State of Minnesota County of ______________________ District Court Probate Division Judicial District: __________________ Court File No. _____________________ Case Type: 14, Conservatorship In Re: Guardianship Conservatorship of ________________________________ Petition for Appointment of: Guardian Conservator TO THE HONORABLE JUDGE OF THE DISTRICT COURT: 1. Petitioner's: Name: Address: 2. Telephone number: Interest in this matter: Respondent's: Name: Address: Telephone number: Age/Date of birth: and if the petition is granted, Respondent will be moved to: The names and addresses of the Respondent's spouse and kindred are: Relationship Name Address a) Spouse (include an adult with whom Respondent has resided for six months or more): 3. b) Kindred: (adult children, parents and adult brothers and sisters; if none of these, then list the nearest adult kin; See Minn. Stat. § 524.5-102 subd. 7) American LegalNet, Inc. www.FormsWorkFlow.com GAC 5-U State ENG Rev 8/16 www.mncourts.gov/forms Page 1 of 9 c) Administrator (if Respondent is in a hospital, nursing home, VA unit, home care agency or other institution): d) Legal Representative (guardian/conservator, representative payee, trustee or custodian of property): e) Persons nominated, proposed, or confirmed by prior order, as guardian or conservator (file applicable document with petition including a prior order, health care directive or related document): (Complete paragraphs 4 and 5 only if you want a Guardian of the person appointed.) 4. A Guardian of Respondent should be appointed because: A. The Respondent is an incapacitated person in that Respondent lacks sufficient understanding or capacity to make or communicate responsible decisions concerning Respondent's person (Describe present general mental condition supporting this allegation): American LegalNet, Inc. www.FormsWorkFlow.com GAC 5-U State ENG Rev 8/16 www.mncourts.gov/forms Page 2 of 9 B. and has demonstrated behavioral deficits evidencing an inability to meet Respondent's needs for medical care, nutrition, clothing, shelter, and/or safety (Describe behavior supporting this allegation): C. 5. and no alternative less restrictive of civil rights and liberties exist, including the use of appropriate technological assistance. The following powers are needed for a Guardian to protect and supervise the person of the Respondent: All of the rights and powers on behalf of the Ward under Minn. Stat. § 524.5313(c) paragraphs 1, 2, 3, 4, 5, 6 and 7. A limited guardianship is not appropriate because (If the Guardian is granted limited powers and duties, specify which powers and duties are vested in the Guardian by this Order.) Have custody of the Ward and establish the place of abode for the Ward within or without the State, Minn. Stat. § 524.5-313(c)(1); Provide for the Ward's care, comfort and maintenance needs, Minn. Stat. § 524.5313(c)(2); Take reasonable care of the Ward's clothing, furniture, vehicles and other personal effects, Minn. Stat. § 524.5-313(c)(3); Give any necessary consent to enable, or to withhold consent for, the Ward to receive necessary medical or other professional care, counsel, treatment or service, Minn. Stat. § 524.5-313(c)(4); Approve or withhold approval of any contract, except for necessities, which the Ward may make or wish to make (only given if no conservator is appointed), Minn. Stat. § 524.5-313(c)(5); Exercise supervision authority over the Ward, Minn. Stat. § 524.5-313(c)(6); Apply on behalf of the Ward for any assistance, services, or benefits available to the Ward through any unit of government, Minn. Stat. § 524.5-313(c)(7); (other) ; and all other powers, duties and responsibilities conferred on the Guardian under applicable law. (Complete paragraphs 6 and 7 only if you want a Conservator of the estate appointed.) 6. A Conservator of Respondent is needed because: A. Respondent is unable to manage property and business affairs because of an impairment in the ability to receive and evaluate information or make decisions, American LegalNet, Inc. www.FormsWorkFlow.com GAC 5-U State ENG Rev 8/16 www.mncourts.gov/forms Page 3 of 9 even with the use of appropriate technological assistance. (Describe present general mental condition supporting this allegation): B. and has demonstrated behavioral deficits evidencing an inability to manage Respondent's estate (Describe behavior supporting this allegation): C. 7. no alternative less restrictive of civil rights and liberties exists, including the use of appropriate technological assistance; and D. Respondent has property that will be dissipated without proper management; or E. funds are needed for the support, care, education, health and welfare of (1) the Respondent; and/or (2) those entitled to the support of the Respondent. The following powers are needed for a Conservator to protect and supervise the estate of the Respondent: All of the rights and powers under Minn. Stat. § 524.5-417 subd. (c) paragraphs 1, 2, 3, 4, 5 and 6. A limited conservatorship is not appropriate because (If the Conservator is granted limited powers and duties, specify which powers and duties are vested in the Conservator by this Order.) Pay reasonable charges for the support, maintenance, and education of the Protected Person in a manner suitable to the Protected Person's station in life and the value of the Protected Person's estate, Minn. Stat. § 524.5-417(c)(1); Pay out of the Protected Person's estate all lawful debts of the Protected Person, Minn. Stat. § 524.5-417(c)(2); Possess and manage the estate of the Protected Person, collect all debts and claims in favor of the Protected Person, or with the approval of the court compromise them, institute suit on behalf of the Protected Person and represent the Protected Person in court proceedings, and invest pursuant to Minn. Stat. § 48A.07(6) and § 501B.151 all funds not currently needed for debts, charges, and management of the estate, Minn. Stat. § 524.5-417(c)(3); Exchange or sell an undivided interest in real property, Minn. Stat. § 524.5417(c)(4); Approve or withhold approval of any contract, except for necessities, which the Protected Person may make or wish to make, Minn. Stat. § 524.5-417(c)(5); Apply on behalf of the Protected Person for any assistance, services, or benefits available to the Protected Person through any unit of government, Minn. Stat. § 524.5-417(c)(6); and (other) ; American LegalNet, Inc. www.FormsWorkFlow.com GAC 5-U State ENG Rev 8/16 www.mnc