Fill and Sign the Justia Petition for Appointment of Conservator for Adult Colorado Form

JDF 841SC R 6/1 9 PETITION FOR APPOINTMENT OF GUARDIAN FOR ADULT Page 1 of 7  District Court  Denver Probate Court ___________________ County, Colorado Court Address: In the Interest of: Respondent COURT USE ONLY Attorney or Party W ithout Attorney (Name and Address): Phone Number: E-mail: FAX Number: Atty. Reg. #.: Case Number: Division Courtroom PETITION FOR APPOINTMENT OF GUARDIAN FOR ADULT 1.  No court proceeding is pending in this state or elsewhere concerning the respondent.  The following proceeding(s) concern(s) the respondent. Identify name of court, case number, state, date, and type of proceeding if any. Name of Court Case Number State Date of Proceeding Type of Proceeding 2. The petitioner is :  a person interested in the welfare of the r espondent. or  the respondent . This is a p etition 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.) 3. Information about the p etitioner: Name: List all names used (also known as, formerly known as, etc.): __________________________________________ Relationship to Respondent: Street Address : City: _____________ State: ____________ Zip Code: ________________________ Mailing Address, if different: City: State: Zip Code: Primary phone: __________________ Alternate phone: _______________________________ Email Address: Does petitioner need an interpreter?  No  Yes (Language:______________________________) JDF 841SC R 6/1 9 PETITION FOR APPOINTMENT OF GUARDIAN FOR ADULT Page 2 of 7 4. Information about the r espondent: Name (REQUIRED) : Age: ______ Date of Birth (REQUIRED) : Sex (REQUIRED): _________ Street address : City: __________________ State: _____________ Zip Code: ________________ Mailing address, if different: City: State: Zip Code: County of Residence: Primary phone: __________________ Alternate phone: _______________________________ Email address: __________________________________________ Does respondent need an interpreter?  No  Yes (Language:______________________________)  If this appointment is made, the respondent’s residence will change to: 5. Information about the r espondent’s spouse , partner in a civil union , or adult who has resided with the r espondent for more than six months in the last year : Name: Relationship to Respondent: Street Address : City: ______________ State: ____________ Zip Code: __________________ Mailing Address, if different: City: State: Zip Code: Primary phone: __________________ Alternate phone: _______________________________ Email address: Does this person need an interpreter?  No  Yes (Language:______________________________) 6. Venue for this proceeding is proper because the r espondent  resides 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 .) 7.  An appointment of a guardian for the respondent has been previously made. (Attach copy of the Order to the Petition .) 8.  A Power of Attorney exists for financial or medical matters . (Attach a copy of the Power of Attorney to the Petition .) T he agent ‘s name and mailing address is : 9.  A valid designated beneficiary agreement exists . (Attach a copy of the agreement to the p etition.) The designated beneficiary’s name and mailing address is: JDF 841SC R 6/1 9 PETITION FOR APPOINTMENT OF GUARDIAN FOR ADULT Page 3 of 7 10. The respondent is unable to effectively receive or evaluate information or both or make or communicate decisions to such an extent that he or she lacks the ability to satisfy essential requirements for physical health, safety, or self -care, even with appropriate and reasonably av ailable technological assistance. (§ 15-14- 102(5), C.R.S.) 11. The respondent’s identified needs cannot be met by less restrictive means, including use of appropriate and reasonably available technological assistance. 12. Guardianship is necessary due to the following disabilities or impairments:  Physician’s letter attached. 13. Petitioner requests the powers and duties to be  unlimited or unrestricted or  limited or with restrictions . The requested limitations or restrictions on the g uardian’s powers and duties, if any, are as follows: 14.  Petitioner is 21 years of age or older , nominates himself or herself and requests to be appointed as g uardian. or  Petitioner nominates the following person , who is 21 years of age or older, to be appointed as guardian. Name: List all names used (also known as, formerly known as, etc.): __________________________________________ Street address : City:_______________ State: _____________ Zip Code: ______________ Mailing address, if different: City: State: Zip Code: Primary phone: ________________ Alternate phone: __________________________ Email Address: Does this person need an interpreter?  No  Yes (Language:______________________________) 15. The nominated g uardian has priority for appointment because he or she is : (§ 15-14-310, C.R.S.)  a g uardian currently acting for the r espondent in Colorado or elsewhere.  