STATE OF MISSOURI COUNTY OF ST. CHARLES ) ) SS. ) IN THE CIRCUIT COURT OF ST. CHARLES COUNTY, MISSOURI PROBATE DIVISION IN THE MATTER OF ___________________________ RESPONDENT #___________________ PETITION FOR APPOINTMENT OF GUARDIAN AND CONSERVATOR 1. ___________________________, age ____, legal mail address _________________ legal residential address, is unable by reason of _____________________________________________ (specific physical and mental condition) to receive and evaluate information or to communicate decisions to such an extent that respondent lacks capacity to meet essential requirements for food, clothing, shelter, safety or other case such that serious physical injury, illness or disease is likely to occur. Respondent is also unable as a result of the above described condition to receive and evaluate information or to communicate decisions to such an extent that respondent lacks ability to manage his financial resources. That respondent, by reason of the conditions described above, is unable to meet respondent's essential daily needs of living and/or to manage his financial resources without supervision and that there are no less intrusive alternatives available to provide for respondent's care and financial needs. The three most recent previous addresses (mailing and residential) of respondent in the last three years. ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ 3. The nature, extent and estimated value of respondent's real property which are located in the State of Missouri, outside the State of Missouri and the personal property of said respondent. Exhibit A 2. 4. The names and addresses of respondent's parents, spouse, children with ages. If none of the previous then the names and addresses of siblings and children of deceased siblings. If none, then the names and addresses of closest known relatives. The Court needs names and relationship of any adult person living with the respondent. The Court needs name and address of any power of attorney. The Court needs name and address of any presently acting trustees of respondent. Exhibit B 5. The name and address of the person having custody of respondent is: ______________________________________. 6. The name and address of respondent's guardian or conservator, if any, in the State or outside the State of Missouri ____________________________________________________________. 7. The proposed guardian/conservator is not guardian or conservator for any other persons except: _________________________________________________________ _________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com 8. Attached hereto and incorporated herein is the consent of the proposed guardian/conservator to act, if appointed. Exhibit C If the proposed guardian or conservator is a non-resident of Missouri, attached is the proposed guardian's or conservator's designation of resident agent and the resident agent's consent to act. Exhibit D Attached is a list of names and addresses of the witnesses who may be called to testify in support of this petition. Exhibit E The relationship of Petitioner to the Respondent: ______________________________. 9. 10. 11. WHEREFORE, Petitioner prays that a hearing be held and if the Court finds that the respondent is (partially) incapacitated and/or (partially) disabled, the Court appoint: _____________________________________________________________. (Proposed Guardian and/or Conservator) The undersigned swears that the matters set forth in the foregoing petition are true and correct to the best knowledge and belief of the undersigned subject to the penalties of making a false affidavit or declaration. Dated: ___________________ ________________________________ Petitioner's signature ________________________________ Address ________________________________ ________________________________ Phone number Attorney for Petitioner: _______________________________________ Address: _______________________________________ _______________________________________ Phone number:_______________________________________ American LegalNet, Inc. www.FormsWorkFlow.com ______________________________ #___________________ EXIBIT A REAL PROPERTY: (BOTH IN AND OUTSIDE THE STATE OF MISSOURI) PERSONAL PROPERTY; Bank and Savings Accounts Certificates of Deposit Stocks and Bonds Vehicles Furniture, Household goods, and wearing apparel Other: ____________________ $____________________ $____________________ $____________________ $____________________ $____________________ $____________________ INCOME (monthly): Social Security $____________________ Supplemental Security Income $____________________ Veterans Administration Benefits $____________________ Company Pension: ______________ $____________________ Interest $____________________ Other: ____________________ $____________________ IF THE PETITIONER CANNOT SUPPLY ANY OF THE ABOVE, THE COURT WILL NEED A SWORN AFFIDAVIT AS TO WHY THEY CANNOT OBTAIN THIS INFORMATION. American LegalNet, Inc. www.FormsWorkFlow.com ______________________________ #____________________ EXHIBIT B PARENTS: MOTHER: ________________________________ ADDRESS:________________________________ FATHER: ________________________________ ADDRESS:________________________________ SPOUSE: NAME: __________________________________ ADDRESS: _______________________________ CHILDREN: NAME: ___________________________ AGE____ ADDRESS: ________________________________ NAME: ___________________________ AGE ___ ADDRESS: ________________________________ NAME: ___________________________ AGE ___ ADDRESS: ________________________________ If no parents, spouse or adult children, then list siblings and children of deceased siblings and if none closest relatives. RELATIVES: NAME: ____________________ RELATIONSHIP __________ ADDRESS:__________________________________________ NAME: ____________________ RELATIONSHIP __________ ADDRESS: _________________________________________ NAME: ____________________ RELATIONSHIP __________ ADDRESS: _________________________________________ ADULT PERSONS LIVING WITH RESPONDENT OTHER THAN ABOVE: NAME: ______________________ RELATIONSHIP ________ ADDRESS: _________________________________________ AGENT ON A DURABLE POWER OF ATTORENY: NAME: _____________________________________ ADDRESS: __________________________________ IF THE