Legal Guardianship Questionnaire

Legal Guardianship Questionnaire

Petitioner Name:   Petitioner Address:
Proposed Guardian Name:   Proposed Guardian Address:
Protected Person Name:   Protected Person Date of Birth:

RECITALS

WHEREAS, Petitioner is an interested person seeking to protect the health, safety, and welfare of the Protected Person by securing a guardianship appointment on account of alleged incapacity; and

WHEREAS, Proposed Guardian is a qualified adult who has expressed a willingness to serve and to exercise the duties of guardian consistent with the best interests of the Protected Person; and

WHEREAS, the information set forth in this Questionnaire will be provided to the court, medical evaluators, and other interested persons to support the petition for guardianship and to assist in the determination of the scope of authority required.

NOW, THEREFORE, Petitioner provides the following statements and representations under penalty of perjury to the best of Petitioner’s knowledge.

1. CURRENT STATUS OF PROTECTED PERSON

2. AUTHORITY SOUGHT

Check all authorities the Petitioner requests the court to grant to the Proposed Guardian:

Personal care and custody — authority to determine residence, provide for daily needs, and make decisions regarding personal care.
Medical decision-making — authority to consent to or refuse medical, surgical, and psychiatric treatment when the Protected Person lacks capacity.
Conservatorship / financial authority — authority to manage income, assets, and contracts on behalf of the Protected Person.
Limited or temporary authority — authority restricted to specified matters or for a specified term as described below.

3. SUPPORTING FACTS AND FUNCTIONAL LIMITATIONS

4. FINANCIAL INFORMATION

5. PROPOSED GUARDIAN BACKGROUND

Has the Proposed Guardian been convicted of a felony or crimes involving moral turpitude?     Is bonding requested or required by the Petitioner?

6. INTERESTED PERSONS AND NOTICE

7. ATTORNEY / REPRESENTATION

8. ADDITIONAL STATEMENTS AND DECLARATIONS

The Petitioner declares that the facts set forth in this Questionnaire are true and correct to the best of Petitioner’s knowledge and belief. Petitioner acknowledges that knowingly making false statements in a document submitted to the court may subject the declarant to penalties for perjury or other legal sanction under applicable law.

9. LEGAL PROVISIONS

Governing Law: This Questionnaire and any petition filed in connection with the matters described herein shall be governed by and construed in accordance with the laws of the state in which the petition is filed. The terms and representations contained in this Questionnaire are intended for submission to the court and shall not be construed to create any private contract between the parties.

Entire Agreement: This document contains the complete written statements of the Petitioner with respect to the facts requested in this Questionnaire. Any oral statements or prior writings not expressly included herein are superseded.

Severability: If any provision of this Questionnaire is held to be invalid or unenforceable, the remaining provisions shall remain in full force and effect.

Amendments and Waiver: Any amendment to information provided in this Questionnaire must be made in writing and signed by the Petitioner. No waiver of any provision shall be effective unless executed in writing by the party granting the waiver.

CERTIFICATION

I certify under penalty of perjury under the laws of the state in which this Questionnaire is submitted that the foregoing is true and correct to the best of my knowledge, information, and belief.

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