SURROGATE222S COURT OF THE STATE OF NEW YORKCOUNTY OF --------------------------------------------------------------------XProceeding for the Appointment of a Guardian forPursuant to SCPA Article 17-A--------------------------------------------------------------------XFiling Fee Paid $ Certs $ Certs $$ Bond, Fee $Receipt No:No: GMD-1 (/201) -1- 2(b). [ ] The Respondent is not admitted to a group home or facility as defined in Section 1.03 and/or Article 15 of the MentalHygiene Law.[ ] The Respondent has been admitted to a group home or facility as defined in Section 1.03 and/or Article 15 of theMental Hygiene Law., Name of group home or facility, Address of group home or facility, Name of Director of group home or facility , Address of Director of group home or facility, Name of the Director of the Mental Hygiene Legal Service, Address of the Director of the Mental Hygiene Legal Service3.The names and permanent addresses of the parents of the Respondent and, if the Respondent is married, theRespondent222s spouse are: [If deceased give date of death and complete Number 6]Name of Parent: Date of Birth: Date of Death: Permanent Address:(Street and Number)(City, Village, Town)(State)(Zip Code)Mailing Address: (If different from permanent address)Name of Parent: Date of Birth: Date of Death:Permanent Address:(Street and Number)(City, Village, Town)(State)(Zip Code)Mailing Address:(If different from permanent address)Name of Spouse: Date of Birth: Date of Death:Permanent Address: (Street and Number)(City, Village, Town)(State)(Zip Code)Mailing Address: (If different from permanent address)4.The names of the adult children and adult siblings, eighteen (18) years of age or older, of the Respondent are as follows:[Add rider if necessary.]Name: Relationship to Respondent: Permanent Address: (Street and Number)(City, Village, Town)(State)(Zip Code)Mailing Address: (If different from permanent address)-2- American LegalNet, Inc. www.FormsWorkFlow.com Name: Relationship to Respondent: Permanent Address: (Street and Number)(City, Village, Town)(State)(Zip Code)Mailing Address: (If different from permanent address)Name: Relationship to Respondent: Permanent Address: (Street and Number)(City, Village, Town)(State)(Zip Code)Mailing Address: (If different from permanent address)Name: Relationship to Respondent: Permanent Address: (Street and Number)(City, Village, Town)(State)(Zip Code)Mailing Address: (If different from permanent address)5.The name and address of the primary care physician if other than a physician having submitted a certification with thepetition:Name of primary care physician: Post Office Address: (Street and Number)(City, Village, Town)(State)(Zip Code)6.If the Respondent222s parents are both deceased, list the names and addresses of the nearest distributees of full age wholive within the State of New York. [If not applicable, so state.]NamePermanent AddressRelationship7.The name and address of the person(s) with whom the Respondent resides and/or the person(s) charged with his/hercare and custody, if other than the parents or spouse:NamePermanent AddressRelationship-3- American LegalNet, Inc. www.FormsWorkFlow.com 8.If Respondent222s parents, spouse, adult children or adult siblings are living but not proposed to be appointed guardian,standby guardian or alternate standby guardian, explain why below.9.The persons proposed to be appointed guardian(s), standby guardian or alternate standby guardian are of soundmind, adult and competent.10.[Please check (a) and (b) for guardian of the Respondent222s person and property; check (a) for guardianship ofthe Respondent222s person only; or (b) for the guardianship of the Respondent222s property only.](a)[ ]Petitioner(s) (is/are) requesting appointment of a guardian(s) of the Respondent222s person and allege(s) thePetitioner(s) (is/are) motivated solely by the best interest of the Respondent for the reasons set forthbelow:(b)[ ]Petitioner(s) (is/are) requesting appointment of a guardian(s) of the Respondent222s property and allege(s) thatthe estimated value of all REAL and PERSONAL property to which the Respondent is entitled is:$[Answer question 11 only if requesting guardianship of the property.]11.(a) PERSONAL PROPERTY [State exact title of all bank accounts with account number and balance; anyinsurance policies by company, policy number, amount insured, name of insured and relationship toRespondent; the name, number of shares and value of all stocks, bonds, and any other personal propertyincluding all causes of action the Respondent may have.](b)REAL PROPERTY [State whether real property is mortgaged or under a lien and the amount thereof. Indicatewhether property is to be occupied as a residence by the Respondent. If not, indicate rental income or whethera sale of the property is contemplated.]Location of PropertyGross Value $Respondent222s InterestAnnual Income $[ ] Mortgaged or [ ] Under a Lien $Rental Income $Residence to be occupied by Respondent [ ] yes [ ] noSale of property contemplated [ ] yes [ ] no-4- American LegalNet, Inc. www.FormsWorkFlow.com (c)ANNUAL INCOME OF RESPONDENT FROM ALL SOURCES:(1)Wages to be received from: $ (2)Pension to be received from: $ (3)Income from trust: $ (4)Governmental entitlements from: $ (5)Other Income: $ (d)STATE SOURCE OF ALL PROPERTY listed above. [If any property is derived from an estate or as a result ofthe death of any person, name the decedent; his or her date of death and relationship to the Respondent; whethera fiduciary has been appointed; court name; file number; and type of letters. Provide a copy of any will or decreedirecting payment. List names and addresses of all banks, insurance companies and persons from whom paymentis expected.]12.Respondent has been duly certified as a person incapable of managing himself/herself and/or his/ her affairs by reasonof [ ] intellectual disability [ ] developmental disability, and such condition is permanent in nature or likely to continueindefinitely, as shown by the certification of:Physician dated: andPhysician/Licensed Psychologist dated: Said certifications shall be attached hereto and made part of the petition. [Where certifications of two licensed physiciansare used, at least one certification must evidence special qualifications to make the certification as set forth in SCPASection 1750 or Section 1750-a. At least one certification must evidence that the physician is familiar with or hasprofessional knowledge in the care and treatment of persons with an intellectual disability or developmental disability,as appropriate.]13.[If application for a limited guardian of the property] Respondent is over the age of 18 years and is employed by, located at (Street/Number)(City, Village/Town)(State)(Zip Code)and is wholly or substantially self supporting by means of his/her wages or earnings from employment.14.The names, permanent addresses, dates of birth and relationship of the guardian(s) is/are:(a)Name of Guardian, if other than Petitioner: Permanent Address: (Street and Number)(City, Village, Town)(State)(Zip Code)Date of Birth: Interest/Relationship to Respondent: Education: Qualifications: to be appointed Guardian of the[ ] person[ ] property [ ] person and property[ ] limited guardian of the property-5- American LegalNet, Inc. www.FormsWorkFlow.com Name of Guardian, if other than Petitioner: Permanent Address: (Street and Number)(City, Village, Town)(State)(Zip Code)Date of Birth: Interest/Relationship to Respondent: Education: Qualifications: to be appointed Guardian of the[ ] person[ ] property [ ] person and property[ ] limited guardian of the property(b)Name of the Standby Guardian: Permanent Address: (Street and Number)(City, Village, Town)(State)(Zip Code)Date of Birth: Interest/Relationship to Respondent: Education: Qualifications: to be appointed Standby Guardian of the [ ] person [ ] property [ ] person and property [ ] limited guardian of the property(c)Name of the First Alternate Standby Guardian:Permanent Address:(Street and Number)(City, Village, Town)(State)(Zip Code)Date of Birth: Interest/Relationship to Respondent: Education: Qualifications: to be appointed First Alternate St