Approved, SCAO JIS CODE: CSR FILE NO. STATE OF MICHIGAN PROBATE COURT COUNTY PETITION FOR APPOINTMENT OF CONSERVATOR PROTECTIVE ORDER CIRCUIT COURT - FAMILY DIVISION A XXX-XX- Estate of Individual alleged to need protection B Last four digits of SSN 1. I, , am interested in this matter Name and make this petition as . State interest/relationship 2. The individual was born , resides in Date County and has property in C County. at Address City, state, zip D 3. An action within the jurisdiction of the family division of circuit court involving the family or family members of the above individual has been previously filed in Court, Case Number assigned to Judge E 4. The individual has , and remains , was is no longer pending. a power of attorney (specify name and address below): a guardian (specify name and address below): a representative payee for social security (specify name and address below): Name and address F G 5. a. The individual is an adult unable to manage his/her property and business affairs effectively because of mental illness chronic use of drugs detention by a foreign power mental deficiency chronic intoxication disappearance physical illness or disability confinement and either the adult has property that will be wasted or dissipated unless proper management is provided. the adult or his/her dependents are in need of money for support, care, and welfare and protection is necessary to obtain or provide money. b. The adult petitioner is mentally competent but because of age or physical infirmity is unable to manage his/her property and affairs effectively, and recognizing the disability, requests the appointment of a conservator. c. The individual is a minor who owns money or property that requires management or protection that cannot otherwise be provided. has or may have business affairs that may be jeopardized or prevented by minority. needs money for support and education and that protection is necessary or desirable to obtain or provide money. d. I am the guardian of the ward and it is in the ward's best interests to sell or otherwise dispose of the ward's real property or interest in real property. 6. The statements in item 5 are supported by the following facts: (Attach a separate sheet if more space is needed.) SEE SECOND PAGE Do not write below this line - For court use only PC 639 (9/08) MCL 700.5104(2), MCL 700.5215(a), MCL 700.5314(b), MCL 700.5401, MCL 700.5404, MCR 5.105(C), MCR 5.125(C)(24) PETITION FOR APPOINTMENT OF CONSERVATOR AND/OR PROTECTIVE ORDER American LegalNet, Inc. www.FormsWorkflow.com H 7. The individual to be protected has an estate of the approximate value as follows: $ $ Real property I J $ Personal property $ Insurance Monthly income 8. The individual to be protected is receiving benefits from governmental agencies as follows: Social Security $ . SSI $ . Veterans Administration $ , claimant number . MDHS $ . Other: $ . 9. The individual to be protected has: a spouse whose name and address are listed below. child(ren) whose name(s) and address(es) are listed below. parent(s) whose name(s) and address(es) are listed below. no living spouse, child(ren), or parent(s). The names and addresses of presumptive heirs are listed below. none of the above (must notify the Attorney General - see instructions for the address of the Attorney General). RELATIONSHIP ADULT/ MINOR NAME K adult minor adult minor adult minor 10. None of the persons named above are under any legal incapacity except: L 11.The individual is currently found at M 12. ADDRESS AND TELEPHONE NO. Name, incapacity, and representative of the person, if any . Address or location It is necessary that a preliminary protective order be entered pending the regular hearing because: I REQUEST that the court: N 13. Appoint , Name, address, and telephone no. who has priority as , as conservator of the estate to be protected. Priority relationship O 14. Preserve and apply the individual's property pending the appointment of a conservator as follows: P Q 15. 16. Enter a protective order that provides . Appoint the guardian as special conservator with authority to sell or otherwise dispose of the ward's real property or interest in real property. I declare under the penalties of perjury that this petition has been examined by me and that its contents are true to the best of my information, knowledge, and belief. R Date Petitioner address Petitioner signature City, state, zip Attorney signature Attorney address Attorney name (type or print) S 17. Bar no. City, state, zip Telephone no. Telephone no. NOMINATION BY PERSON TO BE PROTECTED: I am 14 years of age or older. I nominate as my conservator: Name, address, and telephone no. Date Signature of person to be protected American LegalNet, Inc. www.FormsWorkflow.com INSTRUCTIONS FOR COMPLETING "PETITION FOR APPOINTMENT OF CONSERVATOR" Please type or print neatly in black or blue ink. Items A through S must be read and filled in (when required) before your petition can be filed with the court. Please read the instruction for each item. Then fill in the correct information for that item on the form. A Enter the name of the individual who you believe needs a conservator. B Enter your name in the first line. Enter your relationship to the individual (or your interest) in the second line. C Enter the date the individual was born; what county the individual is a resident of; the address of the place where the individual normally lives, and the county the individual's property is in. D Check this box if there is or has been a case in the family division of the circuit court involving the individual in A . Examples of a family division case are personal protection, abuse or neglect, or a name change. If you have checked this box, enter the name of the court, the case number of the action, the name of the judge assigned to that case. Then place a check in the box indicating whether that case is still pending or not. E Check the boxes that apply and provide the name(s) and address(es). If the individual has a power of attorney and you have a copy of the document, make a copy for the court. F Check the boxes that you believe apply to the individual. G Explain in as much detail as possible the specific facts about the individual's conduct or condition that lead you to believe he or she needs a conservator. Give specific examples of his or her conduct that supports what you checked in F and that demonstrate the need for a conservator. This information is extremely important for the court in making a decision about the need to appoint a conservator. If you are the guardian asking for authority to sell or otherwise dispose of your ward's real property, state the reasons why it is in the ward's best interest to do so. H Specify the approximate value of any real property, personal property, insurance, and monthly income of the individual. An example of real property is a house. Examples of personal property are home furnishings, bank accounts, and checking accounts. I Check whether the individual is currently receiving benefits from governmental agencies and the amount(s). J - K Check all the boxes that apply and enter the names, relationships, addresses and telephone numbers of each relative of the individual. If any of the adults named in J are under legal incapacity, enter the names in K . If you check the last box in J (item 9), you must notify the Attorney General by sending a copy of this form to: Attorney General, Public Administration, PO Box 30736, Lansing, Michigan 48909. L Enter the address where the individual is currently located. This address may or may not be the home of the individual. For example, if the individual is currently in the hospital, enter the name and address of the hospital. M If there is an emergency that requires that a preliminary protective order be entered before the hearing, enter the reason(s). N Enter the name, address, and telephone number of the person you want to be appointed as conservator of the individual. Enter the relationship, if any, that this person has to the individual. If you are the guardian asking for authority to sell or otherwise dispose of your ward's real property, leave this blank and complete Q . O Check this box only if you checked M . P Check this box if you want the individual's property protected but you do not want a conservator appointed. Q Check this box if you want the the guardian appointed special conservator to dispose of real property. R Enter today's date, sign your name, and enter your address and telephone number. S If the individual wants to nominate someone to be the conservator, check the box and enter the name, address, and telephone number of the person the individual is nominating. The individual must sign and date the form. American LegalNet, Inc. www.FormsWorkflow.com