STATE OF SOUTH CAROLINA ) ) ) ) ) ) COUNTY OF: IN THE MATTER OF: IN THE PROBATE COURT PETITION FOR CASE NUMBER: PROTECTIVE ORDER APPOINTMENT OF CONSERVATOR Applicant/Petitioner: Address: Telephone: 1. Nature of interest of undersigned: 2. Information -- Minor/Incapacitated Person Name: Date of Birth: Social Security Number: Address: City/State/Zip Telephone (Home): Age: (Office/other): To my knowledge, the above-named DOES DOES NOT have a will To my knowledge, the above-named DOES DOES NOT have a power of attorney 3. Venue for this proceeding is proper in this county because the above minor/incapacitated person: resides in this county does not reside in this county but has property in this county 4. The name and address of the above person’s guardian, if any, is: ` 5. Information -- Family (list nearest relative first) of allegedly incapacitated person, including dates of birth of minors: Name Date of Birth Address Relationship (use additional sheet if necessary) FORM #540PC (2/2004) 62-5-401, 62-5-404, 62-5-407, 62-5-410, 62-5-411, 62-5-412, 62-5-413, 62-5-414 Page 1 of 3 American LegalNet, Inc. www.USCourtForms.com 6. The following is a general statement of the property, assets and income of the above person, together with an estimate of the value thereof: (A full inventory, Form #550PC, shall be completed and filed with the Court within thirty days of appointment.) Description Value 7. The appointment of a conservator for the above person is necessary because (state reasons justifying appointment): 8. I request the appointment of: Name: Address: Telephone (O): Telephone (H): whose priority for appointment as conservator for the above person is as follows: fiduciary appointed or recognized by the appropriate court of any other jurisdiction in which the protected person resides individual or corporation nominated by the protected person (if fourteen or more years of age and deemed mentally capable of making such a choice) attorney-in-fact appointed by protected person (Pursuant to S.C. Code Ann. Section 62-5-501) spouse of protected person adult child of protected person parent of protected person or person nominated by will of deceased parent other relative of protected person (specify): person nominated by the person who is caring for protected person or paying benefits to him/her nominated by one with priority to serve in his/her stead (specify): other (specify): 9. The following persons are required by statute to be given notice of the time and place of hearing on this Petition: Name FORM #540PC (2/2004) Address Relationship Page 2 of 3 American LegalNet, Inc. www.USCourtForms.com 10. I request that the Court set a time and place of hearing on this Petition; that the Court determine that the above person is a person for whom appointment of a conservator is proper; that the Court appoint as the conservator for the above minor/incapacitated person; and that Letters of Conservatorship be issued to the conservator. Executed this day of , 20 . Signature: VERIFICATION The undersigned, being sworn, states: That the facts set forth in the foregoing statement are true to the best of the undersigned’s knowledge, information and belief. SWORN to before me this day of Signature: Name: Address: , 20 Notary Public for South Carolina My Commission Expires: E-mail: Telephone (O): (H): QUALIFICATION AND STATEMENT OF ACCEPTANCE I accept this appointment and agree to perform the duties and discharge the trust of the office of Conservator of the conservatorship of . Executed this SWORN to before me this day of , 20 Notary Public for South Carolina My Commission Expires: day of , 20 . Signature: Name: Address: E-mail: Telephone (O): (H): Signature: Name: Address: E-mail: Telephone (O): (H): Signature: Name: Address: E-mail: Telephone (O): (H): FORM #540PC (2/2004) Page 3 of 3 American LegalNet, Inc. www.USCourtForms.com