Commonwealth of Massachusetts The Trial Court Probate and Family Court Docket No. REQUEST FOR COUNSEL Division In the Interests of: First Name Middle Name Last Name RESPONDENT NOTICE: Massachusetts General Law c. 190B, § 5-106 provides that an attorney shall be appointed for the Respondent upon request of any person. "If the ward, incapacitated person or person to be protected has adequate resources, his or her counsel shall be compensated from the estate, unless the court shall order that such compensation be paid by the petitioner. Counsel for any indigent ward, incapacitated person or person to be protected shall be compensated by the Commonwealth." I, hereby request the Court appoint First Name Middle Name Last Name an attorney for: Me as I am the person named above as RESPONDENT. (optional) I am 14 or more years of age and I request the Court consider appointing the following attorney to represent me: . The person named above as RESPONDENT. My relationship to the RESPONDENT is . Date Signature of Requesting Party (Address) (City/Town) (Apt, Unit, No. etc.) (State) (Zip) Primary Phone # American LegalNet, Inc. www.FormsWorkFlow.com MUPC 301 (5/30/11)