COUNTY OF VENUE CASE INFORMATION STATEMENT FOR COMPLAINT FOR GUARDIANSHIP DOCKET NUMBER (When available) IMO __________________________, AN ALLEGED INCAPACITATED PERSON PLAINTIFFS COUNSEL TELEPHONE NUMBER FIRM NAME OFFICE ADDRESS NAME OF PARTY REPRESENTED BASIS FOR REQUESTED RELIEF Geriatric/Dementia Mental Illness (not age related) Trauma induced Other ________________________________________ Developmentally disabled individual (DDD)/reaching age of majority NATURE OF GUARDIANSHIP IS THERE A REQUEST FOR IMMEDIATE APPOINTMENT OF A TEMPORARY GUARDIAN? Full Yes No Limited If limited, what activities will If yes, state need/reason for temporary guardian: be performed by the guardian? Medical decisions Yes No Manage finances Access to bank accounts to pay urgent bills Yes No Manage medical care Authority to maintain real property Yes No Manage real property Other Yes No Other If other, state specifics: OTHER RELIEF REQUESTED? Yes No Revocation POA Approval of Medicaid/Asset Protection Planning Relocation of ward Approval of tax planning Rescind prior actions Approval of sale of real property Other If yes, are appraisals attached? Describe other relief requested: Yes No NOTE: Two appraisals are required. DO YOU OR YOUR CLIENT HAVE ANY NEEDS UNDER THE AMERICANS WITH DISABILITIES ACT? Yes No If yes, please identify: ________________________ ___ WILL AN INTERPRETER BE NEEDED? Yes No If yes, for what language: _____________________ ___ ATTORNEY SIGNATURE D ATE American LegalNet, Inc. www.USCourtForms.com>>>> 2 SIDE 2 CASE INFORMATION STATEMENT-GUARDIANSHIP INFORMATION REGARDING ALLEGED INCAPACITATED PERSON (AIP) Name: Date of Birth: Current Age: Address: Is AIPs address an institution, hospital or other similar facility? Yes No INFORMATION REGARDING PROPOSED GUARDIAN Name: Relationship to AIP: Address: If proposed guardian is not the spouse of the AIP, E xplain why the spouse is not the plaintiff: Spouse is deceased Date of Birth: Incapacitated Never married Current Age: Other: ASSETS Real Estate Yes No If yes, provide equity value: $_______________ Financial Assets Yes No If yes, provide total of all financial assets to include cash, bank accounts, stocks, etc. $______________ Personal Property Yes No If yes, provide value: $______________ Other Yes No If yes, provide value: $_____________ (describe) IS THERE ANYTHING UNUSUAL ABOUT THIS MATTER WHICH REQUIRES SPECIAL ATTENTION OF THE COURT? Yes No If yes, provide details: IS THERE A POSSIBILITY OF RETURN TO CAPACITY ? Yes No If yes, is it unlikely? possible? probable? When should reconsideration of capacity take place? PHYSICIANS/PSYCHOLOGISTS CERTIFICATIONS ANNEXED? Yes No Name of First Physician: Date of Exam: Name of Second Physician/Psychologist: Date of Exam: American LegalNet, Inc. www.USCourtForms.com