Approved, SCAO JIS CODE: AGL STATE OF MICHIGAN PROBATE COURT COUNTY CIRCUIT COURT - FAMILY DIVISION ACCEPTANCE OF APPOINTMENT AND REPORT OF GUARDIAN AD LITEM OF ALLEGED INCAPACITATED INDIVIDUAL FILE NO. In the matter of , alleged incapacitated individual 1. I have been appointed by the court as guardian ad litem, and I accept this appointment. 2. I have performed the duties required by statute (see reverse side for list of duties). 3. I visited the alleged incapacitated individual on at Date Location and, to the extent that the individual could comprehend, explained the nature, purpose, and legal effects of a guardian's appointment and otherwise complied with each provision of MCL 700.5305(1). 4. I report to the court as follows: a. the alleged incapacitated individual wishes to: have limits placed on the guardian's powers. object to the appointment of the nominated guardian. contest the petition. to have an attorney appointed. b. There is a disagreement or dispute related to the guardianship, namely I believe it might will not be resolved through court-ordered mediation. c. There are one or more appropriate alternatives to a full guardianship, namely: 1) appointment of a limited guardian with the following powers: 2) appointment of a conservator or a written protective order. 3) the alleged legally incapacitated individual executing one of the following: a patient advocate designation a do-not-resuscitate declaration a durable power of attorney d. The alleged incapacitated individual wishes to be present at the hearing. e. I believe it is in the best interests of the individual to have legal counsel because The individual will retain legal counsel. 5. I recommend the court appoint legal counsel. One or more items in item 4a above are demanded. (no further report or recommendation is required) OR None of the items in item 4a above are demanded. My report to the court and recommendations are attached. Date Signature Address Name (type or print) City, state, zip Telephone no. SEE SECOND PAGE FOR DUTIES OF GUARDIAN AD LITEM Do not write below this line - For court use only PC 627 (9/06) ACCEPTANCE OF APPOINTMENT AND REPORT OF GUARDIAN AD LITEM OF ALLEGED MCL 700.5305, MCR 5.143, MCR 5.403(C) INCAPACITATED INDIVIDUAL American LegalNet, Inc. www.FormsWorkflow.com DUTIES OF GUARDIAN AD LITEM Your duties as guardian ad litem include all of the following: 1. Visit the individual alleged to be incapacitated. 2. Explain to the individual the nature, purpose, and legal effects of the appointment of a guardian. 3. Explain to the individual the hearing procedure and the individual's rights in the hearing procedure, including but not limited to: a. the right to contest the petition. b. the right to request limits on the guardian's powers. c. the right to object to a particular person being appointed guardian. d. the right to be present at the hearing. e. the right to be represented by legal counsel and that legal counsel will be appointed for the person if s/he is unable to afford legal counsel. 4. Inform the individual of the name of any person known to be seeking appointment as guardian. 5. Make determinations and inform the court of those determinations, on all of the following: a. whether the individual alleged to be incapacitated wishes to be present at the hearing. b. whether the individual alleged to be incapacitated wishes to contest the petition. c. whether the individual alleged to be incapacitated wishes limits be placed on the guardian's powers. d. whether the individual alleged to be incapacitated objects to a particular person being appointed guardian. e. whether there are one or more appropriate alternatives to the appointment of a full guardian after considering: i. appointment of a limited guardian, including the specific powers and limitation on those powers the guardian ad litem believes appropriate. ii. appointment of a conservator or another protective order under 700.5401 et seq. iii. execution of a patient advocate designation, do-not-resuscitate declaration, or durable power of attorney with or without limitations on purpose, authority or duration. iv. available support from family members. Family members may often take on the responsibility for the care of an individual. Also, if the individual should be diagnosed as having a reduced life expectancy due to an advanced illness, state law allows for a member of the individual's immediate family or next of kin to make informed decisions regarding the individual receiving, continuing, discontinuing and refusing medical treatment and may choose palliatave treatment and adequate and appropriate pain and symptom management. f. whether a disagreement or dispute related to the guardianship petition might be resolved through court-ordered mediation. American LegalNet, Inc. www.FormsWorkflow.com