In the matter of First, middle, and last name , a legally incapacitated individual þ Last four digits of SSN þ þ 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. þ I, en-USName (type or print)en-US , am interested in this matter and þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ 2. þ I am not aware of any guardianship or pending petitions in this state for a guardianship of the individual. þ 3. þ An action within the jurisdiction of the family division of circuit court involving the family or family members of the above þ þ þ þ þ þ en-US en-US Court, Case Number en-US en-US , þ was assigned to Judge en-US , and þ remains þ is no longer þ pending. 4. þ The alleged incapacitated individual has þ þ a spouse þ þ adult child(ren) þ þ living parent(s) þ whose name(s) and address(es) are listed below. þ þ no spouse, adult child(ren), or parent(s). The names and addresses of presumptive heirs** are listed below. þ þ 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. þ en-US**Presumptive heirs includes minor children, if any. þ ***Notify the Attorney General by sending a copy of this form to: Attorney General, Public Administration, PO Box 30755, Lansing, MI 48909. þ en-USNone of these persons are under any legal incapacity except en-USName, incapacity, and representative of the person, if anyen-US . 5. þ The individual þ þ is þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ number is en-US en-US . en-US(SEE SECOND PAGE)en-USUSE NOTE: þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ American LegalNet, Inc. www.FormsWorkFlow.com File No. 6. þ The adult is a resident of en-USCity, village, or townshipen-US , en-USCounty State þ and has a home address and telephone number of en-USAddress þ þ en-USCity State Zip Telephone no. . þ þ þ þ þ The individual is a citizen of the following foreign country: en-US þ 7. þ The adult has þ en-US a patient advocate/power of attorney for health care. en-US(Specify name and address below.) þ en-US a power of attorney. en-US(Specify name and address below.) þ en-US a conservator. en-US(Specify name and address below.) þ en-USName and address 8. þ The name, address, and telephone number of the person/agency (if any) who currently has care and custody of the individual þ þ are en-US en-US . 9. þ en-USName of court that appointed guardian State Telephone no. þ appointed the guardian for the following reason(s): en-US þ en-US 10. þ 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 þ en-USDate en-USAttorney name (type or print) Bar no. þ en-USApplicant signature en-USAddress þ en-USAddress en-USCity, state, zip Telephone no. þ en-USCity, state, zip Telephone no. þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ 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. þ en-USName of guardian (type or print)en-US is appointed temporary guardian ofen-US þ en-USName of individual (type or print)en-US , a legally incapacitated individual, in this state. en-USDate þ en-USJudge Bar no. þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ en-UStemporary guardian shall be appointed full guardian of the legally incapacitated individual.en-USNOTE TO APPLICANT: þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ en-USORDER APPOINTING GUARDIAN en-USNOTICE TO INTERESTED PERSONS American LegalNet, Inc. www.FormsWorkFlow.com