) IN CIRCUIT COURT ) COUNTY OF _________________ ) __________ JUDICIAL CIRCUIT ****************************************************************************** In the Matter of the _____________________ ) ____GDN________________ ) of ___________________________________, ) INTERESTED PERSON'S PETITION TO ) MODIFY REVOKE TERMINATE a Minor Protected Person. ) ****************************************************************************** I, __________________________ , an Interested Person in the above-captioned matter, being duly sworn upon oath, state and affirm the following: 1. I am filing this Petition and Affidavit on the behalf of the above-named Individual, in that Individual's best interest. 2. I am an Interested Person, as defined in SDCL 29A-5-102, because (describe your relationship to the Individual): _________________________________________________ ___________________________________________________________________________ 3. The Order of Appointment in this matter was entered on ______________ (month), _____ (day), __________ (year). 4. The Order of Appointment required that the above-named Individual receive the following assistance, services, and protection (please detail): ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 5. I request the Court (select one): a. b. TERMINATE this case REVOKE the Guardian/Conservator's authority and replace him/her with: __________________________, ______________, ____________________________________ (Full Legal Name) (DOB, or Tax ID if business) (Mailing Address) STATE OF SOUTH DAKOTA c. MODIFY the Guardianship and/or Conservatorship as follows: _________________ ________________________________________________________________________ ________________________________________________________________________ UJS-151 Interested Person's Petition to Modify / Revoke / Terminate Rev. 05/2016 American LegalNet, Inc. www.FormsWorkFlow.com 6. [If seeking to modify or terminate] This request is based on (1) my observations that the need for the Guardianship and/or Conservatorship has changed; AND/OR (2) the fact that Guardian/Conservator is unable or unwilling to exercise the assigned duties and no other suitable candidate is capable or willing. (Please describe below): [If seeking to revoke] This request is based on the Guardian/Conservator having committed a removable act per SDC 29A-5-504. (Please describe below): ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ I swear or affirm under oath that the information I provided in this Petition and Affidavit is true and correct to the best of my knowledge. I request a hearing on this Petition pursuant to SDCL 29A-5-508. Dated ______________ ___ , ________ (month) (day) (year) _______________________________________ Interested Person's Signature (Sign only in front of Notary or Clerk) ____________________________________ Mailing Address ____________________________________ City, State, and Zip Code ____________________________________ Phone Number ____________________________________ E-mail Address Sworn/affirmed before me this _____ day of __________________, 20____. _____________________________________ (Notary Public / Clerk of Courts) If Notary, my commission expires: __________ (SEAL) UJS-151 Interested Person's Petition to Modify / Revoke / Terminate Rev. 05/2016 American LegalNet, Inc. www.FormsWorkFlow.com