Fill and Sign the Guardianship Petitions Laws and Alternatives Form

PAG74 – Petition to Appoint Guardian for an Adult (Voluntary) (09/2014) Page 1 of 2 STATE OF VERMONT SUPERIOR COURT PROBATE DIVISION Unit Docket No.: In re Guardianship of : PETITION TO APPOINT GUARDIAN FOR AN ADULT (Voluntary) I, _____________________________ request the court to appoint a guardian pursuant Name of Petitioner to 14 V.S.A. §2671 to assist me in the management of my affairs. In support of this petition , I state: 1. I am 18 years old or older . My date of birth is ___________________________________ ; 2. I understand the nature, extent and consequences of the guardianship; 3. I understand how the guardianship can be ended ; 4. I ask that __________________________________ ____ _ be appointed to act as my guardian Name of P roposed Guardian / Co-Guardian with the following powers (check each that applies) : ☐ to have general supervision over me, including my care, habilitation, education, employment and choosing or changing where I live , subject to the requirements of 14 V.S. A. §§2691, 3073 and 3074 ; ☐ to seek, approve or refuse medical or dental treatment, subject to the provisions of 14 V.S.A. §3075 and any constitutional right of mine to refuse treatment ; ☐ to supervise my income and resources; ☐ to approve or withhold approval of any contract I wish to make , except a contract for my basic needs; ☐ to approve or withhold approval of the sale , lease or encumbrance of my real property subject to the provisions of 14 V.S.A. §2881 – 2891; ☐ to seek legal advice and to start or defend against a court action in my name. PAG74 – Petition to Appoint Guardian for an Adult (Voluntary) (09/2014) Page 2 of 2 5. I am ( check one ): ☐ physically able to appear before the court a t a hearing on this petition; OR ☐ not physically able to appear before the court at a hearing on this petition for the following reason: Explain Reason below ☐ I ask to participate in the hearing by telephone; or ☐ I have attached a letter from a physician or qualified mental health professional stating that I understand the nature, extent and consequences of the guardianship and how the guardianship can be ended . I voluntarily request the appointment of a guardian. This request is not made in response to coercion or duress. Date Signature of Petitioner Petitioner’s Mailing Address Petitioner’s Phone Number GUARDIAN’S CONSENT I consent to be appointed guardian of : Date Signature of Guardian Signature of Co -Guardian, if any Guardian’s Mailing Address Co-Guardian’s Mailing Address Guardian’s Phone Number Co-Guardian’s Phone Number