AOC-747 Rev. 7-03 Page 1 of 2 Doc. Code: PEF Case No. PETITION / APPLICATION FOR EMERGENCY APPOINTMENT OF FIDUCIARY FOR DISABLED PERSONS Court County District Commonwealth of Kentucky Court of Justice www.kycourts.net KRS 387.740; 387.720; 395.130 COMMONWEALTH OF KENTUCKY ex rel ________________________________________________________________________________ VS. ________________________________________________________________________________ 1. RESPONDENT PETITIONER Comes Petitioner and requests appointment as emergency limited [ ] guardian OR [ ] conservator for Respondent for the purpose of: __________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ 2. Petitioner states his/her relationship to Respondent is: ________________________________________________ and his/her qualifications for appointment are: ______________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ 3. Petitioner offers as surety on his/her bond the following: ______________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ 4. years of age and resides at: Respondent is _______________________________________________________________________________________________ 5. The person or facility having custody of the Respondent is (name and address): 6. 7. A petition for a Determination of Disability was filed on ,2 . Respondent's [ ] Durable Power of Attorney OR [ ] Health Care Surrogate is: _________________________________________________________________________________________ Name: ___________________________________________________________________________________________ Address: ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ 8. Affidavit(s) are attached setting forth facts, including any danger alleged as imminent, and reasons necessitating such appointment. American LegalNet, Inc. www.FormsWorkFlow.com AOC-747 Rev. 7-03 Page 2 of 2 9. Respondent's next of kin is/are: _________________________________________________________________________________________ Name: ____________________________________________________________________________________________ Address: ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ Relationship: Address: ______________________________________________________________________________________ Name: _____________________________________________________________________________________________ __________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ Relationship: ______________________________________________________________________________________ WHEREFORE, Petitioner respectfully requests that a hearing be held within one (1) week of the filing of this Application. Petitioner's Name: Address: ______________________________________________________________________________ ______________________________________________________________________________________ _______________________________________________________________________________________________ ___________________________________________________________________________________________________ Telephone Number: _______________________________ Date: _______________________________ Social Security No. _____________________________ ____________________________________________ Petitioner's Signature Subscribed and sworn to before me this _____ day of ___________________, 2_____. My Commission expires: ______________________, 2______. ___________________________________________ Name/Title WAIVER OF NOTICE AND REQUEST FOR APPOINTMENT OF FIDUCIARY The undersigned hereby waive notice of hearing and the right to appointment and request the Court to make the appointment herein requested. To be completed if Petitioner is represented by counsel: Petitioner's Attorney: _______________________________________________________________________________ Address: _________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ Telephone No. ___________________________________ ____________________________________________ Attorney's Signature Respondent/Attorney American LegalNet, Inc. www.FormsWorkFlow.com Distribution: Petitioner/Attorney County Attorney