Commonwealth of Massachusetts The Trial Court Probate and Family Court Department Division Docket No. GUARDIANSHIP PETITION GUARDIAN OF PERSON-AND ESTATE years of age, who is Proposed Ward: (PRINT Name) lives at (Street address) (City/Town) PETITIONER (1) (County) (Zip) PETITIONER (2) (PRINT Name) seek(s) (State) (PRINT Name) Limited Guardianship Full Guardianship Mental Illness on the grounds of: Mental Retardation Physical Incapacity or Illness Petitioner(s) respectfully represent(s) that they are-s/he is-it is: parent(s) two (or more) relatives or friends Relationship: a nonprofit corporation organized under the laws of the an agency within the Executive Offices of Health and Commonwealth Human Services or Education. AND that the proposed ward is incapable of taking care of himself/herself by reason of mental illness. 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. unable to make or communicate informed decisions due to physical incapacity or illness. Length of time proposed ward has lived at the above address: days Address at which ward will reside after a decree (temporary or permanent), if any, is entered: months years same as above other (please specify): (Street address) (City/Town) (County) (State) (Zip) The proposed ward has lived with and/or been in the care of the following in the last sixty (60) days: Print Name Relationship Print Name Relationship Guardianship is necessary because: (State the nature and extent of the respondent's alleged lack of capacity.) Limited guardianship is requested. The following powers should be granted to the limited guardian: CJ-P 110 (8/11/08) American LegalNet, Inc. www.FormsWorkflow.com Full guardianship is requested. The reason why limited guardianship is inappropriate is: The respondent's identified needs cannot be met by less restrictive means, including use of appropriate technological assistance. Name of proposed ward's spouse, if any: Print Name Residence Check if Applicable Incompetent Name of proposed ward's child(ren) including child(ren) of a predeceased child, or if none, parent(s), or if none, sibling(s), or if none, heirs apparent or presumptive: Print Name Residence Relationship Is s/he a Minor or Incompetent? Please Sign if you Assent to the Petition Minor Incompetent Minor Incompetent Add Has proposed ward ever been the subject of a guardianship or conservatorship? Yes No Unknown If Yes, where and when? Has proposed ward designated anyone to hold a power of attorney? Yes No Unknown If Yes, Name: (PRINT Name) (Street address) (Relationship) (City/Town) Date signed: (County) (State) (Zip) A copy of the Power of Attorney designation must be attached. Has proposed ward completed a Health Care Proxy? Yes No Unknown If Yes, Name of Agent(s): (PRINT Name) (Street address) (Relationship) (City/Town) Date signed: (County) (State) (Zip) A copy of the Health Care Proxy document must be attached. Click to add another Agent Has proposed ward nominated a guardian or representative payee in any other legal document? Yes No Unknown If Yes, Name(s): (PRINT Name) (Street address) (Relationship) (City/Town) (County) (State) (Zip) Date signed: Please describe the type of document: CJ-P 110 (8/11/08) American LegalNet, Inc. www.FormsWorkflow.com Is proposed ward entitled to benefits, estate, or income paid or payable through the United States Veterans Administration? Yes No Unknown WHEREFORE, the petitioner(s) request(s) that: of (Street address) (PRINT Name) whose relationship to the proposed ward is: (City/Town) (County) (Zip) (State) AND (Please complete if requesting a co-guardian) (Relationship) of (Street address) (PRINT Name) whose relationship to the proposed ward is: (City/Town) (County) (Zip) , or some other suitable person(s), be appointed the (Relationship) Limited Guardian (State) Full Guardian of the person of the proposed ward. and of the estate FURTHERMORE the petitioner(s) request(s): court authorization and approval of a treatment plan for administration of antipsychotic medication(s). court authorization to admit or commit, as permitted by law, to a mental health facility. mental retardation facility. court authorization for the following extraordinary medical procedure(s): The petitioner(s) certify(ies) under the penalties of perjury that the proposed ward's estate does 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) (Street address) (City/Town) (Signature) (Street address) (County) (State) (Zip) (City/Town) Tel. No. (State) (Zip) (State) (Zip) Tel. No. FOR PETITIONER(S): (County) FOR RESPONDENT(S): (Signature) (PRINT Name) (PRINT Name) (Street address) (City/Town) (Signature) (Street address) (County) (State) (Zip) (City/Town) Tel. No. Tel. No. B.B.O # (County) B.B.O # CJ-P 110 (8/11/08) American LegalNet, Inc. www.FormsWorkflow.com