PETITION FOR APPOINTMENT OF GUARDIAN FOR AN INCAPACITATED PERSON In the Interests of: First Name Middle Name Docket No. Commonwealth of Massachusetts The Trial Court Probate and Family Court Division 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: 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 the following address: (Apt, Unit, No. etc.) (City/Town) (State) (Zip) (Address) If this appointment is made, Respondent will reside at (Address) (Apt, Unit, No. etc.) Principal Residence (City/Town) Current Address (State) the following address: (Zip) Respondent is is not alleged intellectually disabled. 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-petitioner(s). 3. The Petitioner is requesting: to be appointed Name: First Name M.I. Last Name that some suitable person be appointed that the person named below be appointed: (Address) (Apt, Unit, No. etc.) (City/Town) (State) (Zip) Primary Phone #: Relationship to Respondent: An attachment to this petition provides information on co-Guardian(s). MPC 120 (1/9/12) American LegalNet, Inc. www.FormsWorkFlow.com page 1 of 6 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 spouse or a spousal nominee; State the reason the proposed guardian(s) should be appointed: Respondent's parent or a parental nominee; OR None of the above. 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. 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: ) ; OR 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 (1/9/12) American LegalNet, Inc. www.FormsWorkFlow.com page 2 of 6 9. List Respondent's: A. Spouse, if any. B. Children, if any. If none, list parents and brothers and sisters or, if none, list heirs apparent or presumptive. C. Current Guardian in the Commonwealth or elsewhere; D. Nominated Guardian in the Commonwealth or elsewhere; E. Current Conservator in the Commonwealth or elsewhere; Name Primary Address Primary Phone Spouse Child Guardian Nominated Guardian Conservator Relative: (relationship) F. Health Care Agent; G. Durable Power of Attorney/Agent; H. Representative Payee; and/or I. 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 MPC 120 (1/9/12) American LegalNet, Inc. www.FormsWorkFlow.com page 3 of 6 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 120 (1/9/12) American LegalNet, Inc. www.FormsWorkFlow.com page 4 of 6 11. Respondent is is not entitled to benefits from the Department of Veterans Affairs or Yes No Uncertain. 12. Does Respondent have any assets, e.g. bank accounts, property? Uncertain. If Yes, identify: Description of Assets, e.g. Bank Accounts, Property, Insurance, Pensions DO NOT INCLUDE NAMES OF INSTITUTIONS OR ACCOUNT NUMBERS Estimated Value of Property Total An attachment to this petition provides additional information. 13. Does Respondent ha