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STATE OF VERMONT SUPERIOR COURT Unit In re Guardianship of : PROBATE DIVISION Docket No.: MOTION FOR EMERGENCY TEMPORARY GUARDIAN I ask the Court to appoint an emergency temporary guardian for ____________________________________ Name of Respondent The nature of the emergency guardianship is: (check one) Financial Medical Other: In support of this request, I state: 1. The respondent's mental state is: 2. Because of Respondent's present mental state, Respondent is unable at this time to make the following decisions: (check all boxes that apply) Medical Financial Other decisions related to Respondent's well-being: (explain below) 3. The following serious and irreparable harm to respondent's physical health or financial interests will result if an emergency temporary guardian is not appointed. PAG94 Motion for Emergency Temporary Guardian (09/2014) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com I request: (check one) A temporary emergency order with notice and hearing I have filed a guardianship petition and request a hearing on the petition at the earliest date after appointment of an attorney for the respondent and after notice of the petition has been given to the respondent. I attach a sworn statement that I am unable to serve notice of the petition as required by the Rules of Probate Procedure due to the emergency need for guardianship. A temporary emergency order without notice and hearing I have filed a guardianship petition and request appointment of an emergency temporary guardian without notice to the respondent and the opportunity for hearing. I attach a sworn statement with specific facts showing that immediate, serious, and irreparable harm will result to the respondent before a hearing on the appointment of an emergency temporary guardian can be held. Date Signature of Petitioner Petitioner's Mailing Address Petitioner's Phone Number Attachments: Petition for Adult Guardianship (Form no. PAG72 ) if not previously filed List of Interested Persons (Form no. PG 73) if not previously filed Statement of Respondent's assets and income (Form no. PG 72) if not previously filed PAG94 Motion for Emergency Temporary Guardian (09/2014) Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com