NameAddressCity, State, Zip CodeTelephone Number~Attorney for~PetitionerIN THE FAMILY COURT OF THE FIRST CIRCUITSTATE OF HAWAI221IIn the Matter of the Guardianship of)FC-G No.))PETITION FOR APPOINTMENT OF A)GUARDIAN OF AN INCAPACITATED,)PERSON; NOTICE OF HEARING(Full Legal Name)))Birthdate:[]Male[]Female)))An Incapacitated Person.))PETITION FOR AN APPOINTMENT OF A GUARDIAN OF AN INCAPACITATED PERSONTO THE HONORABLE PRESIDING JUDGE OF THE FAMILY COURT:Petitioner respectfully alleges as follows:1.This petition is for the appointment of a guardian for:,(Full Legal Name)hereinafter referred to as 223Respondent,224 who is an Incapacitated Person residing or presentwithin the jurisdiction of this Court, pursuant to sections (247247) 560:5-106 and 560:5-108(b) ofthe Hawai221i Revised Statutes (223HRS224).FC Adm 7/16/18PETITION FOR APPOINTMENT OF A GUARDIAN OFINCAPACITATED PERSON; NOTICE OF HEARING1F-P-2019In accordance with the Americans with Disabilities Act, as amended, and other applicable state and federal laws, if yourequire a reasonable accommodation for a disability, please contact the ADA Coordinator at the First Circuit FamilyCourt office by telephone at 954-8200, fax 954-8308, or via email at adarequest@courts.hawaii.gov at least ten (10)working days prior to your hearing or appointment date.Please call the Family Court Service Center at 954-8290 if you have any questions regarding forms or procedures. American LegalNet, Inc. www.FormsWorkFlow.com 2. The information concerns the above-named Petitioner:Name:Residence Address:Current Address (if different from above):Relationship to Respondent:Interest in the Appointment:3.The following information concerns the above-named Respondent:Name:Age:Principal Residence:Current Street Address and, if different, Address of Dwelling if appointment is made:4. The following person is suitable to be appointed guardian of the Respondent:Name:Residence Address:Current Address (if different from above):Relationship to Respondent:The proposed guardian should be selected because: (state reason) 5. The names and addresses of the individuals required by law, HRS 247 560:5-340(b), to benotified of these proceedings are (note if deceased or whereabouts unknown or 223none224): a.Spouse or Reciprocal Beneficiary or if there is no spouse or reciprocal beneficiary, Adult withwhom Respondent has resided for more than six months before the filing of this Petition:Name:Address:FC Adm 7/16/18Page 2 of 10 PagesPETITION FOR APPOINTMENT OF AGUARDIAN OF AN INCAPACITATED PERSON American LegalNet, Inc. www.FormsWorkFlow.com b.Adult Child(ren):Name:Address:Name:Address:Name:Address:Name:Address: or(1)Mother:Name:Address:(2)Father:Name:Address:(3)Adult Siblings:Name:Address:Name:Address:Name:Address:Name:Address:FC Adm 7/16/18Page 3 of 10 PagesPETITION FOR APPOINTMENT OF AGUARDIAN OF AN INCAPACITATED PERSON American LegalNet, Inc. www.FormsWorkFlow.com (4)If there is no adult child or adult sibling, the adult(s) nearest in kinship to theRespondent:Name:Address:Name:Address:Name:Address:6 .The person(s) responsible for care or custody of the Respondent: ~Care home~Hospital~Long term care facility~Name:Address:~Respondent lives alone.7.The person(s) serving as Respondent222s legal representative(s): (Also include title of legalrepresentative - including attorney, representative payee, guardian, conservator, trustee orcustodian of a trust or custodianship of which Respondent is a beneficiary, and agentdesignated under a power of attorney, whether for health care or property.) a.Name:Title:Address:b.Name:Title:Address:If the person(s) has/have been appointed conservator or guardian of the property, provide thecase name and number:Case Number:Case Name:8.The person(s) nominated by the Respondent to serve as guardian:(a)Name:Address:FC Adm 7/16/18Page 4 of 10 PagesPETITION FOR APPOINTMENT OF AGUARDIAN OF AN INCAPACITATED PERSON American LegalNet, Inc. www.FormsWorkFlow.com (b)Name:Address:9.The person(s) appointed by the Respondent as an agent under any medical directive, or healthcare power of