Fill and Sign the De Petition Form

IN THE COURT OF CHANCERY OF THE STATE OF DELAWARE In the Matter of: C.M.#             AN ALLEGED DISABLED PERSON PETITION FOR THE APPOINTMENT OF GUARDIAN OF THE PERSON AND/OR PROPERTY Petitioner       represents: your name 1. Information about Petitioner (You are the Petitioner): a. Current address:             b. Telephone No.:       c. Social Security No.:       d. Relationship to alleged disabled person:       2. Information about the alleged disabled person whose name is: Error: Reference source not found a. Age:       b. Date of birth:       c. Current address:             d. Permanent address:             e. Current mailing address, if different from above             f. If the alleged disabled person is a patient/living at a hospital or an institution, i. Admission date       ii. Admitted by       iii. Reason(s) for admission:       3. Who is paying the alleged disabled person's expenses AND out of what funds?       4. The married status of the alleged disabled person is: ( Check one ) Single Married Divorced Widowed 5. The next of kin of the alleged disabled person are: [The next of kin is/are the person(s) who would be entitled to inherit the alleged disabled person's estate if the alleged disabled person died without having a will]: ( Complete the table below with respect to next of kin. ) NEXT OF KIN NAME RELATIONSHIP TO ALLEGED DISABLED PERSON ADDRESS OF NEXT OF KIN NEXT OF KIN'S AGE                                                                                                                                                                                                                         6. The alleged disabled person is believed to have made a Will that is located at       address where will can be found in the custody of       possession of whom 7. Has the alleged disabled person ever appointed a Power of Attorney? YES NO If " YES ", name of the Power of Attorney:       8. Has the alleged disabled person been represented by a Delaware attorney within 2 years of filing this Petition? YES NO If " YES " briefly explain and include the years of service:       2 9. Has the alleged disabled person ever been a member of the military? YES NO 10. In detailed information, explain why it is necessary for the Court to grant you Guardianship.       11. In the opinion of the Petitioner, will notifying the alleged disabled person that this Petition is being filed, likely result in harm to the alleged disabled person's health? ( Check one ) YES NO 12. List ALL alleged disabled person’s assets: (Attach additional pages if necessary.) PROPERTY ESTEMATED VALUE RETAIL VALUE IF OWNED JOINTLY NAME AND ADDRESS OF JOINT OWNER Cash                   Bank accounts                   Stocks                   Bonds                   Mutual funds                   Securities                   Options                   Annuities                   Home/real estate                   Other real estate                   Motor vehicles/automobile(s)                   Other vehicles                   Business                   Other valuable property (except ordinary household furnishings and clothes)                   Life insurance policy amount                   Other:                         Other:                         13. List ALL believed current sources of income for the alleged disabled person: (Attach additional sheets if necessary). BENEFIT OR SOURCE OF INCOME AMOUNT WHEN RECEIVED HOW OFTEN RECEIVED (one time or regular) Business, profession or self-employment                   Rent payments                   Interest                   Dividends from stocks or bonds                   Qualified and/or non-qualified pension and/or retirement plan                   3 BENEFIT OR SOURCE OF INCOME AMOUNT WHEN RECEIVED HOW OFTEN RECEIVED (one time or regular) Social security retirement                   Social security disability                   VA benefits                   Federal pension (CSRS or FERS)                   Disability or private disability                   Military pension                   IRA                   Any other annuity payments                   Bank account interest                   Gifts                   Other:                         Other:                         14. List ALL debts and monthly expenses of the alleged disabled person: (Attach additional pages if necessary.) DESCRIPTION OF DEBTS AND MONTHLY EXPENSES, BILLS TOTAL DEBT MONTHLY PAYMENT Mortgage (taxes, insurance and escrow) or Rent             Water             Sewer             Electric             Gas             Oil             Garbage             Cable television             Telephone             Household items             Household maintenance and repairs (list) Item:       Item:                               Groceries             Clothing             Health insurance (COBRA)             Medications             Health care             Other out-of-pocket medical and dental expenses for self             Medical and dental expenses for dependents             Laundry and dry cleaning             Cosmetics and toiletries             Hobbies             Barber and hairdresser             4 DESCRIPTION OF DEBTS AND MONTHLY EXPENSES, BILLS TOTAL DEBT MONTHLY PAYMENT Newspaper, magazine subscriptions             Charitable and/or religious donations             Vacation             Entertainment and miscellaneous             Transportation other than automobile             Automobile Monthly payment: Repairs and maintenance: Insurance: Gasoline:                                                 Life insurance payment             Other:                   Other:                   15. Check ONLY the statement(s) below that applies to your situation (the one that is true). If both statements are true, check both boxes. The alleged disabled person is UNABLE TO PROPERLY MANAGE AND CARE FOR HIS/HER PROPERTY and , as a consequence thereof, IS IN DANGER OF DISSIPATING OR LOSING SUCH PROPERTY by becoming the victim of designing person(s). The alleged disabled person is UNABLE TO PROPERLY MANAGE AND CARE FOR HIS/HER PERSON and , as a consequence thereof, IS IN DANGER OF SUBSTANTIALLY ENDANGERING HIS/HER OWN HEALTH or BECOMING SUBJECT TO ABUSE by other person(s). 16. ALL of the following statements must be true before the Court of Chancery will consider this Petition. Check ALL the following statements to acknowledge they are true: THERE IS CURRENTLY NO GUARDIAN for the Person OR the Property of the alleged disabled person. The alleged disabled person is domiciled in the State of Delaware. ATTACHED is the medical report of: Name of attending doctor/physician of alleged disabled person:       Doctor/physician’s office address:       Doctor/physician’s telephone no.:       Petitioner consents to the Register in Chancery of the Court being his/her agent for acceptance of service on behalf of the Petitioner as to any claim arising out of the 5 Guardianship if, by reason of the Guardian’s absence from this State, he/she cannot be personally served. WHEREFORE , Petitioner respectfully requests that: a. This Court appoint him/her as Guardian of: (check all that apply): Guardian of the Property of the alleged disabled person. Guardian of the Person of the alleged disabled person. b. He/she be permitted to serve as Guardian without the necessity of posting surety on the bond. c. A Preliminary Order be entered to schedule a Hearing and to notify interested parties. Date Petitioner's Signature SWORN TO AND SUBSCRIBED before me on this date: Notary Public or Clerk of the Court 6