Fill and Sign the Petition Appointment Conservator 497431001 Form

STATE OF WISCONSIN, CIRCUIT COURT,       COUNTY For Official Use IN THE MATTER OF       Amended Petition for Appointment of Conservator       Date of Birth Case No.       UNDER OATH, I STATE THAT: 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, State 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 options 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. I petition the court to: A. Appoint a consevator of my estate with: 1. duties under §54.19; 2. standard powers under §54.20(1), and 3. powers that do not require court approval under §54.20(3) Conservator of estate’s authority: full limited       B. Authorize the conservator of the estate to exercise additional powers requiring court approval under §54.20(2), other than to make gifts, as follows:       C. I request that bond be waived. set by the court. GN-3350, 04/07 Petition for Appointment of Conservator §54.76, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 1 of 2 Petition for Appointment of Conservator Page 2 of 2 Case No. D. No withdrawals may be made from any account without a specific court order, because the court has dispensed with the requirement of bond and has ordered the guardian of the estate to 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 name of the guardian and the ward, and payable only upon further order of the court. 7. I understand that I will be personally examined by the court at the hearing and that the court will determine the suitability of the nominated conservator or standby conservator. I REQUEST THAT THE COURT: 1. Order a hearing on this petition. 2. Make findings and appointments as requested above. Subscribed and sworn to before me on       Notary Public/Court Official My commission expires:       Signature of Petitioner       Name Printed or Typed       Address       Name of Attorney       Address       Telephone Number       Bar Number       GN-3350, 04/07 Petition for Appointment of Conservator §54.76, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 2