Fill and Sign the Following Proceedings Concerns the Respondent Form

JDF 8 76SC R6/19 PETITION FOR APPOINTMENT OF CONSERVATOR FOR ADULT Page 1 of 8 ❑ District Court ❑ Denver Probate Court ___________________ County, Colorado Court Address: In the Interest of: Respondent COURT USE ONLY Attorney or Party W ithout Attorney (name and address): Phone Number: E-mail: FAX Number: Atty. Reg. #: Case Number: Division Courtroom PETITION FOR APPOINTMENT OF CONSERVATOR FOR ADULT 1. ❑ No court proceeding is pending in this state or elsewhere concerning the respondent. ❑ The following proceeding(s) concern(s) the respondent. Identify name of court, case number, state, date, and type of proceeding if any. Name of Court Case Number State Date of Proceeding Type of Proceeding 2. The petitioner is: ❑ a person who would be a dversely affected by lack of effective management of the respondent’s property and business. ❑ a person who is interested in the estate, financial affairs, or welfare of the respondent . ❑ the respondent . This is a petition for appointment of a : ❑ Permanent Conservator . ❑ Special Conservator . While a petition to establish a conservatorship is pending, there is a need to preserve and apply the property of the respondent as may be required for the support of the respondent or individuals who are in fact dependent upon the respondent . (§ 15-14 -406( 6), C.R.S.) ❑ Special Conservator . There is a need for a protective arrangement or other single transaction . A permanent conservatorship is not requested. (§ 15-14 -412(3), C.R.S.) 3. Information about the petitioner: Name: List all names used (also known as, formerly known as, etc .): __________________________________________ Relationship to Respondent: Street Address: City: ______________________ State: ______________ Zip Code: ___________________ Mailing address, if different: City: State: Zip Code: JDF 8 76SC R6/19 PETITION FOR APPOINTMENT OF CONSERVATOR FOR ADULT Page 2 of 8 Primary Phone: _______________ Alternate Phone: ______________________ Email Address: Does Petitioner need an interpreter? ❑ No ❑ Yes (Language:______________________________) 4. Information about the respondent: Name: Age: Date of Birth: Street Address: City: _________________________ State: _________________ Zip Code: _______________________ Mailing Address, if different: City: State: Zip Code: Does Respondent need an interpreter? ❑ No ❑ Yes (Language:______________________________) ❑ If this appointment is made, the Respondent’s dwelling will change to: 5. Information about the respondent’s spouse , partner in a civil union, or adult who has resided with the respondent for more than 6months in the last year : Name: Relationship to Respondent: Street Address: City: _____________________ State: _______________ Zip Code: __________________ Mailing Address, if different: City: State: Zip Code: Primary phone: ____________________ Alternate phone: ___________________________ Email Address: Does this person need an interpreter? ❑ No ❑ Yes (Language:______________________________) 6. Venue for this proceeding is proper in this county because the respondent ❑ resides in this county. ❑ does not reside in this state but has property in this county. 7. ❑ A Power of Attorney exists for financial or medical matters. (Attach a copy to the petition. ) The agent ’s name and mailing address are : 8. ❑ A valid designated beneficiary agreement exists. ( Attach a copy of the agreement to the petition. ) The designated beneficiary’s name and mailing address are : 9. ❑ A conservator is required because the respondent is unable to manage property and business affairs because he or she is unable to effectively receive and evaluate information or both or to make or JDF 8 76SC R6/19 PETITION FOR APPOINTMENT OF CONSERVATOR FOR ADULT Page 3 of 8 communicate decisions, even with the use of appropriate and reasonably available technological assistance due to the following disabilities or impairments : ❑ Physician’s letter attached. In addition: ❑ the respondent has property which will be wasted or dissipated unless proper management is provided . and/ or ❑ the respondent, or persons entitled to the respondent’s support, require money for support, care, education , health, and welfare, and protection is necessary or desirable to obtain or provide money. 