DECREE AND ORDER OF APPOINTMENT OF GUARDIAN FOR AN INCAPACITATED PERSON Docket No. Commonwealth of Massachusetts The Trial Court Probate and Family Court Division In the Interests of: First Name Middle Name Last Name Incapacitated Person After hearing on the Petition for Appointment of Guardianship filed on (date) The Court finds: 1. The requirements of G.L. c. 190B, § 5-306 (b) (1)-(8) have been met and a basis exists for the guardianship. The nature and extent of the incapacity is detailed in the Medical Certificate(s) on file with the court. 2. A hearing was held relative to the authority to consent to treatment for which a substituted judgment determination is required. See Separate Findings. The Incapacitated Person was was not present. The Court finds that there exist extraordinary circumstances requiring the absence of the Incapacitated Person, that counsel for the Incapacitated Person was present, and that after careful inquiry and upon representations of counsel there are no contested issues of fact. Oral testimony was not required because sufficient documentary evidence was presented or for the following reasons: The Court appoints the following person(s) as Guardian(s) (hereafter "Guardian"): 1. Name: First Name (Address) M.I. Last Name (City/Town) (Apt, Unit, No. etc.) (State) (Zip) Primary Phone #: 2. Name: First Name (Address) M.I. (Apt, Unit, No. etc.) Last Name (City/Town) (State) (Zip) Primary Phone #: The powers and duties of the Guardian are limited to the following: The powers and duties of the Guardian include all powers authorized to a guardian for an incapacitated person under G. L. c. 190B, Article V, Part III exclusive of those powers requiring specific court authorization including authorization to apply for health insurance benefits including MassHealth on behalf of the Incapacitated Person and authorization to obtain copies of statement or any other records from banks, insurance companies or other financial institutions verifying balances and transaction for accounts standing in the name of the Incapacitated Person individually or jointly with another. These powers are not limited are limited as set forth in Exhibit A which is incorporated and merged herein and details those powers retained by the Incapacitated Person. MPC 720 (5/30/11) page 1 of American LegalNet, Inc. www.FormsWorkFlow.com 3 Docket No. In the Interests of: First Name Middle Name Last Name The powers and duties of the Guardian shall further include: 1. Authorization to admit the Incapacitated Person to a nursing facility. The court finds that such admission is in the Incapacitated Person's best interest. 2. Authorization to revoke the Health Care Proxy of the Incapacitated Person. 3. Authorization to apply for health insurance benefits including MassHealth on behalf of the Incapacitated Person. 4. Authorization to obtain copies of statements or any other records from banks, insurance companies or other financial institutions verifying balances and transactions for accounts standing in the name of the Incapacitated Person, individually or jointly with another. After making a substituted determination, the court authorizes treatment of the Incapacitated Person: with antipsychotic medication in accordance with a treatment plan dated which is incorporated herein by reference and which shall be reviewed on or before and, if not sooner extended, shall expire on . The appointment of Counsel for the Incapacitated Person is extended for the limited purpose of representing the Incapacitated Person's interests in any proceeding to renew and/or amend the treatment plan. for the following treatment or action: The Court orders the following: 1. The Guardian shall file with the Court the Initial Guardian's Care Plan/Report within 60 days from this appointment unless previously filed. 2. The Guardian shall file with the Court the Annual Guardian's Care Plan/Report one year from the date of this appointment unless otherwise ordered by the Court, and annually thereafter for the duration of the guardianship and when otherwise ordered by the Court. Forms are available at the Court's Registry office or online at the Court's Web site: http://www.mass.gov/courts/courtsandjudges/courts/probateandfamilycourt/upc.html 3. The Guardian(s) shall serve: without a surety on his, her or their bond because: it is in the best interest of the Incapacitated Person as there are minimal assets under management by the guardian or because: language in a Durable Power of Attorney or Health Care Proxy waives the Guardian's bond or requests a waiver of any necessity of sureties on a bond. MPC 720 (5/30/11) page 2 of American LegalNet, Inc. www.FormsWorkFlow.com 3 Docket No. In the Interests of: First Name Middle Name Last Name with personal or corporate surety on his, her or their bond in the amount of pursuant to G. L. c. 190B §5-410. NO LETTERS OF GUARDIANSHIP FOR AN INCAPACITATED PERSON SHALL ISSUE UNTIL THE BOND IS FILED AND APPROVED. 4. The appointment of counsel in this matter, if any, shall terminate upon the entry of this Decree unless otherwise ordered by this Court herein or hereafter. 5. The Court grants the following additional powers: 6. The parties shall comply with a stipulation or agreement of the parties dated which is filed with the Court and expressly made a part of this Decree and Order. 7. The Court further orders: Date JUSTICE OF THE PROBATE AND FAMILY COURT This appointment has been: SUSPENDED as a Special Guardian has been appointed this date (see separate Order). The authority of the Guardian is suspended during the time the Special Guardian is appointed. TERMINATED (See separate Order). MODIFIED (See separate Order). Date JUSTICE OF THE PROBATE AND FAMILY COURT This appointment has been: REINSTATED as of the date of this Order. TERMINATED (See separate Order). MODIFIED (See separate Order). Date JUSTICE OF THE PROBATE AND FAMILY COURT MPC 720 (5/30/11) page 3 of American LegalNet, Inc. www.FormsWorkFlow.com 3