Fill and Sign the Pg 410 Order Appointing Temporary Guardian State of Alaska Form

AS 13.26.005-. 580 Probate Rules 14 - 19 Page 1 of 7 PG-100 (3/18)(cs) PETITIO N FOR APPOINTMEN T OF A FUL L GUARDIA N FOR AN ADULT IN THE SUPERIOR COURT FOR THE STATE OF ALASKA AT In the Matter of the Protective Proceeding of ) ) ) ) ) ) CASE NO. Respondent (person who needs a guardian) ) ) PETITION FOR APPOINTMENT OF A FULL GUARDIAN FOR AN ADULT [Full guardianship is a legal arrangement where the court appoints a person or institution t o 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). [Someone is incapacitated if his or her ability to receive and evaluate information or to communicate decisions is so impaired that the person cannot provide for their physical health or safety without court-ordered help (including health care, food, shelter, clothing, personal hygiene, and protection).] How long will this appointment need to last? 2. Petitioner's Name Age Mailing Address (box or street number) (city) (state) (ZIP) E-mail Address Home Phone Work Phone Cell Phone Relationship to the Respondent 3. Respondent's Name Date of Birth Mailing Address (box or street number) (city) (state) (ZIP) Residence Address (street address) (city) (state) 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): ( AS 13.27.170) 5. Has anyone filed a petition to protect the respondent from financial abuse? No Yes. Case Number: AS 13.26.005-. 580 Probate Rules 14 - 19 Page 2 of 7 PG-100 (3/18)(cs) PETITIO N FOR APPOINTMEN T OF A FUL L GUARDIA N FOR AN ADULT 6. The r espondent’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 : Dates During the Past Year Place (State & Address) Where Respondent Lived 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, n ame, 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 AS 13.26.005-. 580 Probate Rules 14 - 19 Page 3 of 7 PG-100 (3/18)(cs) PETITIO N FOR APPOINTMEN T OF A FUL L GUARDIA N FOR AN ADULT 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.) Name Phone Address a. Spouse: b. Children: c. Parents: d. Brothers and Sisters: e. If the respondent has none of the above relatives, list the name and address of the respondent's nearest relative: 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. Mon thly Income b.Monthly Expenses Wages, Pension, Retirement FoodSocial Security Rent or MortgageS.S.I. UtilitiesPublic Assistance Car PaymentLongevity Bonus Credit Card PaymentInterest and Dividends InsuranceVeteran's Benefits Medical (not coveredOther monthly income: by insurance) Other: TOTAL TOTAL AS 13.26.005-. 580 Probate Rules 14 - 19 Page 4 of 7 PG-100 (3/18)(cs) PETITIO N FOR APPOINTMEN T OF A FUL L GUARDIA N FOR AN ADULT 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 e.Debts Cash on hand or in savings Mortgagesor checking acco unt Stocks, bonds, CDs, Loans mutual funds Home Credit card balance Other land or buildings Other: Vehicles Businesses Insurance Other Property TOTAL ASSETS TOTAL DEBTS f. Additional Financial Information Does the respondent have a trust? No g. 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: 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: AS 13.26.005-. 580 Probate Rules 14 - 19 Page 5 of 7 PG-100 (3/18)(cs) PETITIO N FOR APPOINTMEN T OF A FUL L GUARDIA N FOR AN ADULT 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. Name Phone Address a. Doctors: b. Counselors and Social Workers: c. Case Managers and Care Coordinators: d. 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: AS 13.26.005-. 580 Probate Rules 14 - 19 Page 6 of 7 PG-100 (3/18)(cs) PETITIO N FOR APPOINTMEN T OF A FUL L GUARDIA N FOR AN ADULT 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 pa rent. (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. (For example, if you checked number (3), you would fill in the name of the respondent’s spouse and the person nominated by the respondent, if any.) Names and Addresses: 17. Wh o do you think the cou rt 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. (For example, if you checked number (3), you would fill in the name of the respondent’s spouse and the person nominated by the respondent, if any.) Names and Addresses: AS 13.26.005-. 580 Probate Rules 14 - 19 Page 7 of 7 PG-100 (3/18)(cs) PETITIO N FOR APPOINTMEN T OF A FUL L GUARDIA N FOR AN ADULT Date Signature of Petitioner or Petitioner's Attorney If attorney, print name and bar number: 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. Date Petitioner's Signature Subscribed and sworn to or affirmed before me at , Alaska on . (date) (SEAL) Clerk of Court, Notary Public, or other person authorized to administer oaths. My commission expires: