2.An action within the jurisdiction of the family division of circuit court involving the family or family members of the individualhas been previously filed inCourt, Case Number, wasassigned to Judge, andremainsis no longerpending.1.I,, am interested in this matter and make this petition as.3.The individual named above, born, is a resident of ,Michigan, and presently lives with/atat .The individual is a citizen of the following foreign country:4.His/her presumptive heirs are as follows: (Attach additional page if needed.)5.A report and evaluation required by lawaccompaniesdoes not accompanythe petition.6.The individual has a developmental disability described as a severe, chronic condition that meets all the following: 1) it isattributable to a mental or physical impairment or a combination of mental and physical impairments; 2) it was manifestedbefore the individual was 22 years old; 3) it is likely to continue indefinitely; and 4) it results in substantial functionallimitations in major life activities of (A minimum of three of the following options must apply and be checked.)self-care,receptive and expressive language,learning,mobility,self-direction,capacity for independent living,economic self-sufficiency,and it reflects the individual's need for a combination and sequence of special, interdisciplinary, or generic care, treatment,or other services that are lifelong or for an extended duration and are individually planned and coordinated.7.The specific nature and extent of the disability is:(PLEASE SEE OTHER SIDE)In the matter of, an individual with an alleged developmental disabilityPC 658 (9/12) PETITION FOR APPOINTMENT OF GUARDIAN, INDIVIDUAL WITH ALLEGED DEVELOPMENTAL DISABILITY JIS CODE: PEGApproved, SCAOFILE NO. Name (type or print)PETITION FOR APPOINTMENT OFGUARDIAN, INDIVIDUAL WITH ALLEGEDDEVELOPMENTAL DISABILITYMCL 330.1100a, MCL 330.1609 State your interest/relationship Do not write below this line - For court use only NAME AGE RELATIONSHIP ADDRESS AND TELEPHONE NUMBER CountyName of person or center or facilityAddress City State Zip Telephone no.Last four digits of SSN Date A B C D E F G H XXX-XX-STATE OF MICHIGANPROBATE COURTCOUNTY OF USE NOTE: If this form is being filed in the circuit court family division, please enter the court name and county in the upper left-hand corner of the form. Street addressCity StateZip Telephone no. Street addressCity StateZip Telephone no. American LegalNet, Inc. www.FormsWorkFlow.com 9.The estimated value of the individual's estate and income are:Real estate:$Personal property:$Yearly income:$Source of yearly income:I REQUEST THAT:10.If a report does not accompany this petition, the court order evaluations to be performed and a report to be prepared.11.The court determine that the individual requires guardianship as an individual with a developmental disability.12.The court determine and appoint ofor appoint some other suitable individual or entity asa.plenary (full) guardian of theindividualestateb.partial guardian of theindividualestatewith the following powers:The proposed guardian is a current service provider. No other individual or agency is suitable to serve as guardian.13.The court authorize the guardian to execute an application for admission tolocated at .14.Pending the appointment of a guardian, the court appoint a temporary guardian or exercise its emergency powersbecause .15.The court appointof as standby guardian.I declare under the penalties of perjury that this petition has been examined by me and that its contents are true to the best ofmy information, knowledge, and belief.AddressCityStateZipTelephone no. Name AddressNameAddressName of facilityDescribe emergency situation Address Signature of petitioner City, state, zipAddress Name (type or print) City, state, zipTelephone no.Telephone no.Bar no.DateSignature of attorney8.A guardian is needed to assist the individual with the following responsibilities and duties: I J K L M N Telephone no.CityStateZip American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS FOR COMPLETING"PETITION FOR APPOINTMENT OF GUARDIAN,INDIVIDUAL WITH ALLEGED DEVELOPMENTAL DISABILITY"Please type or print neatly using black or blue ink.Items A through N must be read and filled in (when required) before your petition can be filed with the court. Please read theinstruction for each item. Then fill in the correct information for that item on the form.AEnter the name of the individual whom you believe needs a guardian.BEnter your name on the first line and your relationship to the individual (or your interest) on the second line.CCheck this box if there is or has been a case in the family division of the circuit court involving the individual in 223A." Examplesof a family division case are a personal protection, abuse or neglect, adoption, name change, or divorce or support action.If the individual is under the age of 19275, the individual may be the subject of a support order if the parents are divorced ora support order was entered. If you have checked this box, enter the name of the court, the case number of the action, thename of the judge assigned to the case. Place a check in the box indicating whether the case is still pending or not.DEnter the date of birth of the individual on the first line, the name of the county the person resides in on the second line, andthe name, address, and telephone number of the person, center or facility where the person is currently located. This addressand telephone number may or may not be the home of the individual.EList the presumptive heirs of the individual. If the individual has a spouse or minor or adult children, list those individuals' names,addresses, ages, relationships and current addresses. If the individual does not have a spouse or children, list the parentsof the individual and if there are no living parents, then the siblings of the individual, with their ages, relationship and currentaddresses. If the individual doesn222t have any siblings, list any other presumptive heirs. If the individual has no presumptiveheirs, you must notify the Attorney General by sending a copy of this form to: Attorney General, Public Administration, POBox 30755, Lansing, MI 48909.FIndicate whether a report and evaluation required by law accompanies or does not accompany the petition.GCheck the appropriate boxes under this item (not less than three).HIndicate the specific nature and extent of the disability. IExplain in detail, giving specific examples why a guardian is needed to assist the individual. For example, the individual isunable to make decisions in all aspects of life, such as residential and medical decisions.JGive an estimated value of the individual222s estate and income. If the individual receives social security benefits or some othertype of monthly benefit, calculate the yearly amount and indicate the source of the income.KEnter on the first line the name of the person you are requesting be appointed guardian of the individual and the address ofthat person on the second line.Check the appropriate box indicating whether you are requesting a plenary (full) guardian or a partial guardian of theindividual and/or the estate and list the powers you desire the guardian to have. A full guardian has custody of the individualand will make all decisions regarding the individual222s person. A partial guardian does not have custody of the individual,which will allow the individual to make certain decisions on his/her own. Please note that unless the individual owns or hasinterest in real estate or substantial other personal property or has income from a source other than social security (unlessthe individual is the beneficiary of a trust), it is generally not necessary to appoint a guardian of the estate.Check the next box if the proposed guardian is a current service provider. A current service provider includes the ownerof an adult foster care home where the individual resides and who is not related to the individual.LCheck this box if it is necessary for the guardian to execute an application for admission to place the individual in a facility.Enter the name of the facility on the first line and the address of