Fill and Sign the Emergency Guardian Form

JDF 841 R8-17 PETITION FOR APPOINTMENT OF GUARDIAN FOR ADULT Page 1 of 6© 2017 Colorado Judicial Department for use in the Courts of ColoradoDistrict Court Denver Probate Court___________________ County, ColoradoCourt Address:In the Interest of:Respondent COURT USE ONLY Attorney or Party Without Attorney (Name and Address): Phone Number: E-mail:FAX Number: Atty. Reg. #.: Case Number:Division Courtroom PETITION FOR APPOINTMENT OF GUARDIAN FOR ADULT 1.The Petitioner is:a person interested in the welfare of the Respondent.orthe Respondent.This is a Petition for appointment of a(n):Permanent Guardian. (§15-14-304(1) and (2), C.R.S.)Emergency Guardian. (not to exceed 60 days). (§15-14-312, C.R.S.) 2.Information about the Petitioner:Name: Relationship to Respondent: Street Address: Mailing Address, if different: City: State: Zip Code: Home Phone #: Email Address: Work Phone #: Does Petitioner need an interpreter? NoYes (Language:______________________________)3.Information about the Respondent: Name (REQUIRED): Age:______ Date of Birth (REQUIRED):Sex (REQUIRED): _________Street Address: Mailing Address, if different: City: State: Zip Code: County of Residence: Home Phone #: Work Phone #: _______________________________Email Address: __________________________________________Does Respondent need an interpreter? NoYes (Language:______________________________) If this appointment is made, the Respondent’s residence will change to: JDF 841 R8-17 PETITION FOR APPOINTMENT OF GUARDIAN FOR ADULT Page 2 of 6© 2017 Colorado Judicial Department for use in the Courts of Colorado4. Information about the Respondent’s spouse, partner in a civil union, or adult who has resided with the Respondent for more than six months in the last year:Name: Relationship to Respondent: Street Address: Mailing Address, if different: City: State: Zip Code: Home Phone #: Email Address: Work Phone #: Does this person need an interpreter? NoYes (Language:______________________________)5.Venue for this proceeding is proper because the Respondentresides in this county.is present in this county. (Check this box only if requesting an Emergency Guardian.) (§15-14-108(2), C.R.S.)is admitted to an institution pursuant to an Order of a court of competent jurisdiction sitting in this county. (Attach copy of the Order to the Petition.) 6.An appointment of a guardian for the Respondent has been previously made. (Attach copy of the Order to the Petition.) 7.A Power of Attorney exists for financial or medical matters. (Attach a copy of the Power of Attorney to the Petition.) The agent‘s name and mailing address is:8.A valid designated beneficiary agreement exists. (Attach a copy of the agreement to the Petition.) The designated beneficiary’s name and mailing address is: 9.The Respondent is unable to effectively receive or evaluate information or both or make or communicate decisions to such an extent that he/she lacks the ability to satisfy essential requirements for physical health, safety, or self-care, even with appropriate and reasonably available technological assistance. (§15-14-102(5), C.R.S.) 10.The Respondent’s identified needs cannot be met by less restrictive means, including use of appropriate and reasonably available technological assistance.11.Guardianship is necessary due to the following disabilities or impairments: Physician’s letter attached. JDF 841 R8-17 PETITION FOR APPOINTMENT OF GUARDIAN FOR ADULT Page 3 of 6© 2017 Colorado Judicial Department for use in the Courts of Colorado12. Petitioner requests the powers and duties to be unlimited/unrestricted or limited/with restrictions. The requested limitations/restrictions on the Guardian’s powers and duties, if any, are as follows: 13. Petitioner is 21 years of age or older, nominates himself/herself and requests to be appointed as Guardian. or Petitioner nominates the following person, who is 21 years of age or older, to be appointed as Guardian. Name: Street Address: Mailing Address, if different: City: State: Zip Code: Home Phone #: Email Address: Work Phone #: Does this person need an interpreter? NoYes (Language:______________________________)14.The nominated Guardian has priority for appointment because he/she is: (§15-14-310, C.R.S.)a Guardian currently acting for the Respondent in Colorado or elsewhere.nominated in writing by Respondent, including nomination in a durable power of attorney or designated beneficiary agreement. an agent under a medical power of attorney. an agent under a general durable power of attorney. the spouse or partner in a civil union of the Respondent. the parent of the Respondent. an adult child of the Respondent. an adult with whom Respondent has resided for more than six months immediately before the filing of this Petition.other: 15.The Respondent nominated the following person as Guardian, but the Petitioner does not seek that person’s appointment for the following reason: Name: Relationship