Request to Assign a Court Visitor Approved Board of District Court Judges June 15, 2012 Revised May 8, 2018 Page 1 of 3 This is a p rivate record. Name Address City, State, Zip Phone Email I am the [ ] Petitioner [ ] Respondent [ ] Interested person [ ] Attorney for the [ ] Petitioner [ ] Respondent [ ] Interested person and my Utah Bar number is In the District Court of Utah Judicial District County Court Address In the Matter of Protection for , Respondent /Protected Per son Request to Assign a Court Visitor Case Number Judge (1) I request that the court assign as a court visitor (Choose one.) [ ] (name), a person who is trained in law, nursing, or social work with no personal interest in the proceedings. [ ] a volunteer (2) I request that the visitor inquire about: (Choose one.) [ ] whether to excuse the Respondent from attending the hearing under Section 75-5-303(5)(a). [ ] the Respondent/circumstances and well-being. [ ] -being and proposed guardian's future plans for the Respondent's residence under Section 75-5-303(5)(d). American LegalNet, Inc. www.FormsWorkFlow.com Request to Assign a Court Visitor Approved Board of District Court Judges June 15, 2012 Revised May 8, 2018 Page 2 of 3 (3) I request that the visitor: (Choose all that apply.) [ ] interview the Respondent/Protected Person; [ ] interview the Proposed Guardian/Guardian; [ ] interview the physician who has examined the Respondent/ Protected Person; [ ] visit the /Protected Person residence and/or proposed residence; [ ] conduct other inquiries and observations; (describe) and file a written report with the court. I declare under criminal penalty under the law of Utah that everything stated in this document is true . Signed at (city, and state or country). Sign atu Date Printed Name American LegalNet, Inc. www.FormsWorkFlow.com Request to Assign a Court Visitor Approved Board of District Court Judges June 15, 2012 Revised May 8, 2018 Page 3 of 3 Certificate of Service I certify that I filed with the court and served a copy of this Request to Assign a Court Visitor on the following people. Method of Service Served at this Address Served on this Date [ ] Mail [ ] Hand Delivery [ ] E - filed [ ] Email (Person agreed to service by email.) [ ] Left at business (With person in charge or in receptacle for deliveries.) [ ] Left at home (With person of suitable age and discretion residing there.) [ ] Mail [ ] Hand Delivery [ ] E - filed [ ] Email (Person agreed to service by email.) [ ] Left at business (With person in charge or in receptacle for deliveries.) [ ] Left at home (With person of suitable age and discretion residing there.) [ ] Mail [ ] Hand Delivery [ ] E - filed [ ] Email (Person agreed to service by email.) [ ] Left at business (With person in charge or in receptacle for deliveries.) [ ] Left at home (With person of suitable age and discretion residing there.) Sign atu Date Printed Name American LegalNet, Inc. www.FormsWorkFlow.com