CIRCUIT COURT OF CLAY COUNTY, MISSOURI PROBATE DIVISION Matter of __________________________________________ No. *Incapacitated *and *Disabled A person alleged to be _____________________________ *GUARDIAN *AND *CONSERVATOR APPLICATION FOR APPOINTMENT OF _____________________________ (Section 475.060 RSMo.) The applicant states to the Court that: 1. __________________________________________, birth date _______________________, whose domicile is _______________________________________________________________________ is *Incapacitated *and *Disabled _____________________________, and is the owner of property with the estimated value of: Real Property $_________________ and Personal Property $_________________. The location and value of any Real Property outside the state of Missouri is: ________________________________________________, County of: _________________, valued at $_________________. 2. The three most recent previous addresses, of the proposed ward, (mailing and residence) for the past three years were: *Guardian *and *Conservator 3. The appointment of a ___________________________ is sought because (must state specific physical or mental conditions which exist): 4. The names and addresses of the parents of the proposed ward are: FATHER: MOTHER: 5. The name and address of the spouse of the proposed ward is: Form 331-A, Revised 8/28/2011 Page 1 of 3 *Strike if inapplicable American LegalNet, Inc. www.FormsWorkFlow.com 6. The names, ages and addresses of all living children are: 7. The proposed ward is in the custody of: Relationship: _____________________________ 8. The name and address of any agent appointed by the proposed ward in any durable power of attorney: 9. The name and address of the trustee(s) for the proposed ward: 10. Does the proposed ward have a permit to carry a firearm? 11. The proposed ward has no Guardian or Conservator except as follows: Name and address: Where appointed: *Guardian *and *Conservator 12. The proposed ___________________________ is not now Guardian or Conservator for anyone else except: 13. (A) Guardianship is sought for the above alleged incapacitated person for the reason that *he *she _________ is unable to receive and evaluate information or communicate decisions to such an extent that *he *she _________ lacks capacity to meet essential requirements for food, clothing, shelter, safety or other care such *his *her that serious physical injury, illness or disease is likely to occur because of __________ physical or mental condition as specified in Paragraph 2 above. *he *she (B) Conservatorship is sought for the above alleged disabled person for the reason that _________ is *he *she unable to receive and evaluate information or to communicate decisions to such an extent _________ lacks *his *her *his *her ability to manage __________ financial resources because of __________ physical or mental condition as specified in Paragraph 2 above. Form 331-A, Revised 8/28/2011 Page 2 of 3 *Strike if inapplicable American LegalNet, Inc. www.FormsWorkFlow.com WHEREFORE, the applicant requests that Letters of *Guardianship of the Person *and *Conservatorship of the Estate ________________________________________________________ of __________________________________________ be issued to: _____________________________________________________________________, and that the matter be supervised by the Court. THE STATEMENTS AND REPRESENTATIONS IN THIS DOCUMENT ARE MADE UNDER OATH AND ARE TRUE AND CORRECT TO BY BEST KNOWLEDGE AND BELIEF. I UNDERSTAND THEY ARE MADE SUBJECT TO THE PENALTIES OF MAKING A FALSE AFFIDAVIT OR DECLARATION. Applicant’s Signature Address Dated: ____________________ Phone STATE YOUR RELATIONSHIP TO THE ALLEGED INCAPACITATED AND/OR DISABLED Attorney Bar No. Address Phone: Other adult relatives to be notified: Name Address Relationship You must attach a list of the names and addresses of all persons who may be called as witnesses, per Section 475.075 RSMo. Form 331-A, Revised 8/28/2011 Page 3 of 3 *Strike if inapplicable American LegalNet, Inc. www.FormsWorkFlow.com