Fill and Sign the Gn 3410 Petition for Appointment of Successor Guardian Form

GN -3350, 10/07 Petition for Appointment of Conservator §54.76, W isconsin 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 Amended Petition for Appointment of Conservator Date of Birth 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, St ate of Wisconsin. My post office address is: 3. The approximate value of my property is as follows : General Description Amounts General Description Amounts Cash/Bank Accounts: $ Other Liquid Assets: $ Real estate: $ 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 am receiving public benefits, including medical assistance, SSI, SSDI or long term community o ptions 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 security : $ 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 & Address Phone Conservator Standby Conservator 6. CONSERVATOR OF THE ESTATE I petition the court to A. appoint and authorize a permanent conservator of the estate to perform the duties of a guardian of the estate under §54.19, W is. Stats., and exercise the powers that do not require court appr oval under §54.20(3) , Wis. Stats . B. authorize the conservator of the estate to exercise additional powers requiring court approval under §54.20(2), Wis. Stats., other than to make gifts, as follows: C. direct that the custodian of the estate deposit the individual’s funds of $100,000 or less in an insured account of a bank, credit union, savings bank or savings and loan association in the na me 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 suitabilit y of the nominated conservator or standby conservator. Petition for Appointment of Conservator Page 2 of 2 Case No. GN -3350, 10/07 Petition for Appointment of Conservator §54.76, W isconsi n 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 f ind ings and appointments as requested above. 3. Waive bond . Set bond as appropriate . 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 Name of Attorney Address Telephone Number Bar Number