Fill and Sign the Appoint Guardian for Form

STATE OF VERMONT PROBATE COURT DISTRICT OF ____________ In Re the Estate of: ) DOCKET No. __________ ) __________________ ) , Deceased ) ) ) LATE OF ) ) __________________ . ) ) ) 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 requests 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. § 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 suits 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 those terms as the guardian deems just and beneficial to the ward. 6. Proposed guardian relationship to proposed ward Name ________________________________________ Address ________________________________________ _______________________________________________________________ I consent to be appointed guardian of the above respondents: Dated ______________ Signed _________________________ Proposed Guardian 7. To the best of my knowledge the proposed ward 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: Name . _______________________________________________________________ I have attached the entry fee and forms No. 73 and No. 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 ________________________________________ _______________________________________________________________ Date: Signed: Print Name: ______________________________ Address: ________________________________________ Telephone: (       ) _______________ Insert below the name of the attorney for the ward, if known: Name ____________________ Address ____________________ ______________________________ Telephone (       ) __________ Rev. 3/2/92