PR-PET5: Revised 12/01/06 Page 1 of 2 Disabled Guardianship IN THE CIRCUIT COURT OF THE 17th JUDICIAL CIRCUIT BOONE COUNTY, ILLINOIS Probate Division IN THE MATTER OF ) ) ) ) ) Alleged Disabled Person ) Case Number PETITION FOR APPOINTMENT OF GUARDIAN FOR DISABLED PERSON Petitioner on oath states: 1. Petitioner is related to respondent as , and his/her interest in respondent is. 2. , respondent, is a disabled person; his/her date of birth is , and place of residence is Boone County, Illinois (is a non-resident of Illinois owning real estate in this county) (owning no real estate but having personal estate in this county). 3. Respondent is an adult person in need of guardianship for the following reason(s): 4. Respondent has (an/no agent or agents appointed under the Illinois Power of Attorney Act) (a/no Guardian) whose name and address are 5. The names and post office addresses of the respondent222s nearest relatives are: (list spouse and adult children, the parents, adult brothers and sisters (if any); if none, nearest known adult kindred;) Name Relationship Post Office Address 6. The name and address of the person with whom, or the facility in which the respondent is residing is: 7. (a) Approximate value of respondent222s personal estate: $ (b) Approximate value of respondent222s real estate: $ (c) The anticipated gross annual income and other receipts of the respondent are: $ (d) Benefit, compensation, pension or insurance payable by the United States of America: $ American LegalNet, Inc. www.FormsWorkFlow.com PR-PET5: Revised 12/01/06 Page 2 of 2 Disabled Guardianship 8. (a) Name Post Office Address age years, relationship occupation is qualified and willing to act as guardian of the respondent222s (estate) (estates and person). (b) of age years (a)(an) is qualified and willing to act as guardian of the respondent222s person only. (c) The guardianship be for the limited purpose of: (d) The guardian, if appointed, is authorized to place the ward in a residential facility, as follows: (e) The duration of the term of guardianship should be (f) (An)(No) authorization to appraise goods and chattels issue to PETITIONER ASKS: (a) be adjudged a disabled person (b) Guardian(s) be appointed for the purpose and terms as above set forth. Notice to Chief Attorney of the Administrator of Veteran222s Affairs (is) (is not) required. Respondent has (a) (no) safety deposit box at at . Name Petitioner Attorney for Petitioner Petitioner222s Signature Address Address City, State Zip City, State Zip Telephone Telephone Email Email Signed and sworn to before me this 20 NOTARY PUBLIC American LegalNet, Inc. www.FormsWorkFlow.com