10. ❑ A conservator i s required because the respondent is missing, detained, or unable to return to the United States . The nature of the respondent’s disappearance or detention and any efforts to locate the respondent are as follows: 11. The petitioner requests the special conservator’s powers and duties be ❑ unlimited/unrestricted or ❑ limited/with restrictions . The property to be placed under the special conservator’s control and the requested limitations/restrictions on the special conservator’s powers and duties, if any, are as follows: 12. The petitioner requests the conservator’s powers and duties be ❑ unlimited/unrestricted or ❑ limited/with restrictions . The property to be placed under the conservator’s control and the requested limitations/restrictions on the conservator’s powers and duties , if any, are as follows: JDF 8 76SC R6/19 PETITION FOR APPOINTMENT OF CONSERVATOR FOR ADULT Page 4 of 8 13. ❑ Petitioner is, 21 years of age or older , nominates himself or herself and requests to be appointed as conservator or special conservator. or ❑ Petitioner nominates the following person , who is 21 years of age or older, to be appointed as conservator or special conservator. Name: List all names used (also known as, formerly known as, etc.): __________________________________________ Relationship to Respondent: Street Address: City: ________________________ State: ________________ Zip Code: ___________________ Mailing Address, if different: City: State: Zip Code: Primary phone: ____________________ Alternate phone: ___________________________ Email Address: Does this person need an interpreter? ❑ No ❑ Yes (Language:______________________________) 14. The nominated conservator has priority for appointment because he or she is : (§ 15 -14 -413, C.R.S. ) ❑ a conservator, guardian , or other fiduciary appointed or recognized by a court in another jurisdiction where the protected person resides. ❑ nominated in writing by respondent , including nomination in a durable power of attorney or designated beneficiary agreement. ❑ an agent appointed by the respondent to manage the respondent’s property under a durable power of attorney. ❑ the s pouse or partner in a civil union of the respondent . ❑ an adult child of the respondent . ❑ a p arent of the respondent . ❑ an a dult with whom respondent has resided for more than 6months immediately before the filing of this petitio n. 15. ❑ The respondent nominated the following person as conservato r, but the petitioner does not seek that person’s appointment for the following reason: Name: List all names used (also known as, formerly known as, etc.): __________________________________________ Relationship to Respondent : Street Address: City: _____________________ State: _______________ Zip Code: ______________________ JDF 8 76SC R6/19 PETITION FOR APPOINTMENT OF CONSERVATOR FOR ADULT Page 5 of 8 Mailing Address, if different: City: State: Zip Code: Primary phone: _________________________ Alternate phone: _______________________ Email Address: 16. The conservator may receive compensation. ❑ The hourly rates to be charged, any amounts to be charged pursuant to a published fee schedule, including the rates and basis for charging fees for any extraordinary services, and any other bases upon which a fee charged to the estate will be calculated , are as stated below or in an attachment to this petition . * ❑ The basis of compensation has not yet been determined. * There is a continuing obligation to disclose any material changes to the basis for charging fees. (§ 15 -10 -602 C.R.S.) 17. The conservator may compensate his, her, or its counsel. ❑ The hourly rates to be charged, any amounts to be charged pursuant to a published fee schedule, including the rates and basis for charging fees for any extraordinary services, and any other bases upon which a fee char ged to the estate will be calculated , are as stated below or in an attachment to this petition . * ❑ The basis of compensation has not yet been determined. * There is a continuing obligation to disclose any material changes to the basis for charging fees. (§ 15 -10 -602 C.R.S.) 18. Sections a and b below identify assets and the source and amount of anticipated income or receipts (public benefits, income, real property, proceeds from insurance policy, proceeds from pension, etc.) , together with an estimate of the value . a. The respondent ’s assets are: Description of Assets (e.g. bank accounts, insurance, pensions, p roperty ) ❑ None . Estimated Value $ Total $ JDF 8 76SC R6/19 PETITION FOR APPOINTMENT OF CONSERVATOR FOR ADULT Page 6 of 8 b. The respondent ’s income is: Description of Income (e.g. social security, pension and insurance ) ❑ None . Estimated Amount of Income $ Total $ 19. ❑ The following person is currently acting as a ❑ guardian and/ or ❑ conservator in Colorado or elsewhere : Name: Relationship to Respondent: Street Address: City: _______________________ State: __________________ Zip Code: _____________________ Mailing Address, if