PETITION TO EXPAND Commonwealth of Massachusetts The Trial Court Probate and Family Court Docket No. MODIFY LIMIT THE POWERS OF A CONSERVATOR Division In the Interest of: Middle Name First Name Last Name Protected Person 1. The Petitioner is: The Conservator of the Respondent; The Protected Person (hereafter referred to as the Protected Person or Respondent); A person interested in the welfare of the Respondent. State the nature of interest: 2. Information about the Protected Person: Name: Age: (Address) Primary Language: Respondent (City/Town) (Apt, Unit, No. etc.) English is Last Name Middle Name First Name Other: (State) (Zip) (State) (Zip) Primary Phone #: is not intellectually disabled/mentally retarded. 3. Information about the Petitioner(s): 1) M.I. First Name (Address) Last Name (City/Town) (Apt, Unit, No. etc.) Primary Phone #: 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 Conservator appointing on Name (date) (hereafter "Conservator") and said Decree(s) are still valid and in full force and effect. 5. 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 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. page 1 of 5 MPC 230 (5/30/11) American LegalNet, Inc. www.FormsWorkFlow.com 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) MPC 230 (5/30/11) page 2 of American LegalNet, Inc. www.FormsWorkFlow.com 5 Q. 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 MPC 230 (5/30/11) page 3 of American LegalNet, Inc. www.FormsWorkFlow.com 5 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 Conservator be expanded as follows (a statutory reference must be provided): B. The powers of the Conservator be modified as follows: C. The powers of the Conservator be limited as follows: In addition, I request that the Court: MPC 230 (5/30/11) page 4 of American LegalNet, Inc. www.FormsWorkFlow.com 5 WHEREFORE, PETITIONER REQUESTS THAT THIS HONORABLE COURT: Expand Modify Limit the powers of the Conservator 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. # MPC 230 (5/30/11) page 5 of American LegalNet, Inc. www.FormsWorkFlow.com 5