nominated in writing by respondent , including nomination in a durable power of attorney or designated beneficiary agreement .  a n a gent under a medical power of attorney .  an a gent under a general durable power of attorney .  the s pouse or partner in a civil union of the r espondent.  the p arent of the r espondent . JDF 841SC R 6/1 9 PETITION FOR APPOINTMENT OF GUARDIAN FOR ADULT Page 4 of 7  an a dult child of the respondent .  a n a dult with whom respondent has resided for more than six months immediately before the filing of this p etition.  other: 16.  The respondent nominated the following person as g uardian , but the petitioner does not seek that person’s appointment for the following reason: Name: List all names used (also known as, formerly known as, etc.): __________________________________________ Relationship to Respondent: Street address : City: ______________ State: ______________ Zip Code: ____________________ Mailing address, if different: City: State: Zip Code: Primary phone: __________________ Alternate phone: _______________________________ Email address: 17.  It is necessary to appoint an E mergency Guardian for the r espondent 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: 18. Information about respondent’s adult children and parents.  None ( If n one, list an adult relative that can be found with reasonable efforts, such as a brother, sister, aunt, uncle, etc.) Name: Relationship to Respondent: Street address : City: ______________ State: ______________ Zip Code: ____________________ Mailing address, if different: City: State: Zip Code: Primary phone: __________________ Alternate phone: _______________________________ Email address: Does this person need an interpreter?  No  Yes (Language:______________________________) Name: Relationship to Respondent: Street address : JDF 841SC R 6/1 9 PETITION FOR APPOINTMENT OF GUARDIAN FOR ADULT Page 5 of 7 City: ______________ State: ______________ Zip Code: ____________________ Mailing address, if different: City: State: Zip Code: Primary phone: __________________ Alternate phone: _______________________________ Email address: Does this person need an interpreter?  No  Yes (Language:______________________________) Name: Relationship to Respondent: Street address : City: ______________ State: ______________ Zip Code: ____________________ Mailing address, if different: City: State: Zip Code: Primary phone: __________________ Alternate phone: _______________________________ Email address: Does this person need an interpreter?  No  Yes (Language:______________________________) 19. Information about each person currently responsible for primary care and custody of the r espondent, including the r espondent’s treating physician :  None Name of Treating Physician: Phone #: Street Address : City: _________________ State: _______________ Zip Code: _______________________ Mailing Address, if different: City: State: Zip Code: Email Address: Name of Caregiver : Phone #: Street Address : City: State: Zip Code: Mailing Address, if different: City: State: Zip Code: Email Address: 20.  The following person is the l egal representative for the respondent not otherwise designated above. (R epresentative 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: JDF 841SC R 6/1 9 PETITION FOR APPOINTMENT OF GUARDIAN FOR ADULT Page 6 of 7 21. 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 p etition. *  The basis of compensation has not yet been determined. * There is a continuing obligation to disclose any material changes to the basis f or charging fees. (§ 15-10-602, C.R.S.) 22. 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 p etition. *  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.) 23. T he respondent ’s assets are : Description of Assets (e.g. bank accounts, insurance , pension s, property )  None Estimated Value $ $ Total $ 24. T he respondent ’s income is : Description of Income (e.g. social security, pension )  None Estimated Amount of Income $ $ Total $ 25. The petitioner requests that an appointment of a g uardian be made after notice and hearing .  In addition, the petitioner requests the following: JDF 841SC R 6/1 9 PETITION FOR APPOINTMENT OF GUARDIAN FOR ADULT Page 7 of 7  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. VERIFICATION I declare under penalty of perjury under the law of Colorado that the foregoing is true and correct. Executed on the ______ day of Executed on the ______ day of (date) (date) _______________________, _________, _______________________, _________, (month) (year) (month) (year) at ______________________________________ at ______________________________________ (city or other location, and state OR country) (city or other location, and state OR country) ______________________________________ _________________ _____________________ (printed name) (printed name) ______________________________________ ______________________________________ (Signature of Petitioner) (Signature of Co- Petitioner, if any) ________________________________________ __________________ Attorney Signature, (if any) Date