effective 7/09 GPCSF 11Court -4- American LegalNet, Inc. www.FormsWorkFlow.com CERTIFICATE OF MAILING OF FINAL ORDER I have this date mailed (or handed) a copy of the Final Order Appointing Emergency Guardian and/or Conservator to the ward, his/her attorney, (his/her guardian ad litem), (his/her representatives,) the guardian(s), the conservator(s), the petitioner(s) and petitioner’s attorney(s). DATE Effective 7/09 PROBATE CLERK /DEPUTY CLERK GPCSF 11Court American LegalNet, Inc. www.FormsWorkFlow.com CERTIFICATE OF FILING CERTIFICATE OF CREATION OF CONSERVATORSHIP ESTATE NO. I have this date hand-delivered and/or mailed for filing a Certificate of Creation of Conservatorship to the Clerk of the Superior Court of each of the following counties, together with payment of any recording costs: DATE PROBATE CLERK/DEPUTY CLERK ADDRESS TELEPHONE Effective 7/09 GPCSF 11 Court American LegalNet, Inc. www.FormsWorkFlow.com Probate Court Return Mailing Address: CERTIFICATE OF CREATION OF EMERGENCY CONSERVATORSHIP (Pursuant to O.C.G.A. § 29-5-13(d)) GEORGIA, County PROBATE ESTATE NO. DATE ORDER ISSUED: GRANTOR: (NAME OF WARD) GRANTEE: (NAME OF EMERGENCY CONSERVATOR(S) OF ABOVE WARD) An Emergency conservatorship of the property has been created for the above-named ward. Said emergency conservatorship expires (initial) a. in 60 days, or on the effective date of the appointment of a permanent conservator, or when the emergency conservator(s) is/are removed, or the dismissal of a petition for the appointment of a conservator, whichever occurs first. b. on a date certain, being , 20 . Original Certificate delivered or mailed to Clerk of Superior Court of County on , 20 . I do hereby certify that the above information is based on the Order of the Probate Court issued on the date set out above and that the above information is true and correct. By: PROBATE CLERK /DEPUTY CLERK Effective 7/09 GPCSF 11 Court American LegalNet, Inc. www.FormsWorkFlow.com GEORGIA PROBATE COURT STANDARD FORM STATE OF GEORGIA COUNTY OF ESTATE NO. LETTERS OF EMERGENCY GUARDIANSHIP OF ADULT WARD From the Judge of the Probate Court of said County. Date of Birth TO: , Guardian(s) RE: , Adult Ward This Court has found that the above-named ward is in need of an emergency guardian and has designated you as such guardian, and you have taken your oath. Your powers and duties as such emergency guardian which were declared by the Court to be those absolutely necessary to respond to the immediate threatened risk are These letters expire a. b. in 60 days, or on the effective date of the appointment of a permanent guardian, or when the emergency guardian(s) is/are removed, or upon the dismissal of a petition for the appointment of a permanent guardian, whichever occurs first. on a date certain, being , 20_____. Given under my hand and official seal, the day of , 20 Probate Judge NOTE: The following must be signed if the judge does not sign the original of this document: Issued by: (Seal) PROBATE CLERK /DEPUTY CLERK Effective 7/09 GPCSF 11 Court American LegalNet, Inc. www.FormsWorkFlow.com . GEORGIA PROBATE COURT STANDARD FORM STATE OF GEORGIA COUNTY OF ESTATE NO. LETTERS OF EMERGENCY CONSERVATORSHIP OF ADULT WARD From the Judge of the Probate Court of said County. Date of Birth TO: , Conservator(s) RE: , Adult Ward This Court has found that the above-named ward is in need of an emergency conservator and has designated you as such conservator, and you have posted bond and taken your oath. Your powers and duties as such emergency conservator which were declared by the Court to be those absolutely necessary to respond to the immediate threatened risk are These letters expire (initial) a. in 60 days, or on the effective date of the appointment of a permanent conservator, or when the emergency conservator(s) is/are removed, or upon the dismissal of a petition for the appointment of a permanent guardian, whichever occurs first. b. on a date certain, being , 20 under my hand and official seal, the day of .Given , 20 Probate Judge NOTE: The following must be signed if the judge does not sign the original of this document: Issued by: (Seal) PROBATE CLERK /DEPUTY CLERK Effective 7/09 GPCSF 11 Court American LegalNet, Inc. www.FormsWorkFlow.com . GEORGIA PROBATE COURT STANDARD FORM STATE OF GEORGIA COUNTY OF ESTATE NO. LETTERS OF EMERGENCY GUARDIANSHIP AND CONSERVATORSHIP OF ADULT WARD From the Judge of the Probate Court of said County. Date of Birth TO: , Guardian(s) and Conservator(s) RE: , Adult Ward, This Court has found that the above-named ward is in need of an emergency guardian and conservator and has designated you as such guardian and conservator, and you have posted bond and taken your oath. Your powers and duties as such emergency guardian and conservator which were declared by the Court to be those absolutely necessary to respond to the immediate threatened risk are These letters expire (initial) a. in 60 days, or on the effective date of the appointment of a permanent guardian and conservator, or when the emergency guardian(s) and conservator(s) is/are removed, or upon the dismissal of a petition for the appointment of a permanent guardian, whichever occurs first. b. on a date certain, being , 20 under my hand and official seal, the 20 . Given day of , . Probate Judge NOTE: The following must be signed if the judge does not sign the original of this document. Issued by: (Seal) PROBATE CLERK /DEPUTY CLERK Effective 7/09 GPCSF 11 Court American LegalNet, Inc. www.FormsWorkFlow.com