Fill and Sign the Petition to Appoint Voluntary Guardian for an Infirm Person Vermont Form

STATE OF VERMONT PROBATE COURT DISTRICT OF ____________ In Re the Estate of: ) DOCKET No. __________ ) __________________ ) , Deceased ) ) ) LATE OF ) ) __________________ . ) ) ) PETITION TO APPOINT VOLUNTARY GUARDIAN FOR AN ADULT PERSON The undersigned petitioner requests that the court appoint a guardian pursuant to 14 V.S.A. § 2671 to assist in the management of my affairs. I state that I am more than 18 years of age (my date of birth is __________________ ) and I am not mentally ill or mentally retarded. The approximate value of my real estate is $ ____________ . The approximate value of my personal property is $ ____________ . My annual income is $ ____________ . (Financial information may be omitted in applications for limited guardianships for medical purposes only.) I have attached the entry fee. I request that the court appoint as my guardian: Name Residence Relationship ___________________ __________________ __________________ ___________________ __________________ __________________ ___________________ __________________ __________________ I request that the guardian have the following powers. (Check applicable requests) 1. To exercise general supervision over me; 2. To approve or withhold approval of any contract, except for necessaries, which I wish to make; 3. To approve or withhold approval of my requests to sell or in any way encumber my personal or real property; 4. To exercise general supervision over my income and resources; 5. To consent to surgery or other medical procedures, subject to the provisions of 14 V.S.A. § 3075 and any constitutional right of mine to refuse treatment; 6. To receive, sue for, and recover debts and demands due me, to maintain and defend actions or suits for the recovery or protection of - 1 - my property or person, settle accounts, demands, claims and actions at law or in equity against me, including actions for injuries to my property or person, and to compromise, release, and discharge the same on those terms as the guardian deems just and beneficial to me. Check one of the following: I will physically appear before the court, or I will not be able to physically appear before the court but the petition is accompanied by a letter from a physician or qualified mental health professional stating that I understand the nature, extent and consequences of the guardianship requested and the procedure for revoking the guardianship. Date: Signed: , Petitioner Print Name: ______________________________ Address: ________________________________________ Telephone: (       ) _______________ I consent to be appointed guardian of the above petitioner: Date: Signed: , Proposed Guardian Print Name: ______________________________ Address: ________________________________________ Telephone: (       ) _______________ Rev. 9/5/95 - 2 -