GEORGIA PROBATE COURT STANDARD FORM Petition for the Appointment of a Guardian and/or Conservator for a Proposed Ward INSTRUCTIONS I. Specific Instructions 1. 2. In any case involving the creation of a conservatorship when the proposed ward owns real property, 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 of this state in which the proposed ward owns real property within 30 days of the date of such order. 3. II. This form is to be used for filing a Petition for the Appointment of a Guardian and/or Conservator for a Proposed Ward pursuant to O.C.G.A. §29- 4-10 and O.C.G.A. §29-5-10. The burden of proof is on the petitioner to present clear and convincing evidence that the proposed ward lacks sufficient capacity to make or communicate significant responsible decisions concerning his or her health or safety and is in need of a guardianship and/or that the proposed ward lacks sufficient capacity to make or communicate significant responsible decisions concerning the management of his or her property and is in need of a conservatorship. General Instructions General instructions applicable to all Georgia probate court standard forms appear in Volume 255 of the Georgia Reports and are available in each probate court. Effective 7/07 GPCSF 12Petitioner 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 A GUARDIAN AND/OR 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 9 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 , telephone number , 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 of telephone number , State , show that: or b. attached hereto as page 9 and made a part of this petition is the completed affidavit of , a physician or psychologist licensed to practice in Georgia or a licensed clinical social worker, who has examined the proposed ward within fifteen days prior to the filing of this petition, show that: 2. Effective 7/07 -1- GPCSF 12Petitioner American LegalNet, Inc. www.FormsWorkflow.com The proposed ward, age , date of birth , social security no. , 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 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 a guardian and/or conservator by reason of the following incapacity: to the extent that the proposed ward (initial one or both): a. (for guardianship:) lacks sufficient capacity to make or communicate significant responsible decisions concerning his/her health or safety. b. (for conservatorship:) lacks sufficient capacity to make or communicate significant responsible decisions concerning the management of his/her property. The facts which support the claim of the need for a guardian and/or conservator are as follows: (NOTE: the Petition cannot be granted unless sufficient facts are presented which support the claim for the need for the appointment of a guardian 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 7/07 -2- GPCSF 12Petitioner American LegalNet, Inc. www.FormsWorkflow.com 4. It is in the best interest of the proposed ward that be appointed guardian and appointed conservator. 5. The forseeable duration of the incapacity will be: and the Court should allow the proposed ward to retain the following rights and powers: . 6. (NOTE: The law requires notice to be given to the spouse, if any, and to all living children, if any, whose addresses are known. If there are no living adult children whose addresses are known, then list at least two adults in the following order of priority: lineal descendants of the proposed ward; parents and siblings of the proposed ward; and friends of the proposed ward. In determining the persons to whom notice is required to be given according to the foregoing rules, the petitioner(s) should not be counted as persons receiving notice.) Pursuant to law, the names, addresses, telephone numbers and relationships of the persons to be notified are as follows: NAME AGE (or over 18) ADDRESS TELEPHONE RELATIONSHIP 7. a. As to the guardianship, prior to the filing of this Petition, to the best of my/our knowledge, the Effective 7/07 -3- GPCSF 12Petitioner American LegalNet, Inc. www.FormsWorkflow.com following individual(s) has/have been nominated to serve under a living will, durable power of attorney for healthcare, order relating to cardiopulmonary resuscitation, or other instrument that deals with the management of the person of the proposed ward in the event of incapacity. If any, please provide their name(s), addresses(es), indicate the nature of their interest, whether they are willing to act or have failed to act under said appointment: b. As to the guardianship, prior to the filing of this Petition, to the best of my/our knowledge, the following individual(s) has/have been nominated in writing to serve as guardian by the proposed ward, his/her spouse, adult child, or parent. If any, please provide their name(s), addresses(es), indicate the nature of their interest, whether they are willing to act under said appointment, and whether the individual(s) is/are an owner, operator, or employee of a caregiving institution in which the proposed ward currently is receiving care: 8. a. As to the conservatorship, prior to the filing of this Petition, to the best of my/our knowledge, the following individual(s) has/have been nominated to serve under a power of attorney, trust, or other instrument that deals with the management of the property of the proposed ward in the event of incapacity. If any, please provide their name(s), addresses(es), the nature of their interest, and indicate whether they are willing to act or have failed to act under said appointment: . b. As to the conservatorship, prior to the filing of this Petition, to the best of my/our knowledge, the following individual(s) has/have been nominated in writing to serve as conservator by the proposed ward, his/her spouse, adult child, or parent. If any, please provide their name(s), addresses(es), the nature of their interest, and indicate whether they are willing to act under said appointment, and whether the individual(s) is/are an owner, operator, or employee of a caregiving institution in which the proposed ward currently is receiving care : . (initial if applicable) The above individual(s) may have the following ownership or financial conflict of interest in serving as conservator: NOTE: A CONFLICT OF INTEREST MAY EXIST IF THE PROPOSED CONSERVATOR IS A CO-OWNER OF A JOINT ACCOUNT OR REAL PROPERTY WITH THE PROPOSED