Order Appointing Temporary Guardian

PETITION FOR APPOINTMENT OF A FULL GUARDIAN FOR AN ADULT

IN THE SUPERIOR COURT FOR THE STATE OF ALASKA AT

In the Matter of the Protective Proceeding of

Respondent (person who needs a guardian)

CASE NO.

PETITION FOR APPOINTMENT OF A FULL GUARDIAN FOR AN ADULT

Full guardianship is a legal arrangement where the court appoints a person or institution to make all decisions on issues such as housing, medical care, legal issues, finances, and services. If you only wish for limited guardianship, use form PG-103. For a conservatorship (financial management only), use form PG-104.

1. Petitioner asks the court to appoint a full guardian for the above-named respondent because the respondent is incapacitated as defined in Alaska Statute 13.26.005(5).

How long will this appointment need to last?

2. Petitioner's Name Age

Mailing Address

E-mail Address

Home Phone Work Phone Cell Phone

Relationship to the Respondent

3. Respondent's Name Date of Birth

Mailing Address

Residence Address

Daytime Phone Social Security No.

4. Has anyone filed a petition for appointment of a guardian for the respondent in any other state? No Yes in (court name & location) by case number (if known):

5. Has anyone filed a petition to protect the respondent from financial abuse? No Yes Case Number:

6. The respondent’s “home state” as defined in AS 13.27.180 is:

Alaska because the respondent was physically present in Alaska for the six consecutive months before the filing date of this petition (except for temporary absences).

because the respondent was physically present in that state for the six consecutive months before the filing date of this petition (except for temporary absences).

I do not know the respondent’s “home state.”

The respondent was in the following states during the year before I filed this petition:

7. a. The respondent lives alone with

b. Who takes care of the respondent?

Name of person or facility

Address Phone

c. Does the respondent currently have a guardian? No Yes

If yes, guardian's name, address and phone

d. Does the respondent currently have a conservator? No Yes

If yes, conservator's name, address and phone

e. Has the respondent given a power of attorney to anyone? No Yes

If yes, name, address and phone

f. Does respondent have a "representative payee" for social security or other benefits? No Yes

If yes, name, address and phone

g. Are there any other restrictions on the respondent’s legal capacity to act on his or her own behalf? No Yes

If yes, describe the restrictions:

h. Does the respondent have a living will or a durable power of attorney for health care or any other document directing how health care decisions should be made if the respondent is unable to make them? No I do not know Yes

Describe (include name of any agent authorized to make health care decisions for the respondent):

i. Is a no-code (Do Not Resuscitate) provision in place for the respondent? No I do not know Yes

8. List the names, addresses and telephone numbers of the following relatives of the respondent: (If respondent has no such relative, write "none" on that line. Attach additional pages if necessary. Do not write on the back of any page.)

Spouse:

Children:

9. List names, addresses and telephone numbers of the respondent’s close friends who may have current information about the respondent:

10. Respondent's Financial Information

a. Monthly Income

Wages, Pension, Retirement

Social Security

S.S.I.

Public Assistance

Longevity Bonus

Interest and Dividends

Veteran's Benefits

Other monthly income:

TOTAL

b. Monthly Expenses

Food

Rent or Mortgage

Utilities

Car Payment

Credit Card Payment

Insurance

Medical (not covered by insurance)

Other:

TOTAL

c. Other Income Received During Last 12 Months

Permanent Fund Dividends (PFD) received in last 12 months

Native/Other Corporation Dividends not listed above

Value of gifts or inheritances received in last 12 months

Other:

d. Assets

Cash on hand or in savings or checking account

Stocks, bonds, CDs, mutual funds

Home

Other land or buildings

Vehicles

Businesses

Insurance

Other Property

TOTAL ASSETS

e. Debts

Mortgages

Loans

Credit card balance

Other:

TOTAL DEBTS

f. Additional Financial Information

Does the respondent have a trust? No Yes Name of Financial Institution and trustee:

Does the respondent belong to a Native Corporation? No Yes Name of Native Corporation:

Please list the institutions where the respondent has savings, checking or investment accounts:

Petitioner has no knowledge of the respondent's financial situation.

11. Is the respondent a veteran entitled to the payment of money from the U.S. Department of Veterans Affairs? Yes No

12. Describe the respondent’s mental or physical state which causes you to think he or she cannot take care of all of his or her living responsibilities:

13. List examples that show how the respondent's limitations have, or may, lead to physical injury or illness and the need for a guardian:

14. List people you know who have knowledge that might help the court determine the capacity and needs of the respondent including the respondent’s ability to manage his or her property and affairs.

Doctors:

Counselors and Social Workers:

Case Managers and Care Coordinators:

Others (Teachers, Clergy, etc.):

15. Letters or Evaluations:

Attached to this petition are letters or evaluations from a doctor, ANP, neuropsychologist, psychologist, or psychiatrist indicating the respondent’s diagnoses and how the diagnoses impacts the respondent’s ability to make considered decisions regarding his or her affairs.

I do not have any letters or evaluations to attach.

16. Who do you think the court should appoint guardian?

Name

Address Phone

This person's relationship to the respondent is:

This person has priority to be appointed under AS 13.26.465 because he or she is:

(1) nominated by the respondent.

(2) the respondent’s spouse.

(3) the respondent’s adult child.

(4) the respondent’s parent.

(5) the respondent’s relative whom the respondent lived with for at least six months during the year before filing this petition.

(6) the respondent’s relative or friend who has shown a sincere and longstanding interest in the respondent’s welfare.

(7) a private professional conservator.

(8) the public guardian.

If there are unchecked boxes above the one you checked, list the names and addresses of persons who could check those boxes.

17. Who do you think the court should appoint conservator? (Can be same as guardian.)

Name:

Address: Phone

This person's relationship to the respondent is:

This person has priority to be appointed under AS 13.26.465 because he or she is:

(1) nominated by the respondent.

(2) the respondent’s spouse.

(3) the respondent’s adult child.

(4) the respondent’s parent.

(5) the respondent’s relative whom the respondent lived with for at least six months during the year before filing this petition.

(6) the respondent’s relative or friend who has shown a sincere and longstanding interest in the respondent’s welfare.

(7) a private professional conservator.

(8) the public guardian.

If there are unchecked boxes above the one you checked, list the names and addresses of persons who could check those boxes.

Verification

I state on oath or affirm that I have read this petition and that all statements made in it are true to the best of my knowledge and belief.

Subscribed and sworn to or affirmed before me at , Alaska on

(SEAL)

Clerk of Court, Notary Public, or other person authorized to administer oaths.

My commission expires: