GAC105 State ENG Rev 8/16 www.mncourts.gov/forms Page 1 of 6 State of Minnesota District Court Probate Division County of Judicial District: Court File No. Case Type: 14, Conservatorship Guardianship In Re: Guardianship Conservatorship of 1.Date of Interview: Place: Others present during the interview: 2.Person oriented as to time and place. Knowledge of: Time of day: Date: Place: 3.Physical appearance: 4.Were the notice and petition read to the Respondent? 5.Questions put to the person and his/her responses: A)Do you understand the nature, purpose and effect of these proceedings? B)You must be physically present at the hearing on this petition. Do youunderstand? American LegalNet, Inc. www.FormsWorkFlow.com GAC105 State ENG Rev 8/16 www.mncourts.gov/forms Page 2 of 6 C) The law requires that the Court appoint an attorney to represent you, unless you wish to hire your own, or an attorney is provided by others, or you waive, in writing, the right to have an attorney. If you can afford it, you must pay the Court. Do you understand what I have told you? You have a right to hire your own attorney. Do you wish to obtain your own attorney? Do you want to have the Court-appointed attorney? Do you wish to waive your right to be represented by an attorney? Was a waiver signed? If an attorney is to be retained: What is his/her name? If an attorney is to be appointed by the Court: is the Court-appointed attorney who will be available to represent you. Was a copy of the Order Appointing Attorney given to the Respondent? Visitor Comments Any need for an attorney? D) Is English your second language? Yes No Do you want an Interpreter at the hearing? Yes No If Yes, what language? E) Which of your family members is closest to you and in whom do you have trust and confidence? F) Who are your other family members? G) Do you know , the proposed guardians/conservators? American LegalNet, Inc. www.FormsWorkFlow.com GAC105 State ENG Rev 8/16 www.mncourts.gov/forms Page 3 of 6 Would you like to be appointed your guardian/conservator, or neither? If neither, is there someone you would prefer to be your guardian/conservator? Who? If the Petition is for guardianship What powers would you like the guardian to have: 1)The power to have custody of you and be responsible for finding you aplace to live? 2)The power to provide for your care, comfort and needs?3)The power to take care of your personal belongings?4)The power to provide for medical care and treatment?5)The power to be responsible for any contracts you make?6)The power to have supervision over you?7)The power to apply on your behalf for any assistance, services, or benefitsavailable to you. If the Petition is for conservatorship of estate: The power to pay for your support and maintenance?The poer to pay your debts?The power to have and manage your estate? American LegalNet, Inc. www.FormsWorkFlow.com GAC105 State ENG Rev 8/16 www.mncourts.gov/forms Page 4 of 6 4) The power to exchange or sell your interest or purchase other heirs interest in inherited real estate? 5) The power to approve or withhold approval of any contract, except necessities, which you may wish to make? 6) The power to apply on your behalf for any assistance, services, or benefits available to you? 6. Report on residence: A) Is place visited the place of abode? B) Type of abode: C) Address: D) General condition of abode, if a private residence: 7. Conclusions of Visitor: A) follows: B) If guardianship: It seems appropriate to grant all powers to the guardian: Yes No If No, the following powers seem appropriate: American LegalNet, Inc. www.FormsWorkFlow.com GAC105 State ENG Rev 8/16 www.mncourts.gov/forms Page 5 of 6 Have custody of the Ward and establish the place of abode for the Ward within or without the State, M.S. 247 524.5-313 (c)(1); ort and maintenance needs, M.S. 247 524.5-313 (c)(2); personal effects, M.S. 247 524.5-313 (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, M.S. 247 524.5-313 (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), M.S. 247 524.5-313 (c)(5); Exercise supervision authority over the Ward, M.S. 247 524.5-313 (c)(6); Apply on behalf of the Ward for any assistance, services, or benefits available to the Ward through any unit of government (only given if no conservator is appointed) M.S. 247 524.5-313 (c)(7); (other).. C) If conservatorship: It seems appropriate to grant all powers to the conservator: Yes No If No, the following powers seem appropriate: 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 -417 (c)(1); Pay out of the Protected Person's estate all lawful debts of the Protected Person, M.S. 247 524.5-417 (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 M.S. 247 48A.07 and 501B.151 all funds not currently needed for debts, charges, and management of the estate, M.S. 247 524.5-417 (c)(3); Exchange or sell an undivided interest in real property, M.S. 247 524.5-417 (c)(4); Approve or withhold approval of any contract, except for necessities, which the Protected Person may make or wish to make, M.S. 247 524.5-417 (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, M.S. 247 524.5-417 (c)(6); and (other). 8. Additional comments: A. Living arrangement preference of the Respondent: B. Other: American LegalNet, Inc. www.FormsWorkFlow.com GAC105 State ENG Rev 8/16 www.mncourts.gov/forms Page 6 of 6 Does the Respondent take medication(s) that could interfere with judgment? Yes No 9. I informed the Respondent that I would be preparing this report and that a copy of it would be available to him/her and his/her attorney, not later than 5 days prior to the hearing. 10. I, the Visitor, have no personal interest in these proceedings. Signature of Court Visitor Dated: American LegalNet, Inc. www.FormsWorkFlow.com