PP-205 (Rev.7-1-08) WARNING: IF YOUR NAME APPEARS IN ITEM 4, THIS PROCEEDING MAY RESULT IN SEVERE LIMITATIONS UPON YOUR PERSONAL LIBERTY. STATE OF MAINE COUNTY PROBATE COURT DOCKET NO. In Re JOINED PETITIONS: Incapacitated/Protected Person APPOINTMENT OF GUARDIAN AND CONSERVATOR 1. Name, address and telephone number of petitioner: 2. Name and address of nominee to become guardian: (If same as item 1, enter "same."). 3. Date of birth of person listed in item 2, and relationship of such person to the incapacitated person, or, in the alternative, describe the official purpose and scope of services furnished by the institution listed in item 2: 1 4. Name and residence address of incapacitated person: 2 5. Current location of incapacitated person: 6. Date of birth of incapacitated person if known - if birthdate is not known, give approximate age in years: American LegalNet, Inc. www.FormsWorkFlow.com PP-205 (Rev. 7-1-08) Page 2 of 5 7. Names and addresses of all persons who must be notified, including the incapacitated person and the relationship of each person to the incapacitated person: 3 (Use separate sheet if necessary.) The following must be notified: the person alleged to be incapacitated/needing protection, his spouse, domestic partner, parents and all adult children; any person currently serving as his guardian or conservator or who has his care and custody; the closest adult relative who can be found if he has no spouse, domestic partner, parent or adult child; an adult friend if no spouse, domestic partner, parent or adult child can be found; the director or chief executive officer of the institution where the allegedly incapacitated person/person to be protected resides and any governmental agency paying or planning to pay benefits to the person to be protected. NAME ADDRESS RELATIONSHIP 8. Any person listed in item 7 other than the allegedly incapacitated person may waive notice and hearing and agree to this appointment by signing here: 9. Is a temporary guardian required? Yes No. If yes, state here the reasons why and the name and address of the suggested temporary guardian: An affidavit setting forth the factual basis for the emergency and the specific powers requested is required. 4 10. State name of examining physician and/or licensed psychologist and date, not later than 10 days before the hearing, when his written report will be filed with the Court. 5 11. Will the incapacitated person attend the hearing? Yes No. If no, state the reason why not. 6 American LegalNet, Inc. www.FormsWorkFlow.com PP-205 (Rev. 7-1-08) Page 3 of 5 12. Is the incapacitated/protected person currently represented by counsel? 7 Yes No. If yes, state name, address and telephone number of said counsel. If no, an Attorney, visitor or guardian ad litem will be appointed by the Court. 13. Does the petitioner request that the Court order that notice be served on the incapacitated person by the visitor? 8 Yes No. 14. Has the nominee attached an acceptance of appointment? Yes No. If no, state when it is to be filed. 15. Has the nominee attached a guardianship plan? Yes No. If no, state when it is to be filed. 9 16. , specifically including, in every case, the nature and extent of the alleged incapacity and the reasons why the person to be protected is allegedly unable to manage his/her property and affairs effectively. 10 17. (a) The petitioner believes that a (full) (limited) guardianship is appropriate in this case. If full, state facts warrant such an appointment. If limited, include a statement of proposed powers of the guardian, together with a statement of facts demonstrating wadaptive limitations or other conditions warrant those specific powers. 11 or limitation is reqadaptive limitations or other conditions warrant this appointment. If expanded or limited powers are requested, include a statement of facts demonstrating why the protected peradaptive limitations or other conditions warrant those specific powers. 12 American LegalNet, Inc. www.FormsWorkFlow.com PP-205 (Rev. 7-1-08) Page 4 of 5 18. Name, address, qualifications and priority of nominee to be conservator. 13 19. Has nominee attached acceptance of appointment as conservator? Yes No. If no, state when it is to be filed. 20. Has the nominee attached a conservatorship plan? 14 Yes No. 21. Is a bond attached? Yes No. If no, explain why not. If a Court order is sought with respect to type of amount of bond, state here all the particulars of the order sought and reasons therefor. 15 22. Set forth a general description of the assets of the protected person, including estimated values and location by county. Include any benefits being paid or anticipated from any governmental agency: 23. Is an interim Court order sought pursuant to 18-A MRSA 247 5-408? Yes No. If so, set forth in detail the order sought and the reasons therefor. Attach a proposed order. 24. Is a temporary conservator required? Yes No. If yes, state here the reason why and the name and address of the suggested temporary conservator. An affidavit setting forth the factual basis for the emergency and the specific powers requested is required. 16 NOTE: All required reports and plans must be filed at least 10 days prior to any hearing on this petition. 17 American LegalNet, Inc. www.FormsWorkFlow.com PP-205 (Rev. 7-1-08) Page 5 of 5 The petitioner believes that the person alleged in this petition to be incapacitated is impaired to the extent that he lacks sufficient understanding or capacity to make or communicate responsible decisions concerning his person and that the appointment of a guardian is necessary or desirable as a means of providing continuing care and supervision of the person of the proposed ward. Petitioner also requests that the Court determine that the above person is a person for whom appointment of a conservator is proper, make the appointment prayed for, and let letters of appointment issue to the conservator. Dated: Petitioner or Attorney shall be signed by at least one attorney of record in his Name, address, telephone number and Bar Registration Attorneys appearing for other parties Number of attorney for petitioner, if any. Name of attorney Name of party 1 See 18-A MRSA 247 5-311 for priority of persons who may serve as guardian. 2 The address listed here or in item 5 must be in this county to establish venue. See 18-A MRSA 247 5-302. 3 The following must be notified: See 18-A MRSA 247 5-309 and 5-405. (1) The person alleged to be incapacitated/needing protection, his spouse, domestic partner, parents and all adult children; (2) Any person currently serving as his guardian or conservator or who has his care and custody; (3) The closest adult relative who can be found if he has no spouse, domestic partner, parent or adult child. (4) An adult friend if no spouse, domestic partner, parent or adult child can be found; (5) The director or chief executive officer of the institution where the allegedly incapacitated person/person to be protected resides. See Rule 4(d)(1)(D) of the MRPP. (6) Any governmental agency paying or planning to pay benefits to the person to be protected. (i.e. Social Security AdministratioAdministration, etc.) See 18-A MRSA 247 5-406. 4 See 18-A MRSA 247 5-310; 5-310-A. 5 ses. Said report shall be filed at least 10 days prior to the hearing on the petition. See 18-A MRSA 247 5-303(b) and (d); 247 5-407(b) and 5-407(b) and (d). 6 See 18-A MRSA 247 5-303(b) and 5-407(b). 7 See 18-A MRSA 247 5-303(b) and (c); 247 5-407(b) and (b-1). Visitor, guardian ad litem, or attorney shall be appointed unless incapacitated person has counsel or will attend hearing or appointment will serve no useful purpose. 8 See 18-A MRSA 247 5-309(b); 247 5-405(a). 9 See 18-A MRSA 247 5-303(a). The plan must be filed at least 10 days before hearing. See 18-A MRSA 247 5-303(d). 10 See 18-A MRSA 247 5-101 and 247 5-401. 11 See 18-A MRSA 247 5-105. 12 See 18-A MRSA 247 5-426 and 247 5-408. 13 See 18-A MRSA 247 5-410. 14 See 18-A MRSA 247 5-407(b). The plan must be filed at least 10 days before hearing. See 18-A MRSA 247 5-407(d). 15 See 18-A MRSA 247 5-411 and 5-412. 16 See 18-A MRSA 247 5-408(a) 17 See 18-A MRSA 247 5-303(d