STATE OF VERMONT SUPERIOR COURT Unit In re Guardianship of : PROBATE DIVISION Docket No.: LIST OF INTERESTED PERSONS Under 14 V.S.A. 3061(5), an interested person in an adult guardianship proceeding is a responsible adult who has a direct interest in a person in need of guardianship and includes: the person in need of guardianship (the respondent); the spouse of the respondent; the parents of the respondent; the adult children of the respondent; a proposed guardian; an agent for the respondent named in a power of attorney and/or advance directive; a person nominated as guardian in an advance directive. For each person listed, specify the person's relationship to or interest in the Respondent. Name Address E-Mail Address (if known) Telephone Number Name Respondent Proposed Guardian Address E-Mail Address (if known) Telephone Number OTHER INTERESTED PERSONS Name Address Relationship to/ Interest in Respondent E-Mail Address (if known) Telephone Number Name Address Relationship to/ Interest in Respondent E-Mail Address (if known) Telephone Number I declare that the list of persons above (with additional sheets, if any, attached) is complete and accurate to the best of my knowledge, information, and belief, after diligent inquiry. Date Petitioner's Signature Subscribed and sworn before me, this _________day of_______________________ Notary Public List of Interested Persons Sheet 1_ of ____. PG73 � List of Interested Persons (09/2014) American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 2 ADDITIONAL SHEET � if required (List of Interested Persons) Name Address Relationship to/ Interest in Respondent E-Mail Address (if known) Telephone Number Name Address Relationship to/ Interest in Respondent E-Mail Address (if known) Telephone Number Name Address Relationship to/ Interest in Respondent E-Mail Address (if known) Telephone Number Name Address Relationship to/ Interest in Respondent E-Mail Address (if known) Telephone Number Name Address Relationship to/ Interest in Respondent E-Mail Address (if known) Telephone Number Name Address Relationship to/ Interest in Respondent E-Mail Address (if known) Telephone Number Name Address Relationship to/ Interest in Respondent E-Mail Address (if known) Telephone Number Name Address Relationship to/ Interest in Respondent E-Mail Address (if known) Telephone Number List of Interested Persons Sheet of ____. PG73 � List of Interested Persons (09/2014) American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2