Fill and Sign the New York Court Form

SURROGATE'S COURT OF THE STATE OF NEW YORK COUNTY OF __________________ Filing Fee Paid $____________________Certs $______________________Certs $______________________$ Bond, Fee $__________Receipt No:_______________ No.______________Proceeding for the Appointment of a PermanentGuardian of the Person and Estate of ___________________ An Adult (Name of Respondent) Family File No._____________TO THE FAMILY COURT: The Petitioners respectfully allege to this Court that: 1. We are the parents of _______________________ (Name of Respondent) , an adult resident citizen over the age of 21 and a citizen of the County of _____________, the subject of this Petition. We are submitting this Petition in order to be appointed Guardians of the Person and Property of ____________________ (Name of Respondent) .2.Our names are ___________________________________ (Names of Petitioners) and we live at ___________________________________________________________________ ____________ (street address, city, county, state, zip code). 3. The name, date of birth and residence of the person over the age of 21 who is the subject of this proceeding is as follows: A. Name:______________________ (Name of Respondent),B. Date of Birth: __________________ (Date of Birth of Respondent) ,C.Complete address: _____________________________________________ _____________________ (Address of Respondent) 4. The subject of this proceeding is not a Native American child under or over the age of 18 who is subject to the Indian Child Welfare Act of 1978 (25 U.S.C. §§1901-1963). 5. The name and relationship of person with whom the subject of this proceeding resides are as follows: A.Person with whom subject resides: (specify name of institution) _______________________________________:B.Relationship to subject: (Specify if institution is appointed guardian or some other official capacity over Respondent) __________________ ____________________________________________________________.C.Address:________________________________________________ ___________________________ (street address, city, county, state, zip code) . 6.The religion of the person who is the subject of this proceeding is __________________.7. The names, relationship and post office addresses of the birth parents of the subject of the proceeding, the name and address of the person with whom the subject resides, if other than the parent(s), on whom process should issue; and such other persons concerning whom the court is required to have information, are as follows: Relationship Name Complete Address Deceased? TPR? Birthmother: _______________ __________________________ NoNoBirth father: ________________ __________________________ NoNoPerson with whom ________________________________ (specify name and addressthe subject resides, _________________________________ of institution)if other than parents: _________________________________Parenthood of Petitioners of the Respondent has never been given up in any way. 8.Appointing the Petitioners as Guardians of the Person and Property of ________________________ (Name of Respondent) would be in his best interests and would care for him and preserve his because we his parents and are able and willing to see to his daily needs.9.(Include if applicable): The local social services district performed an assessment, as required by S.C.P.A. §1704(8), that recommended the following [specify and attach a copy of the assessment]: _______________________________________________________________10.No guardian pursuant to will or deed, or guardian of the person pursuant to Section 384 or 384-b of the Social Services Law, has been previously appointed for the subject of this proceeding, except [specify]: ______________________________________________________ ______________________________________________________________________________ 11. Neither of Petitioners have never been the subject of an indicated report, as such term is defined in of the Social Services Law §412, that has been filed with the statewide register of child abuse and maltreatment pursuant Social Services Law §422. 12. Neither of Petitioners have never been the subject of, or the respondent in, a child protective proceeding pursuant to Article Ten of the Family Court Act. 13. Neither of Petitioners have never been the subject of an Order of Protection or Temporary Order of Protection in any criminal, matrimonial or Family Court proceeding(s). 14. The person who is the subject of this proceeding is over the age of 18 and has consented to the appointment of the guardian, a copy of which is attached. 15. There are no persons interested in this proceeding other than those mentioned above. 16. No prior application has been made to any court, including a Native- American tribunal, for the relief requested herein (except [specify]: _____________________________). 