GN-3350, 05/18 Petition for Appointment of Conservator 24754.76, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 1 of 2 STATE OF WISCONSIN, CIRCUIT COURT, COUNTY IN THE MATTER OF Name Date of Birth Amended Petition for Appointment of Conservator Case No. UNDER OATH, I STATE: 1. I am unwilling or believe I am unable to properly manage my assets or income and voluntarily ask the court to appoint a conservator. 2. I am an adult resident of County, State of Wisconsin. My mailing address is: [Street, City, State, Zip] 3. The approximate value of my property is as follows: General Description Amounts General Description Amounts Cash/Bank Accounts: $ Other Liquid Assets: $ Real E state: $ Other Assets : $ A. Assets previously derived from or benefits now due and payable from U.S. Department of Veterans Affairs are: none See attached B. I receive public benefits, including medical assistance, SSI, SSDI or long term community options program benefits: No Yes, type and amount: C. Any other claim, income, compensation, pension, insurance or allowance to which I may be entitled is: none. as follows: See attached General Description Amounts [Monthly] General Description Amounts [Monthly] Social S ecurity : $ Investment Income : $ Pension : $ Other : $ 4. I do not do have a current, valid Financial Durable Power of Attorney. Activated. Name, address and phone number: 5. I nominate as conservator of my estate: See attached Type of Conservator Name Mailing Address [Street, City, State, Zip] Telephone Number Conservator Standby Conservator 6. CONSERVATOR I petition the court to A. appoint and authorize a permanent conservator to perform the duties of a guardian of the estate under 24754.19, Wis. Stats., and exercise the powers that do not require court approval under 24754.20(3), Wis. Stats. B. authorize the conservator to exercise additional powers requiring court approval under 24754.20(2), Wis. Stats., (other than to make gifts) as follows: C. daccount of a bank, credit union, savings bank or savings and loan association in the name of the custodian and the ward, payable only upon further order of the court, and waive bond for the custodian of the estate. 7. I understand that I will be personally examined by the court at the hearing and that the court will determine the suitability of the nominated conservator or standby conservator. American LegalNet, Inc. www.FormsWorkFlow.com GN-3350, 05/18 Petition for Appointment of Conservator 24754.76, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 2 I REQUEST THE COURT: 1. Order a hearing on this Petition. 2. Make findings and appointments as requested above. 3. Waive bond. Set bond as appropriate. 4. Other: State of County of Subscribed and sworn to before me on Notary Public/Court Official Name Printed or Typed My commission/term expires: Petitioner Name Printed or Typed Address Date DISTRIBUTION: 1. Court 2. Petitioner 3. Proposed Conservator/Proposed Standby Conservator 4. Presumptive Heirs 5. Agent under Durable Power of Attorney 6. Other: American LegalNet, Inc. www.FormsWorkFlow.com