Commonwealth of Massachusetts Plymouth Division The Trial Court Probate and Family Court Department Docket No. GUARDIANSHIP PETITION GUARDIAN OF PERSON - AND ESTATE Name of proposed ward Please check applicable box and/or strike out Inapplicable language where appropriate. Basis for the Guardianship: Me ntal Illne s s Me ntal R e tardation Phys ical Incapacity or Illne s s Special Requests: for court authorization to treat with antipsychotic medication(s) in accordance with the treatment plan for court authorization to admit or commit to a mental health or mental retardation facility extraordinary medical authority To the Justices of the Probate and Family Court: RESPECTFULLY represents PETITIONER (2) PETITIONER (1) (PRINT name of petitioner) (PRINT name of petitioner) that they are - he/she is: parent(s) two (or more) relatives or friends a nonprofit corporation organized under the laws of the Commonwealth an agency within the Executive Off ice 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 incapable of taking care of himself/herself by reason of mental illness. is mentally retarded to the degree that he/she is incapable of making informed decisions with respect to the conduct of his/her personal and/or financial affairs. is unable to make or communicate informed decisions due to physical incapacity or illness. List all heirs apparent or presumptive of ward: NAME (Please indicate if person is 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. [Guardianship of mentally retarded persons ONLY] A Clinical Team report is filed with this petition. (See, G.L.M. c. 201, §6A and Uniform Probate Court Practice XXII(A)) CJ-P 110 (10/97) pcpfc - c.g.f. (GUARDIANSHIP PETITION BACK) WHEREFORE, the petitioner(s) pray(s) that (name of proposed guardian(l)) (city or town) (street address) (state) (zip code) (state) (zip code) - and (name of proposed guardian(2), if applicable) (city or town) (street address) - or some other suitable person - be appointed the guardian of the person - and - the estate of the ward. FURTHERMORE the petitioner(s) request(s): court authorization to treat with antipsychotic medication(s) in accordance with the treatment plan. court authorization to admit or commit to a mental health or mental retardation facility. court authorization for the following extraordinary medical procedure(s): The Petitioner(s) certify(ies) under the penalties of perjury that - the ward's estate does not exceed $100.00 and that - the statements contained herein are true to the best of his/her/their knowledge and belief. Dated: PETITIONER (1) PETITIONER (2) (signature of petitioner) (signature of petitioner) (street address) (street address) (city or town) Tel. No. ( (state) (zip code) (city or town) Tel. No. ( ) The undersigned hereby assent(s) to the foregoing petition. (state) (zip code) ) 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, §§ 6, 6A,6B, 7; Probate Court Rule 2913; and, Uniform Probate Practice XXII and XXII(A). 2. A bond must be furnished. 3. If certified that the ward's estate is less than $100.00, no filing fee is required. If the ward's estate is $100.00 of more, a $150.00 filing fee, a $50.00 bond and $15.00 surcharge must be paid upon filing. 4. A Medical Certificate must be filed in accordance with Uniform Probate Practice XXII.