17. State exact title and amount of all of the following Personal Property of Respondent: A. All bank accounts with account number and balance; ___________________________________________________________________________________ ___________________________________________________________________________________ B. Any insurance policies by company, policy number, amount insured, name of insured and relationship to respondent; ______________________________________________________________________________________________________________________________________________________________________C. The name, number of shares and value of all stocks, bonds, and any other personal property including all causes of action the respondent may have. ______________________________________________________________________________________________________________________________________________________________________ 18. State the following regarding Real Property of Respondent or as it relates to Respondent A.Location of Property:_____________________________________________;B.Gross Value of Property: $_________________________;C.Respondent’s Interest in Property:$_________________________;D.Annual Income generated by property $_________________________;E.Rental Income of property $____________________;F.Amount of Mortgage or Lien covering property______________________;G.Whether or not property is to be occupied by Respondent_______________:H.Is Sale of Property contemplated? ________. 19.Annual Income of Respondent from all sources: A.Wages to be received from: $ _________________B.Pension to be received from: $ _________________C.Income from Trust: $ _________________D.Governmental entitlements from: $ _________________E.Other Income: ________________________________$ _________________ 20.Source of property listed above: A.List any property listed above derived from an estate or as a result ofthe death of any person___________________________________________B.Name the decedent________________________________________C.Date of death and relationship to the Respondent; D.Whether a fiduciary has been appointed; court name; file number; and type of letters. Provide a copy of any will or decree directing payment. _______________________________________________________________________ F.List names and addresses of all banks, insurance companies and persons from whom payment is expected. ____________________________________________________________________ 21. Respondent has been duly certified as a person incapable of managing himself and/or his her affairs by reason of mental retardation developmental disability, and such condition is permanent in nature or likely to continue indefinitely, as shown by the certification of: A.Name of Physician____________________________________________; certification dated ___________________.B.Name of Physician____________________________________________; certification dated ___________________.C.Name of Licensed Psychologist _________________________________; certification dated ___________________.Said certifications shall be attached hereto and made part of the Petition. (Where certifications of two licensed physicians are used, at least one certification must evidence special qualifications to make the certification as set forth in SCPA Section 1750 or Section 1750) (At least one certification must evidence that the physician is familiar with or has professional knowledge in the care and treatment of persons with mental retardation or developmental disabilities, as appropriate). 22.Respondent is able to attend the hearing to be scheduled by the court. or 23.Respondent’s presence at the hearing should be dispensed with because respondent is medically incapable of being present to the extent that attendance is likely to result in physical harm to respondent. (Certification of certifying physician must so attest). WHEREFORE, Petitioners request:A.That an order be entered appointing them to be the guardians of the person and property of _________________________ (Name of Respondent), and that letters of guardianship so issue. B. The appearance of the Respondent (should be) or (should not be) required at any hearing. C. The Guardian of the person be authorized and empowered to make all decisions with respect to the medical and dental needs of the Respondent and to render consent to any medical procedures which are necessary to the health and welfare of the Respondent unless the court directs otherwise. A health care decision may include a decision to withhold or withdraw life- sustaining treatment as defined in subdivision (j) of 81.03 of the Mental Hygiene Law. D. The guardian of the person and property be directed to collect and receive all moneys and other property of the Respondent jointly with a clerk of the Surrogate’s Court, or depository subject to the provisions of SCPA 1708, and shall deposit same in the name of the Guardian subject to order of the Court with either: 1. Bank Depository named _____________________________ (Name) located at _______________________________________________________________ ______________ (street address, city, county, state, zip code)2. Bank Depository named ____________________________ (Name) located at _______________________________________________________________ _______________ (street address, city, county, state, zip code)E.The bond of the Guardian be dispensed with. Witness our signatures the _____ day of ___________________, 20______. VERIFICATION STATE OF NEW YORK ) )ss.: COUNTY OF________________ ) _______________________________________________ (Names of Petitioners), both being duly sworn, says that they are the Petitioners in the above-named proceeding and that the foregoing Petition is true to their own knowledge. Sworn to before me this ______ day of _______________________. 20______. Petitioner Petitioner _____________________________________ Deputy Clerk of the CourtNotary Public