STATE OF VERMONT SUPERIOR COURT Unit In re Guardianship of : PROBATE DIVISION Docket No.: PETITION TO APPOINT GUARDIAN FOR AN ADULT (Involuntary) I ask the court to appoint a guardian or a limited guardian for Name of Respondent In support of this request, I state: 1. Information about the person in need of a guardian: Name of Respondent Street Address Mailing Address if different Current Location of Respondent if Different from Above DOB Town Phone Number Age1 State Zip 2. Reason for Guardianship A guardianship is necessary because Respondent is unable to manage, without the supervision of a guardian, some or all aspects of his or her personal or financial affairs as a result of: Significantly sub-average intellectual functioning which exists concurrently with deficits in adaptive behavior; and/or A physical or mental condition that results in significantly impaired cognitive functioning which grossly impairs judgment, behavior, or the capacity to recognize reality. Under Vermont law, guardianship shall be utilized only as necessary to promote the well-being of the individual and to protect the individual from violations of his or her human and civil rights. It shall be designed to encourage the development and maintenance of maximum self-reliance and independence in the individual and only the least restrictive form of guardianship shall be ordered to the extent required by the individual's actual mental and adaptive limitations. The State of Vermont recognizes the fundamental right of an adult with capacity to determine the extent of health care the individual will receive. 14 V.S.A. �3060 1 Respondent must be at least 18 years old or within four months of his/her 18 th birthday. American LegalNet, Inc. www.FormsWorkFlow.com PAG72 � Petition to Appoint Guardian for an Adult (Involuntary) (10/2014) Page 1 of 5 3. Existing or Pending Guardianships There is no guardian, limited guardian or pending guardianship proceeding for the Respondent in this state or any other state. There is an existing guardian or limited guardian for the Respondent. Name of Guardian Please provide the following information Mailing Address County and State where case was filed Type of Guardianship Copy of Appointment is attached Docket Number There is a pending guardianship proceeding. Please provide the following information County and State where action is filed 4. Advance Directives and Powers of Attorney To my knowledge, Respondent does not have an advance directive. Respondent has an advance directive Name of Agent Please provide the following information Mailing Address Copy of Directive is attached To my knowledge Respondent does not have a power of attorney Respondent has a power of attorney Name of Agent Please provide the following information Mailing Address Copy of Power of Attorney is attached 5. Relationship of Petitioner to Respondent My relationship to the Respondent is: Relative __________________ Social Worker Physician Friend/Neighbor Public Official Other ________________________________ 6. Reason to Appoint a Guardian The specific reasons that I am seeking a guardianship for the Respondent are as follows: Describe your reasons. Please be specific about the facts that support your request. PAG72 � Petition to Appoint Guardian for an Adult (Involuntary) (10/2014) American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 5 7. Nomination of Guardian I ask that the Court appoint me as guardian I ask that the Court appoint another person as guardian Name of proposed guardian Please provide the following information. If you are proposing more than one guardian, provide information about the co-guardian in 7A below. Mailing Address Relationship between proposed guardian and Respondent: Relative __________________ Social Worker Physician Friend/Neighbor Public Official Other ____________________________ 7A. Nomination of Co-Guardian I am not requesting a co-guardian. I am requesting a co-guardian whose information is below. Name of proposed co-guardian Please provide the following information about the proposed coguardian. Mailing Address Relationship between proposed co-guardian and Respondent: Relative __________________ Social Worker Physician Friend/Neighbor Public Official Other ____________________________ 8. Proposed Guardianship Powers I ask that the Guardian be given the following powers: to have general supervision over the Respondent, including care, habilitation, education, employment and choosing or changing where the Respondent lives, subject to the requirements of 14 V.S.A. ��2691, 3073 and 3074; to seek, approve or refuse medical or dental treatment, subject to the provisions of 14 V.S.A. �3075 and any constitutional right of the Respondent to refuse treatment; to supervise Respondent's income and resources; to approve or withhold approval of any contract Respondent wishes to make, except a contract for basic needs; to approve or withhold approval of the sale, lease or encumbrance of Respondent's real property subject to the provisions of 14 V.S.A. �2881 � 2891; to seek legal advice and to start or defend against a court action in Respondent's name. 9. Alternatives to Guardianship I have considered the following alternatives to guardianship: Describe each alternative (e.g. power of attorney, representative payee, etc.) you have considered and explain why it is unsuitable. PAG72 � Petition to Appoint Guardian for an Adult (Involuntary) (10/2014) American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 5 10. Evaluation of Respondent I understand that the Court must order an evaluation of the Respondent at the Respondent's expense unless the Respondent is indigent. The evaluation must be performed by someone who has specific training and demonstrated competence to evaluate a person in need of guardianship. The evaluation shall be completed within 30 days of the filing of the petition with the court unless the time period is extended by the court for cause. I propose that the following person perform the evaluation of the Respondent: Name of Proposed Evaluator Please provide the following information Mailing Address Phone Number 11. Attorney for Respondent I understand that the Court must appoint an attorney to represent the respondent in this proceeding. Respondent does not have an attorney Respondent is currently represented by an attorney whose name and contact information are as follows: Name of Proposed Attorney Please provide the following information Mailing Address Phone