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Order Appointing Temporary Guardian For An Incapacitated Person Form. This is a Massachusetts form and can be use in Probate And Family Court Statewide.
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Tags: Order Appointing Temporary Guardian For An Incapacitated Person, MPC 620, Massachusetts Statewide, Probate And Family Court
ORDER APPOINTING TEMPORARY
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 Motion for Appointment of Temporary Guardian(s),
The Court finds:
1. Notice pursuant to G. L. c. 190B §§5-308(c-e) was:
Properly given.
Shortened or waived in whole or in part because the Court finds that an immediate emergency situation exists
which requires the immediate appointment of a Temporary Guardian. The nature of the emergency is that the
Respondent has acute care needs which require immediate attention or:
2. It is necessary to appoint a Temporary Guardian because of the likelihood of an immediate and substantial harm to the
health, safety, or welfare of the Incapacitated Person and that no other person appears to have authority to act in the
circumstances.
3.
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 exists extraordinary circumstances requiring the absence of the Incapacitated Person,
that counsel for the Incapacitated Person was present and 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
The Court appoints the following person(s) as Temporary Guardian(s) (hereafter "Temporary Guardian"):
1. Name:
First Name
(Address)
Last Name
M.I.
(Apt, Unit, No. etc.)
(City/Town)
(State)
(Zip)
Primary Phone #:
2. Name:
First Name
(Address)
Last Name
M.I.
(Apt, Unit, No. etc.)
(City/Town)
(State)
(Zip)
Primary Phone #:
THIS APPOINTMENT OF TEMPORARY GUARDIAN IS NOT A FINAL DETERMINATION OF THE RESPONDENT'S
INCAPACITY PURSUANT TO G.L. c. 190B, §5-101(9).
MPC 620 (5/30/11)
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Docket No.
In the Interests of:
First Name
Middle Name
Last Name
The Temporary Guardian may exercise only the powers specified in this Order. The powers of the Temporary Guardian
are as follows:
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.
5.
The powers and duties of the Temporary Guardian are 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 and
include the authorization to apply for health insurance benefits including MassHealth on behalf of the Incapacitated
Person and authorization to obtain copies of statements and any other records from banks, insurance companies,
or other financial institutions verifying balances and transactions for accounts standing in the name of the
are not limited
are limited
Incapacitated Person, individually or jointly with another. These powers
as set forth in Exhibit A which is incorporated and merged herein and which detail those powers retained by the
Incapacitated Person.
6.
Only the following powers:
After making a substituted judgment 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 seven days after that date, at 4:00 PM, unless sooner extended.
with the following treatment or action:
The Court orders the following:
1. If this Order was issued without full notice, post-appointment notice must be given together with a statement
that the appointment may be vacated and heard as a de novo matter as expeditiously as possible. Said notice
must be given within seven days from the date of this appointment to the alleged Incapacitated Person and those
persons named in the petition who were not previously given notice in accordance with G. L. c. 190B 5-308(c). A
certification stating such notice has been given must be filed within seven days of the appointment or the
appointment may be vacated sua sponte.
2.
The Court has appointed counsel for the Incapacitated Person. See Separate Order Appointing Counsel.
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Docket No.
In the Interests of:
First Name
Middle Name
Last Name
3. The Temporary Guardian(s) shall serve:
without 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 Temporary 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.
with personal or corporate surety on his, her or their bond in the amount of
pursuant to G. L. c. 190B §5-307.
NO LETTERS OF TEMPORARY GUARDIANSHIP FOR AN INCAPACITATED PERSON
SHALL ISSUE UNTIL THE BOND IS FILED AND APPROVED.
4. This appointment of the Temporary Guardian(s) shall expire 90 days from today or on
.
(Date)
If this date is more than 90 days from the date of appointment, the Court finds the following extraordinary
circumstances warrant a later date:
5. A
hearing shall be held on this matter on
:
6.
a.m.
p.m. at the
at
Probate and Family Court.
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 order.
(Date)
7. The Court further orders:
Date
JUSTICE OF THE PROBATE AND FAMILY COURT
MPC 620 (5/30/11)
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