IN THE CIRCUIT COURT OF THE TWENTY-SECOND JUDICIAL CIRCUIT McHENRY COUNTY, ILLINOIS Probate Division IN THE MATTER OF ) ) ) ) ) ) Hearing on Petition set for ____________________________ 20_____ McHenry County Government Center, 2200 N. Seminary Ave., Woodstock, IL 60098 ______________________________________________ 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 _____________________________________ McHenry 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 respondent's 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 respondent's personal estate: $___________________________________________ (b) Approximate value of respondent's 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: $_______________ PR-PET5: Revised 12/01/06 Page 1 of 2 Disabled Guardianship American LegalNet, Inc. www.FormsWorkflow.com 8. (a) Name________________________________________________________________________________ Post Office Address________________________________________________________________________ age ___________ years, relationship_______________________________ occupation ___________________ is qualified and willing to act as guardian of the respondent's (estate) (estates and person). (b) _____________________________________________ of ______________________________________ age ___________ years (a)(an) ____________________________________ is qualified and willing to act as guardian of the respondent's 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) (b) __________________________________________________ be adjudged a disabled person Guardian(s) be appointed for the purpose and terms as above set forth. Notice to Chief Attorney of the Administrator of Veteran's Affairs (is) (is not) required. Respondent has (a) (no) safety deposit box at ________________________________________________ at ______________________________________. Name________________________________________ Petitioner_______________________________________ Attorney for Petitioner Petitioner's Signature Address______________________________________ Address________________________________________ City, State Zip_________________________________ City, State Zip___________________________________ Telephone____________________________________ Telephone______________________________________ Signed and sworn to before me this ____________________________________20_________ _______________________________________________ NOTARY PUBLIC PR-PET5: Revised 12/01/06 Page 2 of 2 Disabled Guardianship American LegalNet, Inc. www.FormsWorkflow.com