PETITION FOR APPOINTMENT OF CONSERVATOR FOR DISABLED PERSON OR FOR SINGLE TRANSACTION In the Interests of: First Name Middle Name Docket No. Commonwealth of Massachusetts The Trial Court Probate and Family Court Division Last Name Person to be Protected/Respondent Minor Adult The Court, whenever feasible, shall grant to a Conservator only those powers necessary based on the Protected Person's limitations and demonstrated needs and will issue orders that will encourage the development of the Protected Person's maximum self-reliance and independence. 1. Information about Respondent: Name: Primary Language: Principal Residence: (Address) (Apt, Unit, No. etc.) (City/Town) (State) (Zip) Age: First Name M.I. Last Name English Other Primary Phone #: Date Residence was established: Current Address: Same as Above or (Address) the following address: (Apt, Unit, No. etc.) (City/Town) (State) (Zip) If this appointment is made, Respondent's dwelling will be (Address) Principal Residence (Apt, Unit, No. etc.) Current Address (City/Town) the following address: (State) (Zip) If the residence and current address are outside of the Commonwealth, state the location of Respondent's property within the county: (Address) (Apt, Unit, No. etc.) (City/Town) (State) (Zip) 2. Information about the Petitioner: Name: First Name (Address) M.I. (Apt, Unit, No. etc.) (City/Town) Last Name (State) (Zip) Primary Phone #: State your interest in the appointment: Relationship to Respondent: An attachment to this petition provides information on co-petitioners. 3. Petitioner is requesting: to be appointed Name: First Name M.I. Last Name that some suitable person be appointed the following person be appointed: (Address) (Apt, Unit, No. etc.) (City/Town) (State) (Zip) Primary Phone #: Relationship to Respondent: American LegalNet, Inc. www.FormsWorkFlow.com An attachment to this petition provides additional information. MPC 130 (5/30/11) page 1 of 6 4. He or she has priority of appointment because the nominee is: 5. This is a Petition for: The appointment of a Limited Conservator With limitations as follows: . The appointment of a Conservator State why a limited conservator is inappropriate: Authorization of the following protective arrangement or single transaction: The appointment of a Special Conservator to assist in the accomplishment of the above-stated protective arrangement or other authorized single transaction. 6. Unless the Respondent is a minor, a Medical Certificate dated with an examination having taken place within 30 days of the filing of the petition or, if Respondent is alleged to be Intellectually Disabled, a Clinical Team Report dated with an examination having taken place within 180 days of the filing of the petition: is filed with this Petition or is on file with the Court (Docket No. ); OR is not filed with this Petition and is not on file with the Court. If a Medical Certificate or Clinical Team Report is not filed with this Petition, or on file with this Court, you must immediately file and present a motion requesting that the Court permit it to be filed late or waive the filing requirement. An affidavit must accompany the motion explaining why it is impossible to file a Medical Certificate or Clinical Team Report with this Petition. 7. A conservator is necessary and in the best interest of Respondent because Respondent is: a minor; OR alleged disabled for reasons other than minority. A description of the nature and extent of the Respondent's alleged incapacity is detailed in the most recent Medical Certificate or Clinical Team Report filed with this Petition or is described as follows: OR detained or otherwise unable to return to the United States. State the relevant circumstances, including the time and nature of detention or inability to return and a description of any search or inquiry concerning the person's whereabouts: AND Respondent has property which will be wasted or dissipated unless proper management is provided; AND/OR Respondent or persons entitled to Respondent's support require money for support, care, and welfare, and protection is necessary or desirable to obtain or provide money. 8. Respondent MPC 130 (5/30/11) is is not alleged to be Intellectually Disabled. page 2 of 6 American LegalNet, Inc. www.FormsWorkFlow.com 9. List Respondent's: A. Spouse and Children. If none, list parents and brothers and sisters or, if none, list heirs apparent or presumptive. B. Current Guardian in the Commonwealth or elsewhere; C. Nominated Guardian in the Commonwealth or elsewhere; D. Current Conservator in the Commonwealth or elsewhere; Name Primary Address Primary Phone Spouse Child Guardian Nominated Guardian Conservator Relative: (relationship) E. Health Care Agent; F. Durable Power of Attorney/Agent; G. Representative Payee; and/or H. Caretaker in the last 60 days. Relationship (Check all that apply) Representative Payee Health Care Proxy Durable Power Holder Had care & custody in the last 60 days. Indicate if this person is: Minor Incompetent Spouse Child Guardian Nominated Guardian Conservator Relative: Representative Payee Health Care Proxy Durable Power Holder Had care & custody in the last 60 days. (relationship) Minor Incompetent Spouse Child Guardian Nominated Guardian Conservator Relative: Representative Payee Health Care Proxy Durable Power Holder Had care & custody in the last 60 days. (relationship) Minor Incompetent can LegalNet, Inc. ormsWorkFlow.com MPC 130 (5/30/11) page 3 of 6 American LegalNet, Inc. www.FormsWorkFlow.com 10. Does the Respondent have, in the Commonwealth or elsewhere: If yes, a copy of the document is: Information/Explanation: (If a Petition has been filed but not allowed, please list Court and Docket Number of pending case) Yes and the person's information is listed at Q.9 A current Guardian? No Uncertain Yes and the person's information is listed at Q.9 A document nominating a Guardian? No Uncertain Yes and the person's information is listed at Q.9 A current Conservator? No Uncertain Yes and the person's information is listed at Q.9 A Representative Payee? No Uncertain Yes and the person's information is listed at Q.9 A Health Care Agent? No Uncertain Yes and the person's information is listed at Q.9 A Durable Power of Attorney/Agent? No Uncertain Attached Unavailable Attached Unavailable Attached Unavailable Attached Unavailable Attached Unavailable Attached Unavailable MPC 130 (5/30/11) page 4 of 6 American LegalNet, Inc. www.FormsWorkFlow.com 11.