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Petition For Appointment Of 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: Petition For Appointment Of Guardian For An Incapacitated Person, MPC 120, Massachusetts Statewide, Probate And Family Court
PETITION FOR APPOINTMENT OF
GUARDIAN FOR AN
INCAPACITATED PERSON
Commonwealth of Massachusetts
The Trial Court
Probate and Family Court
Docket No.
Division
In the Interests of:
Middle Name
First Name
Last Name
Alleged Incapacitated Person/Respondent
The Court shall encourage the development of maximum self-reliance and independence of the Incapacitated Person and
make appointive and other orders only to the extent necessitated by the Incapacitated Person's limitations or other conditions
warranting the procedure.
1. Information about the Respondent:
Age:
Name:
Primary Language:
Last Name
M.I.
First Name
English
Other:
Primary Phone #:
Principal Residence:
(Address)
(City/Town)
(Apt, Unit, No. etc.)
(State)
(Zip)
Date Residence was established:
Current Address:
Same as Above or
(Address)
the following address:
If this appointment is made, Respondent will reside at
(Address Line 1)
Respondent
is
(State)
(City/Town)
(Apt, Unit, No. etc.)
Principal Residence
Current Address
(City/Town)
(Apt, Unit, No. etc.)
(Zip)
the following address:
(State)
(Zip)
is not alleged intellectually disabled.
2. Information about the Petitioner:
Name:
First Name
(Address)
M.I.
(Apt, Unit, No. etc.)
Last Name
(City/Town)
(State)
(Zip)
Relationship to Respondent:
Primary Phone #:
State your interest in the appointment:
An attachment to this petition provides information on co-petitioner(s).
3. The Petitioner is requesting:
to be appointed
that some suitable person be appointed
that the person named below be appointed:
Name:
First Name
(Address)
Primary Phone #:
MPC 120 (5/30/11)
M.I.
(Apt, Unit, No. etc.)
Last Name
(City/Town)
(State)
(Zip)
Relationship to Respondent:
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4. He or she has priority of appointment because the nominee is (choose one):
Nominated in a durable power of attorney by Respondent;
Respondent's parent or a parental nominee; OR
Respondent's spouse or a spousal nominee;
None of the above.
State the reason the proposed guardian(s) should be appointed:
5. This is a Petition for appointment of a (choose one):
Limited Guardian.
State the powers being sought:
to apply for health insurance benefits including MassHealth on behalf of Respondent;
to obtain copies of statements or any other records from banks, insurance companies, or other financial
institutions verifying balances and transactions of accounts standing in the name of the Incapacitated Person,
individually or jointly with another.
Other:
OR
General Guardian.
State the reasons why a Limited Guardianship is inappropriate:
6. 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 this 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. The reason a guardianship is necessary is detailed in the most recent Medical Certificate or Clinical Team Report
filed with this petition or is described as follows:
8. The nature and extent of Respondent's alleged incapacity is detailed in the Medical Certificate or Clinical Team
Report filed with this petition or is described as follows:
MPC 120 (5/30/11)
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9. List Respondent's:
A. Spouse and Children. If none, list parents and brothers and sisters or, if none, list heirs apparent or presumptive.
E. Health Care Agent;
B. Current Guardian in the Commonwealth or elsewhere;
F. Durable Power of Attorney/Agent;
C. Nominated Guardian in the Commonwealth or elsewhere;
G. Representative Payee; and/or
D. Current Conservator in the Commonwealth or elsewhere;
H. Caretaker in the last 60 days.
Name
Primary Address
Relationship
(Check all that apply)
Primary Phone
Indicate if this
person is:
Spouse
Representative Payee
Minor
Child
Health Care Proxy
Incompetent
Guardian
Durable Power Holder
Nominated Guardian
Had care & custody in the last
Conservator
60 days.
Relative:
(relationship)
Spouse
Representative Payee
Minor
Child
Health Care Proxy
Incompetent
Guardian
Durable Power Holder
Nominated Guardian
Had care & custody in the last
Conservator
60 days.
Relative:
(relationship)
Spouse
Representative Payee
Minor
Child
Health Care Proxy
Incompetent
Guardian
Durable Power Holder
Nominated Guardian
Had care & custody in the last
Conservator
60 days.
Relative:
(relationship)
MPC 120 (5/30/11)
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10. Does the Respondent have, in the
Commonwealth or elsewhere:
If yes, a copy of the
document is:
Yes and the person's information is listed at Q.9
A current Guardian?
Attached
No
Information/Explanation:
(If a Petition has been filed but not
allowed, please list Court and
Docket Number of pending case)
Unavailable
Uncertain
Yes and the person's information is listed at Q.9
A document nominating a Guardian?
Attached
No
Unavailable
Uncertain
Yes and the person's information is listed at Q.9
A current Conservator?
Attached
No
Unavailable
Uncertain
Yes and the person's information is listed at Q.9
A Representative Payee?
Attached
No
Unavailable
Uncertain
Yes and the person's information is listed at Q.9
A Health Care Agent?
Attached
No
Unavailable
Uncertain
Yes and the person's information is listed at Q.9
A Durable Power of Attorney/Agent?
Attached
No
Unavailable
Uncertain
MPC 120 (5/30/11)
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11. Respondent
is
is not
entitled to benefits from the Department of Veterans Affairs or
12. Does Respondent have any assets, e.g. bank accounts, property?
Yes
No
Description of Assets, e.g. Bank Accounts, Property, Insurance, Pensions
DO NOT INCLUDE NAMES OF INSTITUTIONS OR ACCOUNT NUMBERS
Uncertain.
Uncertain. If Yes, identify:
Estimated Value of Property
Total
An attachment to this petition provides additional information.
13. Does Respondent have any anticipated income?
Yes
No
Description of Income, e.g. Social Security, Interest
DO NOT INCLUDE NAMES OF INSTITUTIONS OR ACCOUNT NUMBERS
Uncertain. If Yes, identify:
Amount of Anticipated
Monthly Income or Receipts
Total
An attachment to this Petition provides additional information.
14.
Petitioner seeks specific Court authorization:
to admit Respondent to a nursing facility;
to treat Respondent with antipsychotic medication in accordance with a treatment plan;
for the following treatment or action for which a substituted judgment determination may be required:
to revoke the Health Care Proxy of Respondent.
WHEREFORE, PETITIONER REQUESTS THAT THIS HONORABLE COURT:
Appoint
Petitioner
First Name
M.I.
Last Name
Some suitable person
as
limited guardian(s)
general guardian(s)
of Respondent, with any specific authorization as may be requested in
paragraph 14 above.
MPC 120 (5/30/11)
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Petitioner requests the Court waive sureties on the Bond for the following reasons:
The Respondent has minimal funds to be managed and requiring sureties would place a financial burden on the
Respondent.
A Conservator is appointed or is being requested.
Other:
In addition, Petitioner requests that the Court:
SIGNED UNDER THE PENALTIES OF PERJURY
I affirm or swear under oath that I have read the foregoing Petition and that the statements set forth therein are true and correct to
the best of my knowledge.
Date:
Signature of Petitioner
Date:
Signature of Co-petitioner (if applicable)
I assent to the foregoing Petition:
Print Name
Signature
Date
Date
Date
Date
Attorney for Petitioner
(Print name)
(Address)
(City/Town)
(Apt, Unit, No. etc.)
(State)
(Zip)
Primary Phone:
B.B.O. #
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