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