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Petition To Expand- Modify-Limit The Powers Of A Guardian Form. This is a Massachusetts form and can be use in Probate And Family Court Statewide.
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Tags: Petition To Expand- Modify-Limit The Powers Of A Guardian, MPC 220, Massachusetts Statewide, Probate And Family Court
PETITION TO
EXPAND
Commonwealth of Massachusetts
The Trial Court
Probate and Family Court
Docket No.
MODIFY
LIMIT
THE POWERS OF A GUARDIAN
Division
In the Interest of:
Middle Name
First Name
Last Name
Incapacitated Person (Respondent)
1. The Petitioner is:
The Guardian of the Respondent;
The Incapacitated Person (hereafter referred to as the Incapacitated Person or Respondent);
A person interested in the welfare of the Respondent. State the nature of interest:
2. Information about the Incapacitated Person:
Name:
Age:
(Address)
Primary Language:
Respondent
English
is
Last Name
Middle Name
First Name
(City/Town)
(Apt, Unit, No. etc.)
Other:
(State)
(Zip)
Primary Phone #:
is not intellectually disabled/mentally retarded.
3. Information about the Petitioner(s):
1)
M.I.
First Name
(Address)
Primary Phone #:
Last Name
(Apt, Unit, No. etc.)
(City/Town)
(State)
(Zip)
Relationship to Respondent:
An attachment to this petition provides information on additional co-petitioners.
4. This Court entered a Decree and Order of Appointment of Guardian appointing:
on
Name
(date)
(hereafter "Guardian") and said Decree is still valid and in full force and effect.
5. 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 mentally retarded, a Clinical Team Report dated with and 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.
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6. 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)
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7. 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.6
A document nominating a 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.6
A current Guardian?
Attached
No
Unavailable
Uncertain
Yes and the person's information is listed at Q.6
A current Conservator?
Attached
No
Unavailable
Uncertain
Yes and the person's information is listed at Q.6
A Representative Payee?
Attached
No
Unavailable
Uncertain
Yes and the person's information is listed at Q.6
A Health Care Agent?
Attached
No
Unavailable
Uncertain
Yes and the person's information is listed at Q.6
A Durable Power of Attorney/Agent?
Attached
No
Unavailable
Uncertain
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8. Respondent
is
is not
entitled to benefits from the Department of Veterans Affairs or
9. Does Respondent have any assets, e.g. bank accounts, property?
Yes
No
Uncertain.
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.
10. Does Respondent have any anticipated income?
Yes
No
Uncertain.
If Yes, identify:
Description of Income, e.g. Social Security, Interest
DO NOT INCLUDE NAMES OF INSTITUTIONS OR ACCOUNT NUMBERS
Amount of Anticipated
Monthly income or Receipts
Total
An attachment to this petition provides additional information.
11.
The Petitioner(s) request(s) (choose A, B, or C below):
A. The powers of the Guardian be expanded as follows:
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;
to apply for health insurance benefits including MassHealth on behalf of Respondent;
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.
Other:
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B. The powers of the Guardian be modified as follows:
C. The powers of the Guardian be limited as follows:
WHEREFORE, PETITIONER REQUESTS THAT THIS HONORABLE COURT:
Expand
Modify
Limit
the powers of the Guardian as set forth in Paragraph 11 above.
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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