CIRCUIT COURT OF CLAY COUNTY, MISSOURI PROBATE DIVISION NO. Matter of , an incapacitated person. APPLICATION FOR ORDER AUTHORIZING ADMISSION OF WARD TO MENTAL *HEALTH *RETARDATION FACILITY (Sec. 475.121 RSMo.) As Guardian of the above name incapacitated person, I hereby state to the Court as follows: 1. That on the ______ day of _____________________________, 20_____, _____________________________________________ was adjudged by this Court to be incapacitated and that I was appointed by the Court as Guardian of said Ward. 2. *A – That the above named Ward was admitted to _____________________________________________________________ on the _____ day of ______________________, 20_____ and, has been found by the attached evaluation to have a mental disorder other than mental retardation and is suitable for inpatient admission to a mental health facility under Section 632.120 RSMo. *B – That the above named Ward has been found by the attached evaluation to be in need of admission to a mental retardation facility under Section 633.120 RSMo. WHEREFORE, as Guardian, I request that this Court enter an order authorizing the admission of the above named Ward to_____________________________________________________________________, a mental *health *retardation facility. THE STATEMENTS AND REPRESENTATIONS IN THIS DOCUMENT ARE MADE UNDER OATH AND ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF. I UNDERSTAND THEY ARE MADE SUBJECT TO THE PENALTIES OF MAKING A FALSE AFFIDAVIT OR DECLARATION. Date:_______________________ _________________________________________ Guardian *strike if inapplicable Form 355-A Revised 3/14/2003 Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com