WC-226b PETITION FOR APPOINTMENT OF TEMPORARY CONSERVATOR FOR LEGALLY INCAPACITATED ADULT GEORGIA STATE BOARD OF WORKERS' COMPENSATION PETITION FOR APPOINTMENT OF TEMPORARY CONSERVATOR FOR LEGALLY INCAPACITATED ADULT Board Claim No. Employee Last Name Employee First Name M.I. SSN or Board Tracking # Date of Injury EMPLOYEE IDENTIFYING INFORMATION Address County of Injury City State Zip Code Employee E-mail PETITIONER IDENTIFYING INFORMATION Last Name First Name Address M.I. Social Security Number Birthdate City State Zip Code County of Residence Petitioner E-mail Re: , name of Legally Incapacitated Adult, Petition for Appointment of Temporary Conservator of Legally Incapacitated Adult. 1. Pursuant to the provisions of O.C.G.A. 34-9-226 (name of petitioner) hereby petitions the State Board of Workers’ Compensation to appoint a temporary conservator for the above-referenced legally incapacitated adult to bring or defend an action under this Chapter, to receive and administer weekly income benefits on behalf of and for the benefit of said legally incapacitated adult for a period not to exceed 52 weeks and/or to compromise and terminate any claim and receive any sum in settlement for the benefit of and use of said legally incapacitated adult where the net settlement amount is less than $100,000. 2. (State the relationship between the petitioner and the incapacitated adult and attach supporting documentation including marriage certificates, birth certificates, or orders of custody or support, etc.) 3. (State the reasons the conservator is necessary including facts which support the claim of incapacity. This petition must be accompanied by an affidavit given by a qualified physician who has recently examined the alleged legally incapacitated adult.) 4. (List the names and addresses of the spouse and all adult children of the incapacitated adult who are living and whose addresses are known; or if none, then the names and addresses of the two next of kin who are living and whose addresses are known; or if only one next of kin, then that one; or if none, then the names and addresses of two adult friends. Name Name Address Address City State 5. Zip Code City State Zip Code State Zip Code (List the names and addresses of any appointed representatives of the incapacitated adult.) Name Name Address Address City State Zip Code City 6. The Board should exercise its discretion and allow petitioner to receive and administer workers’ compensation benefits for said legally incapacitated adult. 7. Petitioner will hold and use such property for the benefit of the legally incapacitated adult and shall be legally accountable to the legally incapacitated adult for the proper handling of such property. IF YOU HAVE QUESTIONS PLEASE CONTACT THE STATE BOARD OF WORKERS’ COMPENSATION AT 404-656-3818 OR 1-800-533-0682 OR VISIT http://www.sbwc.georgia.gov WILLFULLY MAKING A FALSE STATEMENT FOR THE PURPOSE OF OBTAINING OR DENYING BENEFITS IS A CRIME SUBJECT TO PENALTIES OF UP TO $10,000.00 PER VIOLATION (O.C.G.A. 34-9-18 AND 34-9-19). WC-226b REVISION . 07/2012 226b 1 OF 3 PETITION FOR APPOINTMENT OF TEMPORARY CONSERVATOR FOR LEGALLY INCAPACITATED ADULT American LegalNet, Inc. www.FormsWorkFlow.com WC-226b PETITION FOR APPOINTMENT OF TEMPORARY CONSERVATOR FOR LEGALLY INCAPACITATED ADULT GEORGIA STATE BOARD OF WORKERS' COMPENSATION Name Telephone Number ATTORNEY (If applicable) Address GA Bar Number City State Zip Code VERIFICATION Personally appeared before me the undersigned petitioner who on this oath states that the facts set forth in the foregoing petition are true. Petitioner Name Address Telephone Number City Sworn to and subscribed before me this State day of Zip Code , (day) (month) . (year) Notary Public CERTIFICATE OF SERVICE I hereby certify that I have today sent a copy of this form to all parties named above and to the State Board of Workers’ Compensation, 270 Peachtree Street, N.W., Atlanta, GA 30303-1299. Signature Date IF YOU HAVE QUESTIONS PLEASE CONTACT THE STATE BOARD OF WORKERS’ COMPENSATION AT 404-656-3818 OR 1-800-533-0682 OR VISIT http://www.sbwc.georgia.gov WILLFULLY MAKING A FALSE STATEMENT FOR THE PURPOSE OF OBTAINING OR DENYING BENEFITS IS A CRIME SUBJECT TO PENALTIES OF UP TO $10,000.00 PER VIOLATION (O.C.G.A. 34-9-18 AND 34-9-19). WC-226b REVISION . 07/2012 226b 2 OF 3 PETITION FOR APPOINTMENT OF TEMPORARY CONSERVATOR FOR LEGALLY INCAPACITATED ADULT American LegalNet, Inc. www.FormsWorkFlow.com WC-226b PETITION FOR APPOINTMENT OF TEMPORARY CONSERVATOR FOR LEGALLY INCAPACITATED ADULT GEORGIA STATE BOARD OF WORKERS' COMPENSATION CONFIDENTIAL Name Claim Number EMPLOYEE / CLAIMANT , name of Legally Incapacitated Adult, Petition for appointment of Temporary Conservator for Legally Incapacitated Adult. CONSENT FORM I hereby authorize the State Board of Workers’ Compensation to receive any criminal history record information pertaining to me which may be in the files of any state or local criminal justice agency in Georgia. I have attached a copy of a criminal history record check for each jurisdiction, other than Georgia, where I have resided at any time during the five year period immediately prior to the date of this petition. I have lived in the following states other than Georgia: State Period I have never been arrested or convicted of any crime in Georgia or any other state except as follows: Date Crime Disposition Full Name State Signature of Petitioner Birthdate Social Security Number Address Sex Race City Sworn to and subscribed before me this State day of , (day) (month) Zip Code . (year) Notary Public IF YOU HAVE QUESTIONS PLEASE CONTACT THE STATE BOARD OF WORKERS’ COMPENSATION AT 404-656-3818 OR 1-800-533-0682 OR VISIT http://www.sbwc.georgia.gov WILLFULLY MAKING A FALSE STATEMENT FOR THE PURPOSE OF OBTAINING OR DENYING BENEFITS IS A CRIME SUBJECT TO PENALTIES OF UP TO $10,000.00 PER VIOLATION (O.C.G.A. 34-9-18 AND 34-9-19). WC-226b REVISION . 07/2012 226b 3 OF 3 PETITION FOR APPOINTMENT OF TEMPORARY CONSERVATOR FOR LEGALLY INCAPACITATED ADULT American LegalNet, Inc. www.FormsWorkFlow.com