THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) Guardianship of PETITION FOR GUARDIAN OF INCAPACITATED PERSON 1. Petitioner name Address Petitioner name Address 2. Attorney for petitioner Firm name Address 3. Proposed ward name Address Date of birth Telephone Relationship to ward Telephone Relationship to ward Telephone Telephone Bar ID # 4. Name of person or institution having care or custody of the proposed ward Telephone Address 5. The petitioner asks that guardianship be granted to: Proposed guardian name Relationship to proposed ward Address Proposed guardian name Relationship to proposed ward Address Date of birth Occupation Telephone Date of birth Occupation Telephone 6. Has the proposed ward nominated a guardian in accordance with RSA 464-A:10? Yes Address 7. Attorney for proposed ward Firm name Address NHJB-2165-P (01/02/2014) Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com No If yes, name of guardian nominated by proposed ward Telephone Telephone Bar ID # Case Name: Guardianship of Case Number: PETITION FOR GUARDIAN OF INCAPACITATED PERSON 8. List the name and address of the ward's: spouse, parents, adult children and adult siblings. For each person listed, write the relationship to the ward in the space provided. Name Address Relationship 9. List the names and addresses of any adults, other than the proposed guardian, who will be living in the same household as the ward. Those persons must provide the court with a completed Criminal Record Release Authorization form and a DHHS Record Release Authorization form. 10. Does proposed ward have a durable power of attorney? (If yes, a guardianship over the estate may not be necessary.) 11. Does proposed ward have a durable power of attorney for health care? (If yes, a guardianship over the person may not be necessary) 12. Does proposed ward have a living will? 13. Petition is made for guardianship over the ward's: 14. Guardianship sought will be: temporary person estate Yes Yes Yes No No No person & estate not temporary/enduring If temporary guardianship is sought, state the reasons why a long term guardianship would not be appropriate. 15. Length of time for which appointment of guardian is requested: indefinite time days 16. Briefly describe real estate owned by the proposed ward. months years Approximate value of real estate $ 17. Briefly describe personal property owned by the proposed ward. Approximate value of personal property $ NHJB-2165-P (01/02/2014) Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Guardianship of Case Number: PETITION FOR GUARDIAN OF INCAPACITATED PERSON 18. Briefly describe sources and amount of income of the proposed ward. 19. The petitioner requests that the court find the ward incapable of exercising the following rights, namely the right to: (check all appropriate boxes) Travel or decide where to live Refuse or consent to medical or other professional care, counseling, treatment or service, including the right to admit or discharge the ward from any hospital or other medical institution providing such at the lawful direction of the guardian of the person Marry or Divorce Make a will or waive the provisions of a will Hold or obtain a motor vehicle operator's license Testify in any judicial or administrative proceedings Have access to, grant release of, withhold, deny, or refuse authorization for the guardian of the person to obtain access to and release the ward's confidential records and papers insofar as the same may be reasonably needed by the guardian of the person to ensure that the ward's mental, emotional and physical health concerns are properly addressed and treated Possess or manage real or personal property or income from any source Make gifts Lend or borrow money Pay or collect debts Manage or run a business Convey or hold property Cancel, reject or oppose any authority or power granted to the guardian of the estate and/or person Continue to act as a member of a partnership Initiate, defend or settle lawsuits Make contracts or grant power of attorney or other authorizations Make decisions concerning educational matters and training Other (please specify) NOTE: THE COURT MAY IMPOSE ADDITIONAL ORDERS AS A RESULT OF THE HEARING. NHJB-2165-P (01/02/2014) Page 3 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Guardianship of Case Number: PETITION FOR GUARDIAN OF INCAPACITATED PERSON 20. As required by RSA 464-A:4, III, a statement must be provided below containing facts showing the necessity for the appointment of the guardian of the person and estate, or the person, or the estate of the proposed ward, including specific factual allegations as to the proposed ward's financial transactions, personal actions or actual occurrences which are claimed to demonstrate his/her inability to manage an estate, or to provide for personal needs for health care, food, clothing, shelter or safety. All evidence of inability must be within 6 months and one incident must have occurred within 20 days of the filing of this petition. (Please use additional sheets, if necessary.) Date Petitioner's Signature (must be in the presence of notarial officer) Date Petitioner's Signature (must be in the presence of notarial officer) State of This instrument was acknowledged before me on , County of by Date Petitioner name(s) My Commission Expires Affix Seal, if any Signature of Notarial Officer / Title NHJB-2165-P (01/02/2014) Page 4 of 4 American LegalNet, Inc. www.FormsWorkFlow.com