to Respondent: Street Address: Mailing Address, if different: City: State: Zip Code: Home Phone #: Email Address: Work Phone #: JDF 841 R8-17 PETITION FOR APPOINTMENT OF GUARDIAN FOR ADULT Page 4 of 6© 2017 Colorado Judicial Department for use in the Courts of Colorado16. It is necessary to appoint an Emergency Guardian for the Respondent because complying with the normal procedures for the appointment of a Guardian will likely result in substantial harm to the Respondent’s health, safety, or welfare and no other person appears to have authority and willingness to act in the circumstances. (§15-14-312, C.R.S.) The nature of the emergency is as follows:17. Information about Respondent’s adult children and parents. None (If none, list an adult relative that can be found with reasonable efforts, such as a brother, sister, aunt, uncle, etc.) Name: Relationship: __________________________Street Address: Mailing Address, if different: City: State: Zip Code: Home Phone #: Email Address: Work Phone #: Does this person need an interpreter? NoYes (Language:______________________________)Name: Relationship: __________________________Street Address: Mailing Address, if different: City: State: Zip Code: Home Phone #: Email Address: Work Phone #: Does this person need an interpreter? NoYes (Language:______________________________)Name: Relationship: Street Address: Mailing Address, if different: City: State: Zip Code: Home Phone #: Email Address: Work Phone #: Does this person need an interpreter? NoYes (Language:______________________________)18.Information about each person currently responsible for primary care and custody of the Respondent, including the Respondent’s treating physician: None Name of Treating Physician: Phone #:Street Address: Mailing Address, if different: City: State: Zip Code: Email Address: Name of Caregiver: Phone #: JDF 841 R8-17 PETITION FOR APPOINTMENT OF GUARDIAN FOR ADULT Page 5 of 6© 2017 Colorado Judicial Department for use in the Courts of ColoradoStreet Address: Mailing Address, if different: City: State: Zip Code: Email Address: 19.The following person is the Legal Representative for the Respondent not otherwise designated above. (Representative payee, trustee, custodian of a trust, etc. §15-14-102(6), C.R.S.) Name: Type of Legal Representative: Phone #: Email Address: Mailing Address:City: State: Zip Code: 20.The Guardian may receive compensation.The hourly rates to be charged, any amounts to be charged pursuant to a published fee schedule, including the rates and basis for charging fees for any extraordinary services, and any other bases upon which a fee charged to the estate will be calculated, are as stated below or in an attachment to this Petition. *The basis of compensation has not yet been determined.* There is a continuing obligation to disclose any material changes to the basis for charging fees. (§ 15-10-602, C.R.S.)21.The Guardian may compensate his, her or its counsel.The hourly rates to be charged, any amounts to be charged pursuant to a published fee schedule, including the rates and basis for charging fees for any extraordinary services, and any other bases upon which a fee charged to the estate will be calculated, are as stated below or in an attachment to this Petition. *The basis of compensation has not yet been determined.* There is a continuing obligation to disclose any material changes to the basis for charging fees. (§ 15-10-602, C.R.S.) JDF 841 R8-17 PETITION FOR APPOINTMENT OF GUARDIAN FOR ADULT Page 6 of 6© 2017 Colorado Judicial Department for use in the Courts of Colorado22. The Respondent’s assets are: Description of Assets (e.g. bank accounts, insurance, pensions, property) NoneEstimated Value $$Total$23.The Respondent’s income is: Description of Income (e.g. social security, pension) None Estimated Amount of Income $$Total$The Petitioner requests that an appointment of a Guardian be made after notice and hearing. In addition, the Petitioner requests the following: By checking this box, I am acknowledging I am filling in the blanks and not changing anything else on the form. By checking this box, I am acknowledging that I have made a change to the original content of this form.(Checking this box requires you to remove JDF number and copyright at the bottom of the form.) VERIFICATION AND ACKNOWLEDGMENT I (Petitioner) verify that the facts set forth in this document are true as far as I know or am informed. I understand that penalties for perjury follow deliberate falsification of the facts stated herein. (§15-10-310, C.R.S.) ____________________________________________ Signature of Petitioner DateThe foregoing instrument was acknowledged before me in the County of ________________, State of Colorado, this ____day of ____________, 20___, by the Petitioner.My Commission Expires: ________________ _____________________________________________ Notary Public/Deputy Clerk ______________________________________Signature of Attorney Date