Commonwealth of Massachusetts The Trial Court Probate and Family Court Department Bristol Division Docket No. CONSERVATORSHIP PETITION Name of proposed ward Please check applicable box and/or strike out inapplicable language where appropriate. Basis for the Conservatorship: Physical Incapacity (ward must assent to petition) Mental Weakness Mental Retardation To the Justices of the Probate and Family Court: RESPECTFULLY represents PETITIONER (1) MilitaryM.I.A./P.O.W PETITIONER (2) (PRINT name of petitioner) (PRINT name of petitioner) that they are - he/she is: parent(s) one (or more) relative(s) or friend(s) (petition regarding mentally retarded person only) parent(s) two (or more) relative(s) or friend(s) a nonprofit corporation organized under the laws of the Commonwealth an agency within the Executive Office of Human Services or Educational Affairs. AND that whose address is (name of proposed ward) (street address) (city or town) (county) (state) (zip code) is a person who is unable to properly care for his/her property by reason Of mental weakness. is a person who is unable to properly care for his/her property by reason of physical incapacity (person must assent to petition). is a mentally retarded person to the degree that he/she is incapable of making informed decisions with respect to the conduct of his/her financial affairs and that the failure to appoint a conservator would create an unreasonable risk to his/her property. is a person who is declared missing in action or a prisoner of war while serving in the Armed Forces of the United States. List all heirs apparent or presumptive of ward: NAME (please indicate if person(s) is/are a minor or incompetent) RESIDENCE RELATIONSHIP The ward is - is not - entitled to benefits, estate, or income paid or payable through the United States Veterans Administration. [Conservatorship of mentally retarded persons ONLY] A Clinical Team report is filed with this petition (See, G.L.M. c. 201, §1 6B and Uniform Probate Court Practice XXII(A)) CJ-P 101 (10/93) American LegalNet, Inc. www.USCourtForms.com bcpfc - c.g.f. (CONSERVATORSHIP PETITION BACK) WHEREFORE, the petitioner(s) pray(s) that (name of proposed conservator(l)) (state) (zip code) (state) (city or town) (street address) _ and (zip code) (name of proposed conservator (2)) (city or town) (street address) _ or some other suitable person(s) - be appointed the conservator(s) of the estate of the ward to have charge and management of the ward's property, subject to G.L.M. c. 201, §§ 16B, 20 and the direction of the Court. I/We certify under the penalties of perjury that - the proposed ward's estate does not exceed $100.00 and that the statements contained herein are true to the best of my/our knowledge and belief. Dated: PETITIONER (2) PETITIONER (1) (signature of petitioner) (signature of petitioner) (street address) (street address) (city or town) Tel. No. ( (state) (zip code) (city or town) Tel. No. ( ) (state) (zip code) ) The undersigned WARD hereby assents to the foregoing petition. Pursuant to G.L.M. c. 201, § 16 when seeking a conservatorship of a person who by reason of physical incapacity is unable to properly care for hislher property the ward must assent (signature of ward) (date) The undersigned hereby assent to the foregoing petition. PETITION - DECREE Filed: Citation issued: Returnable: Allowed: For Petitioner(s): For Respondent: (name) (street address) (city or town) Tel. No. ( B.B.O. # ) (name) (street address) (state) (zip code) (city or town) Tel. No. ( (state) (zip code) ) B.B.O. # INSTRUCTIONS 1. Refer to G.L.M. c. 201, §§ 16,16A,l 613, 21; Probate Court Rule 2913; and, Uniform Probate Practice XXII and XXII(A). 2. A bond with sureties must be furnished. 3. If certified that the ward's estate is less than $100.00, no filing fee is required, otherwise $150.00 filing fee, a $50.00 bond, and a $15.00 surcharge must be paid upon filing 4. A Medical Certificate must be filed in accordance with Uniform Probate Practice XXII. American LegalNet, Inc. www.USCourtForms.com bcpfc - c.g.f.