STATE OF VERMONT SUPERIOR COURT Unit In re Guardianship of : PROBATE DIVISION Docket No.: MOTION FOR PERMISSION TO CHANGE/CONTINUE RESIDENTIAL PLACEMENT As the guardian for Respondent, I request the Court's approval of the following : (Check One) A change in Respondent's residential placement. The continuation of an emergency change in residential placement. This change was made on ________________________________ due to the following emergency circumstance: Date of change Specifically describe the emergency circumstances. The change in residential placement is: (check one) Admission to nursing home From private home to : group home residential care home assisted living residence boarding home Other: (describe)___________________________________________________________ In support of this request, I state: 1. I have been granted the power to choose or change the residence of Respondent pursuant to 14 V.S.A. Section 3069(c)(1) ; AND PAG98 � Motion for Permission to Change/Continue Residential Placement (09/2014) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com 2. The change in residence is/was necessary because: Specifically describe the facts that support your request. Date Signature of Guardian Printed Name of Guardian Guardian's Mailing Address Guardian's Phone Number PAG98 � Motion for Permission to Change/Continue Residential Placement (09/2014) Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com