Fill and Sign the Petition for Guardian of Incapacitated Person New Form

NHJB-2165-P (01/02/2014) Page 1 of 4 THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) Guardianship of PETITION FOR GUARDIAN OF INCAPACITATED PERSON 1. Petitioner name Relationship to ward Address Telephone Petitioner name Relationship to ward Address Telephone 2. Attorney for petitioner Telephone Firm name Bar ID # Address 3. Proposed ward name Date of birth Address Telephone 4. Name of person or institution having care or custody of the proposed ward Telephone Address 5. The petitioner asks that guardianship be granted to: Proposed guardian name Date of birth Relationship to proposed ward Occupation Address Telephone Proposed guardian name Date of birth Relationship to proposed ward Occupation Address Telephone 6. Has the proposed ward nominated a guardian in accordanc e with RSA 464-A:10? Yes No If yes, name of guardi an nominated by proposed ward Address Telephone 7. Attorney for proposed ward Telephone Firm name Bar ID # Address Case Name: Guardianship of Case Number: PETITION FOR GUARDIAN OF INCAPACITATED PERSON NHJB-2165-P (01/02/2014) Page 2 of 4 8. List the name and address of the ward’s: spouse, parents, adult children and adult siblings. For each person listed, write the relations hip to the ward in the space provided. Name Address Relationship 9. List the names and addresses of any adults, other than the proposed guardian, who will be li ving in the same household as the wa rd. Those persons must provide th e court with a completed Criminal Record Release Authorizatio n form and a DHHS Record Re lease Authorization form. 10. Does proposed ward have a durable power of attorney? Yes No (If yes, a guardianship over t he estate may not be necessary.) 11. Does proposed ward have a durable power of attorney for health care? Yes No (If yes, a guardianship over the person may not be necessary) 12. Does proposed ward have a living will? Yes No 13. Petition is made for guar dianship over the ward's: person estate person & estate 14. Guardianship sought will be: temporary not temporary/enduring If temporary guardianship is so ught, state the reasons why a long term guardianship would not be appropriate. 15. Length of time for which appointment of guardian is requested: indefinite time days months years 16. Briefly describe real esta te owned by the proposed ward. Approximate value of real estate $ 17. Briefly describe personal property owned by the proposed ward. Approximate value of personal property $ Case Name: Guardianship of Case Number: PETITION FOR GUARDIAN OF INCAPACITATED PERSON NHJB-2165-P (01/02/2014) Page 3 of 4 18. Briefly describe sources and amount of income of the proposed ward. 19. The petitioner requests that the court find the ward incapable of exercising the following rights, namely the right to: (che ck all appropriate boxes) Travel or decide where to live Refuse or consent to medi cal or other professional care, counseling, treatment or service, including the right to admit or discharge the ward from any hospital or other medical institution providing such at the lawful direction of the guardian of the person Marry or Divorce Make a will or waiv e the provisions of a will Hold or obtain a moto r vehicle operator's license Testify in any judicial or administrative proceedings Have access to, grant release of, withhold, d eny, or refuse authorization for the guardian of the person to obtain access to and release the ward's confidential records and papers insofar as the same may be reasonably needed by the guardian of the person to ensure that the ward's mental, emotional and physical h ealth concerns are properly addressed and treated Possess or manage real or personal property or income from any source Make gifts Lend or borrow money Pay or collect debts Manage or run a business Convey or hold property Cancel, reject or oppose any authority or po wer granted to the guardian of the estate and/or person Continue to act as a member of a partnership Initiate, defend or settle lawsuits Make contracts or grant power of attorney or other authorizations Make decisions concerning educational matters and training Other (please specify) NOTE: THE COURT MAY IMPOSE ADDITIONAL ORDERS AS A RESULT OF THE HEARING. Case Name: Guardianship of Case Number: PETITION FOR GUARDIAN OF INCAPACITATED PERSON NHJB-2165-P (01/02/2014) Page 4 of 4 20. As required by RSA 464-A:4, III, a statement must be provided below containing facts showing the necessity for the appointment of the guardian of the person and estate, or the person, or the estate of the proposed ward, including specific factual allegations as to the proposed ward's financial transactions, personal actions or actual occurrences which are claimed to demonstrate his/her inability to manage an esta te, or to provide for personal needs for health care, food, clothing, shelter or safety. All evidence of inability must be within 6 months and one incident must have occurred within 20 days of the filing of this petition. (Please use additional sheets, if necessary.) Date Petitioner's Signature (must be in the presence of notarial officer) Date Petitioner's Signature (must be in the presence of notarial officer) State of , County of This instrument was acknowledged bef ore me on by Date Petitioner name(s) My Commission Expires Affix Seal, if any Signature of Notarial Officer / Title