In the matter of First, middle, and last name , a legally incapacitated individual � Last four digits of SSN � � en-USCourt ORI*en-USDate of birthen-USRaceen-USSexen-USAddress of incapacitated individual where now founden-US*Court ORI is to be completed by the court. 1. � I, en-USName (type or print)en-US , am interested in this matter and � � � � � � � � � � � � � � � � 2. � I am not aware of any guardianship or pending petitions in this state for a guardianship of the individual. � 3. � An action within the jurisdiction of the family division of circuit court involving the family or family members of the above � � � � � � en-US en-US Court, Case Number en-US en-US , � was assigned to Judge en-US , and � remains � is no longer � pending. 4. � The alleged incapacitated individual has � � a spouse � � adult child(ren) � � living parent(s) � whose name(s) and address(es) are listed below. � � no spouse, adult child(ren), or parent(s). The names and addresses of presumptive heirs** are listed below. � � none of the above. (must notify the Attorney General***) en-USNAMEen-USRELATIONSHIPen-USADDRESS AND TELEPHONE NUMBERen-USStreet addressen-USCityen-USStateen-USZipen-USTelephone no.en-USStreet addressen-USCityen-USStateen-USZipen-USTelephone no.en-USStreet addressen-USCityen-USStateen-USZipen-USTelephone no. � en-US**Presumptive heirs includes minor children, if any. � ***Notify the Attorney General by sending a copy of this form to: Attorney General, Public Administration, PO Box 30755, Lansing, MI 48909. � en-USNone of these persons are under any legal incapacity except en-USName, incapacity, and representative of the person, if anyen-US . 5. � The individual � � is � � � � � � � � � � � � � � � number is en-US en-US . en-US(SEE SECOND PAGE)en-USUSE NOTE: � � � � � � � � � � � � � � � � � � � � � � � � � � � American LegalNet, Inc. www.FormsWorkFlow.com File No. 6. � The adult is a resident of en-USCity, village, or townshipen-US , en-USCounty State � and has a home address and telephone number of en-USAddress � � en-USCity State Zip Telephone no. . � � � � � The individual is a citizen of the following foreign country: en-US � 7. � The adult has � en-US a patient advocate/power of attorney for health care. en-US(Specify name and address below.) � en-US a power of attorney. en-US(Specify name and address below.) � en-US a conservator. en-US(Specify name and address below.) � en-USName and address 8. � The name, address, and telephone number of the person/agency (if any) who currently has care and custody of the individual � � are en-US en-US . 9. � en-USName of court that appointed guardian State Telephone no. � appointed the guardian for the following reason(s): en-US � en-US 10. � en-USI REQUESTen-US that the court of this state appoint me guardian of the individual in accordance with the laws of this state.en-USI declare under the penalties of perjury that this application has been examined by me and that its contents are true to the best en-USof my information, knowledge, and belief. en-USAttorney signature � en-USDate en-USAttorney name (type or print) Bar no. � en-USApplicant signature en-USAddress � en-USAddress en-USCity, state, zip Telephone no. � en-USCity, state, zip Telephone no. � � � � � � � � � � � � � � � � � � � � � copy of the guardian's letters of appointment in the other state and an acceptance of appointment in this state. en-USIT IS ORDERED: 2. � en-USName of guardian (type or print)en-US is appointed temporary guardian ofen-US � en-USName of individual (type or print)en-US , a legally incapacitated individual, in this state. en-USDate � en-USJudge Bar no. � � � � � � � � � � � � � � � � � � � � � � � � en-UStemporary guardian shall be appointed full guardian of the legally incapacitated individual.en-USNOTE TO APPLICANT: � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � en-USORDER APPOINTING GUARDIAN en-USNOTICE TO INTERESTED PERSONS American LegalNet, Inc. www.FormsWorkFlow.com