COMMONWEALTH OF KENTUCKY � PETITIONER en-USVS. � RESPONDENT en-US has reasonable grounds or knowledge to lead him/hen-USeren-USto believe Respondent appears to be unable to provide for his/her physical health and safety and/or manage his/heren-USen-USen-USen-USen-USen-USen-US2. en-USName of Respondent:en-US en-USen-USen-USen-USen-USen-USen-USa. Respondent has resided at this address for the previous years months.en-USb. Is this address a hospital, treatment facility, correctional facility, or long-term care facility? en-USen-US Yes en-USen-US Noen-US4. Is Respondent currently physically located at his or her permanent address above? en-USen-US Yes en-USen-US No If No, en-US(check one)en-USen-USen-USen-USen-US b. Respondent's current location is unknown at this time.en-US5. Is Respondent a citizen or a permanent resident of the United States? en-USen-US Yes en-USen-US Noen-USen-USned in KRS en-US17.500? en-USen-US Yes en-USen-US No en-USen-US Unknownen-USen-USssify the en-USen-USen-US Yes en-USen-US No en-USen-US Uen-USnknownen-US8. The en-USnature of Respondent222s disabilityen-US and the facts or reasons supporting the need for determination of disabien-USen-USen-USen-USen-USen-USearly en-USen-USESTATE � en-USVALUen-USE Real Property � $ Personal Property � $ Yearly Income � $ en-USSource of Yearly Income en-US � en-USRev. 7-18en-USPage 1 of 2en-USCommonwealth of Kentuckyen-USCourt of Justice en-US www.courts.ky.goven-USen-USPETITION TO DETERMINEen-USIF DISABLED lexet justitia COMMONWEALTHOFKENTUCKY COURTOFJUSTICE District en-USCase No. Court � County � Division � en-USAddressen-USAddress American LegalNet, Inc. www.FormsWorkFlow.com 10. � en-USName of en-USen-US Person or en-USen-US Facility having custody of Respondent:en-US en-US � 11. � Respondent222s en-USen-US en-USDurable Power of Attorneyen-US OR en-USen-US en-USHealth Care Surrogateen-US � � � � � � � � � � � en-USWHEREFORE,en-US Petitioner requests the Court inquire into Respondent222s ability to care for himself/herself and to manaen-USgeen-USen-USApplication for Appointment of Fiduciaryen-US en-USand further requestsen-US: � 1. � Trial by jury; � 2. � Counsel to represent the Respondent; and � 3. � Court appointment of a physician, advanced practice registered nurse, or physician assistant; a psychologist; � � this Petition. , 2 � en-US Date � Signature of Petitioner en-USen-USAttorney222s Name:en-US en-USAddress:en-US en-USen-USen-USen-USTelephone Number: en-US � � en-USAttorney Signatureen-USAOC-740en-USRev. 7-18en-USPage 2 of 2en-USSUBSCRIBED and SWORN to before me this day of , 2.en-USen-US. � County, Kentucky � Name/Title American LegalNet, Inc. www.FormsWorkFlow.com