attorney:(a)Name:Address:(b)Name:Address:10.In absence of an agent appointed by the Respondent under a medical directive or health carepower of attorney, the person designated as a surrogate authorized to make a health caredecision for Respondent under the Hawai221i Uniform Health-Care Decisions Act is:Name:Address:Relationship to Respondent:11.The following interested person(s) has/have filed with the Circuit Court of the First Circuit,pursuant to HRS 247 560:5-116, a request for notice before entry of any order in a guardianshipor protective proceeding relative to the above-named Respondent:a.Name:Address:Relationship to Respondent:b.Name:Address:Relationship to Respondent:c.Name:Address:Relationship to Respondent:d.Name:Address:Relationship to Respondent:FC Adm 7/16/18Page 5 of 10 PagesPETITION FOR APPOINTMENT OF AGUARDIAN OF AN INCAPACITATED PERSON American LegalNet, Inc. www.FormsWorkFlow.com e.Name:Address:Relationship to Respondent:12.Petitioner has made inquiry of all reasonable sources as to the names and addresses ofperson(s) in paragraphs 5 through 11, where applicable, and has not been able to obtaininformation other than as alleged in said paragraphs.13.Such appointment is necessary because the Respondent is unable to receive and evaluateinformation or make or communicate decisions to such an extent that he/she lacks the abilityto meet essential requirements for physical health, safety, or self-care, even with appropriateand reasonably available technological assistance because: (Briefly describe the nature and extent of Respondent222s alleged incapacity.)This is based on the (and listother supporting documents, if any) attached to the List of Exhibits, which is being submittedseparately.14.An~unlimited~limited guardianship is requested because: (Explain why a limited guardianship is inappropriate or if a limited guardianship is requested, statepowers to be granted to the limited guardian.)15.The following information concerns the Respondent222s property:a.General statement of Respondent222s property:FC Adm 7/16/18Page 6 of 10 PagesPETITION FOR APPOINTMENT OF AGUARDIAN OF AN INCAPACITATED PERSON American LegalNet, Inc. www.FormsWorkFlow.com b.Estimated value (including insurance or pension):c.Source and amount of other anticipated income or receipts (do not include social securitynumbers, bank account numbers, etc.):16.The Respondent~is~is not represented by an attorney.17.~The Respondent is expected to attend the hearing.~The Respondent is not expected to attend the hearing andThe Petitioner respectfully requests the Respondent222s attendance be excused pursuantto HRS 247 560:5-308(a) because:18.The Petitioner further requests the appointment of a Guardian ad Litem for the Respondentand/or of a K364kua K342n342wai, if deemed necessary by the Court, pursuant to HRS 247247 560:5-115and 5-305(a). The duties and reporting requirements of the K364kua K342n342wai should be:FC Adm 7/16/18Page 7 of 10 PagesPETITION FOR APPOINTMENT OF AGUARDIAN OF AN INCAPACITATED PERSON American LegalNet, Inc. www.FormsWorkFlow.com WHEREFORE, Petitioner requests that:1.A time and place be set for hearing on the issue of incapacity hereof, and that due notice of theforegoing matter and of the time and place of hearing on this petition be given to all requiredpersons.2.[]The Court excuse the Respondent222s attendance pursuant to HRS sec. 560:5-308(a) and appointa Guardian ad Litem for the Respondent and/or a K364kua K342n342wai, if deemed necessary by theCourt, pursuant to HRS sec. 560:5-115 and 5-305(a).3.The Court make the following findings:(a)that this Court has jurisdiction in this matter;(b)that(Full Legal Name of Respondent)is an Incapacitated Person as defined in HRS sec. 560:5-102; (c)that the appointment of~limited~unlimited guardianship is necessary in order toprovide continuing care and supervision of said Incapacitated Person; and(d)that, the nominee(Name of Proposed Guardian)named in paragraph 4 above, is a fit and proper person to serve as guardian.4. be appointed guardian of the(Name of Proposed Guardian)above-named Incapacitated Perso