WARD. (list) 9. Regarding other petitions for guardianship and/or conservatorship, (initial if applicable) Effective 7/07 -4- GPCSF 12Petitioner American LegalNet, Inc. www.FormsWorkflow.com a. (Name) , residing at , has been appointed as an emergency or permanent guardian/conservator for the proposed ward in the following county and state: b. . A ruling on a Petition for the appointment of an emergency or permanent guardian/conservator is pending in the following county and state: . c. A petition for emergency or permanent guardianship/conservatorship has been denied or dismissed within the prior two years by a court in the following county and state: . d. A petition for emergency or permanent guardianship/conservatorship has been denied or dismissed within the prior two years by a court in this state; however, there has been a significant change in the condition or circumstances of the proposed ward as shown by the affidavit or evaluation, attached as Exhibit “A.” 10. All known income and assets of the proposed ward are shown on page 11 attached hereto. 11. A guardian ad litem should be appointed, because the following additional powers pursuant to O.C.G.A. §29-4-23 (b) and O.C.G.A. §29-5-23(c) are requested, with the reasons for such request: 12. Additional Data: Where full particulars are lacking, state here the reasons for any such omission. Effective 7/07 -5- GPCSF 12Petitioner American LegalNet, Inc. www.FormsWorkflow.com 13. It is in the best interest of the proposed ward that the within nominated guardian and/or conservator be appointed. WHEREFORE, petitioner(s) pray(s): 1. 2. 3. 4. 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 upon receipt of the evaluation report, the court order a hearing to determine the need for a guardian and/or conservator for the proposed ward; and that a guardian and/or conservator be appointed for the proposed ward. 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: Effective 7/07 State Bar # -6- GPCSF 12Petitioner 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 Printed Name My Commission Expires -------------------------------------------------------------------------------------------------------------------------------------Sworn to and subscribed before me this day of , 20 . Second Petitioner, if any NOTARY/CLERK OF PROBATE COURT My Commission Expires Effective 7/07 Printed Name -7- GPCSF 12Petitioner American LegalNet, Inc. www.FormsWorkflow.com CONSENT TO SERVE AS GUARDIAN/CONSERVATOR RE: Petition for the appointment of guardian and/or conservator for . I/We, having been nominated as guardian and I/we, , having been nominated as conservator of the above-named proposed ward, do hereby consent to serve as such. Proposed Guardian/Conservator Proposed Guardian/Conservator Name Print Name Print Address Address Telephone Telephone Proposed Guardian/Conservator Print Name Address Telephone Effective 7/07 -8- GPCSF 12Petitioner American LegalNet, Inc. www.FormsWorkflow.com STATE OF GEORGIA COUNTY OF PROBATE COURT OF RE: COUNTY Petition for appointment of a guardian and/or conservator for . AFFIDAVIT OF PHYSICIAN, PSYCHOLOGIST, OR LICENSED CLINICAL SOCIAL WORKER 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, 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 20 day of , . NOTE: The examination on which this affidavit is based must occur W ITHIN 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. (for guardianship:) lacks sufficient capacity to make or communicate significant responsible decisions concerning his/her health or safety. b. (for conservatorship:) lacks sufficient capacity to make or communicate significant responsible decisions concerning the management of his/her property. The following facts support said diagnosis: (cont.) Effective 7/07 -9- GPCSF 12Petitioner American LegalNet, Inc. www.FormsWorkflow.com The foreseeable limits on the duration of such incapacity are: WITNESS MY HAND AND SEAL this day of , 20 . Sworn to and subscribed before me this day of , 20 . Signature of (Physician)(Psychologist)(Social Worker) Notary Public My commission expires on the of , 20 (NOTARIAL SEAL AFFIXED) day Typed Name . NOTE: The examination on which this affidavit is based must occur WITHIN FIFTEEN DAYS prior to the filing of the petition. Effective 7/07 -10- GPCSF 12Petitioner American LegalNet, Inc. www.FormsWorkflow.com 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 Parcel 1 State 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 7/07 -11- GPCSF 12Petitioner 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 7/07 -12- $ GPCSF 12Petitioner 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 7/07 $ -13- GPCSF 12Petitioner 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 Effective 7/07 GPCSF 12Petitioner American LegalNet, Inc. www.FormsWorkflow.com ACKNOWLEDGMENT OF SERVICE PROPOSED WARD ESTATE NO. Due and legal service of the Petition for Appointment of a Guardian and/or Conservator is hereby acknowledged by the following interested persons as shown in paragraph 6, in addition to any nominated guardian(s) and/or conservator(s). The undersigned acknowledges that he/she has received a copy of the Petition and all further service and notice is waived. SIGNATURE(S) Sworn to and subscribed before me this day of , 20 . NOTARY/CLERK OF PROBATE COURT Printed Name My Commission Expires -----------------------------------------------------------------------------------------------------------------------------Sworn to and subscribed before me this day of , 20 . NOTARY/CLERK OF PROBATE COURT Printed Name My Commission Expires ------------------------------------------------------------------------------------------------------------------------------Sworn to and subscribed before me this day of , 20 . NOTARY/CLERK OF PROBATE COURT Printed Name My Commission Expires ------------------------------------------------------------------------------------------------------------------------------Sworn to and subscribed before me this day of , 20 . NOTARY/CLERK OF PROBATE COURT Printed Name My Commission Expires ---------------------------------------------------------------------------------------------------------------------------Sworn to and subscribed before me this day of , 20 . NOTARY/CLERK OF PROBATE COURT My Commission Expires Effective 7/07 Printed Name -15- GPCSF 12Petitioner American LegalNet, Inc. www.FormsWorkflow.com