different: City: State: Zip Code: Primary phone: ____________________ Alternate phone: ___________________________ Email Address: Does this person need an interpreter? ❑ No ❑ Yes (Language:______________________________) 20. Information about adult children and parents. ❑ None (If none , list an adult relative that can be found with reasonable efforts , such as a brother, sister, aunt, uncle , etc.) : Name: Relationship: ❑ Adult Child or ❑ Parent Street Address: City: _______________________ State: __________________ Zip Code: _____________________ Mailing Address, if different: City: State: Zip Code: Primary phone: ____________________ Altern ate phone: ___________________________ Email Address: Does this person need an interpreter? ❑ No ❑ Yes (Language:______________________________) Name: _______________ ______________________________ Relationship : ❑ Adult Child or ❑ Parent Street Address: City: _______________________ State: __________________ Zip Code: _____________________ Mailing Address, if different: City: State: Zip Code: Primary phone: ____________________ Alternate phone: ___________________ ________ Email Address: JDF 8 76SC R6/19 PETITION FOR APPOINTMENT OF CONSERVATOR FOR ADULT Page 7 of 8 Does this person need an interpreter? ❑ No ❑ Yes (Language:______________________________) Name: Relationship: Street Address: City: _______________________ State: __________________ Zip Code: _____________________ Mailing Address, if different: City: State: Zip Code: Primary phone: ____________________ Alternate phone: ___________________________ Email Address: Does this person need an interpreter? ❑ No ❑ Yes (Language:______________________________) 21. ❑ The following person had the primary c are and custody of Respondent during the 60 days prior to the filing of this Petition : Name: Relationship: Street Address: City: __________________ State: _________________ Zip Code: _____________________________ Mailing Address, if different: City: State: Zip Code: Primary phone: _____________________________ Alternate phone: _______________________ Email Addre ss: Dates of Care: Does this person need an interpreter? ❑ No ❑ Yes (Language:______________________________) 22. Information about each person currently responsible for the primary care and custody of the Respondent, including the Respondent’s treating physician: ❑ None Name of Treating Physician: Primary Phone: Alternate Phone: ______________________ Street Address: City: ____________________________ State: ____________________ Zip Code: ________________ Mailing Addr ess, if different: City: State: ___ Zip Code: ________ Email Address: Name of Caregiver: Primary Phone: Alternate Phone: ________________________ Street Address: City: __________________________ State: _________________ Zip Code: ___________________ Mailing Address, if different: City: State: ___ Zip Code: ________ Email Address: JDF 8 76SC R6/19 PETITION FOR APPOINTMENT OF CONSERVATOR FOR ADULT Page 8 of 8 23. ❑ The following person is a legal representative for the respondent not otherwise designated above . (R epresentative payee, trustee , custodian of a trust , etc. § 15 -14 -102(6), C.R.S.) Name: Type of Legal Representative: Street Address: ______________________________________________________________ City: ________________ State: ______________ Z ip Code: ____________________ Mailing Address , if different : City: State: Zip Code: Primary Phone: ____________________________ Alternate Phone: _____________________________ Email Address: 24. The petitioner requests that appointment of a conservator be made after notice and hearing . ❑ In addition, the petitioner request s the following : ❑ By checking this box, I am acknowledging I am filling in the blanks and not changing anything else on the form. ❑ By checking this box, I am acknowledging that I have made a change to the original content of this form. VERIFICATION I declare under penalty of perjury under the law of Colorado that the foregoing is true and correct. Executed on the ______ day of Executed on the ______ day of (date) (date) _______________________, _________, _______________________, _________, (month) (ye ar) (month) (year) at ______________________________________ at ______________________________________ (city or other location, and state OR country) (city or other location, and state OR country) _____________________________ __ _______________________________ (printed name) (printed name) _______________________________ _______________________________ (Signature of Petitioner ) (Signature of Co -Petitioner , if any) ________________________________________ __________________ Attorney Signature, (if any) Date