) IN CIRCUIT COURT ) COUNTY OF _________________ ) __________ JUDICIAL CIRCUIT ) ****************************************************************************** In the Matter of the ___________________ of ) ____GDN________________ ) ___________________________________, ) PROTECTED PERSON'S PETITION TO ) MODIFY REVOKE TERMINATE a Protected Person. ) ****************************************************************************** I, __________________________ , the Protected Person in the above-captioned matter, being duly sworn upon oath, state and affirm the following: 1. The Order of Appointment in this matter was entered on ______________ (month), _____ (day), __________ (year). 2. The Order of Appointment required that I receive the following assistance, services, and protection (please detail): ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 3. I have been contacted by my Guardian/Conservator as follows (please describe frequency and types of contact--in person, over the phone, etc.--and your ability to communicate): _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ STATE OF SOUTH DAKOTA 4. 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) UJS-152 Protected Person's Petition to Modify / Revoke / Terminate Rev. 05/2016 American LegalNet, Inc. www.FormsWorkFlow.com c. MODIFY the Guardianship and/or Conservatorship as follows: _________________ ________________________________________________________________________ ________________________________________________________________________ 5. [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) _______________________________________ Protected Person's Signature (sign only in front of Notary or Clerk) ________________________________________ Print Name of Person Assisting Petitioner (if any) ____________________________________ Mailing Address ____________________________________ City, State, and Zip Code ____________________________________ Phone Number ____________________________________ E-mail Address ____________________________________ Signature of Person Assisting Petitioner ______________________________ Phone Number � Person Assisting ____________________________________________ Mailing Address, City, State, & Zip � Person Assisting Signed and sworn to before me on this ______ day of _________________, ________. __________________________________ Notary Public/Deputy Clerk of Courts Commission Expires: UJS-152 Protected Person's Petition to Modify / Revoke / Terminate Rev. 05/2016 American LegalNet, Inc. www.FormsWorkFlow.com (SEAL)