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In the matter of First, middle, and last name Last four digits of SSN , a minor 1. I am interested in this matter and make this petition as custodial paren\ t of the minor . 2. An action within the jurisdiction of the family division of circuit cour\ t involving the family or family members of the minor has been previously filed in Court, Case Number , was assigned to Judge , and remains is no longer pending. 3. The minor was born Date , is female, male, is unmarried, resides in County at Address \ City/Township State \ Zip and is presently located in County at Address (only if different than above) City/Township \ State Zip . The minor is a citizen of the following foreign country: . 4. The minor is not an Indian child as defined in MCR 3.002(12). It is unknown whether the minor is an Indian child as defined in MCR 3.0\ 02(12). \ *Also list persons who had principal care and custody of the minor 5. The persons interested in this proceeding are: \ during the 63 days before filing the petition. NAME RELATIONSHIP ADDRESS AND TELEPHONE NUMBER Parent/DOB Street address CityStateZip Telephone no. Parent/DOB Street address City StateZip Telephone no. Conservator Street address City StateZip Telephone no. Guardian Street address City StateZip Telephone no. Person with care/ custody of minor* Street address City StateZip Telephone no. None of these persons are under any legal incapacity except Name, incapacity, and representative of the person, if any . XXX-XX- Do not write below this line - For court use only (SEE SECOND PAGE) USE NOTE: If this form is being filed in the circuit court family division, please\ enter the court name and county in the upper left-hand corner of the fo\ rm. PC 650 (12/17) PETITION FOR APPOINTMENT OF LIMITED GUARDIAN OF MINOR MCL 700.5205, MCR 5.125(C)(19), MCR 5.404 Approved, SCAO JIS CODE: LGM STATE OF MICHIGAN PROBATE COURT COUNTY OF PETITION FOR APPOINTMENT OF LIMITED GUARDIAN OF MINOR FILE NO. File No. 6. The welfare of the minor will be served by the appointment. 7. A proposed limited guardianship placement plan is attached. I REQUEST: 8. Name whose address is Address City/Township StateZip Telephone no. be appointed limited guardian of the minor. 9. Other: 10. I CONSENT TO THE SUSPENSION OF MY PARENTAL RIGHTS. I declare under the penalties of perjury that this petition has been exa\ mined by me and that its contents are true to the best of my information, knowledge, and belief. Date Date Signature of custodial parent Signature of custodial parent Address Address City, state, zip Telephone no. City, state, zip Telephone no. NOTE: If both parents have custody, each must sign. 11. I am 14 years of age or older. I nominate Name as my guardian who lives at AddressCityStateZip . Date Signature of minor Attorney signature Attorney name (type or print) Bar no. Address City, state, zipTelephone no. USE NOTE: If a parent is incarcerated and under the jurisdiction of the Michigan D\ epartment of Corrections, the petitioner must comply with MCR 2.004(B)\ . /s/ /s/ /s/ /s/ Petition for Appointment of Limited Guardian of Minor (12/17)