Probate Court Form No. 72 (page 1 of 2) Petition to Appoint a Guardian for a Mentally Disabled Adult STATE OF VERMONT DISTRICT OF ______________________ PROBATE COURT IN RE _______________________________ DOCKET NO. __________________ PETITION TO APPOINT A GUARDIAN FOR A MENTALLY DISABLED ADULT The undersigned represents that it is necessary that a guardian be appointed for the following person: Name ______________________ Residence ________________________ Date of Birth ___________________ Age ___________ who is currently located at ____________________________________. In support of this petition the undersigned provides the following: 1.The petitioner’s interest in the proposed ward is_____________ _________________________________________________________________. 2. A near relative of the proposed ward is Name Address __________________________ _______________________________ 3. The proposed ward is alleged to be (Check the appropriate boxes) ( ) mentally ill ( ) mentally retarded. 4. Specific reasons with supporting facts why guardianship is requested. (Attach sheets if needed). _________________________________________________________________________________ _________________________________________________________________________________ __________________________________________________________________________ 5. The petitioner request the following powers. (Check applicable powers). ( ( ( ( ( ( ) a. To exercise general supervision over the ward; ) b. To approve or withhold approval of any contract, except for necessaries, which the ward makes; ) c. To approve or withhold approval of request to sell or in any way encumber the ward’s personal or real property; ) d. To exercise general supervision over the ward’s income and resources; ) e. To consent to surgery or other medical procedures, subject to the provisions of 14 V.S.A. Section 3075 and any constitutional right of the ward to refuse treatment; ) f. To receive, sue for, and recover debts and demands due the ward, to maintain and defend actions or suite for the recovery or protection of the ward’s property or person, settle accounts, demands claims and actions at law or in equity against the ward, including actions for injuries to the property or person of the ward, and to compromise, release, and discharge the same on those terms as the guardian deems just and beneficial to the ward. American LegalNet, Inc. www.FormsWorkflow.com Probate Court Form No. 72 Page 2 of 2 Petition to Appoint a Guardian for a Mentally Disabled Adult 6. Relationship to Proposed Ward Name ___________________ Address__________________ __________________ 7. Proposed guardian ___________________________ To the best of my knowledge the proposed was has/has not executed a durable power of attorney for health care. If a durable power of attorney has been executed, the name and address of the person named as the agent are: ___________________________________ _______________________________________________________________________ I consent to be appointed guardian of the above respondent: Dated ________________________ Signed _________________________ Proposed Guardian I have attached the entry fee and Forms Number 73 and number 75. The undersigned understands that the court must order an evaluation of the proposed ward to be performed by a qualified mental health professional which must be completed and filed with the court within 30 days of the filing of the petition with the court, and I suggest to the court that the following qualified person perform the examination: Name _____________________ Address ___________________ __________________________ Dated _________________ Signed _____________________, Petitioner Print Name _________________ Address ____________________ ___________________________ Telephone ( ) ______________ Insert below the name of the attorney for the ward, if known: Name _____________________ Address ___________________ __________________________ Telephone ( ) _____________ American LegalNet, Inc. www.FormsWorkflow.com