DATE FILEDFORCOURT USE ONLY Name ofPetitionerhereby petitions the Probate Court of the City/Town of to appoint a limitedguardian/guardian for , who currently resides at:Street AddressCity/Town StateZip Codeand whose date of birth is: .Based on an assessment conducted by:Name of AssessorDate of Assessmentit has been determed that the respondent, , lacks decision-making ability in one or more of the following areas as indicated: Check applicable areas: Health Care Financial Matters Residence Association Other PETITION FOR LIMITED GUARDIANSHIP OR GUARDIANSHIPRIGL 33-15-1 et seq. & RIGL 33-15-47PC-2.3 (Rev. 07/17) Probate CourtPage 1 of 3 STATE OF RHODE ISLANDCounty ofEstate ofAlias PROBATE COURT OF THECity or Town ofNo. American LegalNet, Inc. www.FormsWorkFlow.com Durable Power of Attorney for Health Care Power of Attorney Durable Power of Attorney Trusts Joint Property Arrangements Money Management Single Court Transactions Housing Options Other No criminal background that would interfere with guardianship status. Demonstrated willingness to undergo training.The respondent has the following heirs at law:NAMERELATIONSHIPRESIDENCEAttach form PC-9.1 Waiver, if applicable. PC-2.3 (Rev. 07/17) Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Petitioner: To the best of my knowledge or belief, the statement(s) contained within this document are truthful and accurate.Signature of PetitionerDateStreet AddressCity/TownStateZip CodeEmailPhoneNumberNotary:Name of NotaryStateCountySignature of Notary PublicDateCommission ID#Notary SealPC-2.3 (Rev. 07/17) Page 3 of 3 DECREE decreed thatbe appointed guardian of the person and estate of Entered as an order and decree of the court on:Name ofProbate JudgeDateSignature of Probate Judge SIGN HERE SIGN HERE American LegalNet, Inc. www.FormsWorkFlow.com