Michigan > Statewide > Probate > Guardianships and Conservatorships
Petition For Appointment Of Guardian Individual With Alleged Developmental Disability PC 658 - Michigan
| Petition For Appointment Of Guardian Individual With Alleged Developmental Disability Form. This is a Michigan form and can be used in Guardianships and Conservatorships Probate Statewide . |
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Approved, SCAO JIS CODE: PEG STATE OF MICHIGAN PROBATE COURT COUNTY OF PETITION FOR APPOINTMENT OF GUARDIAN, INDIVIDUAL WITH ALLEGED DEVELOPMENTAL DISABILITY FILE NO. A B In the matter of 1. I, Name (type or print) State your interest/relationship , an individual with an alleged developmental disability , am interested in this matter and make this petition as . C 2. An action within the jurisdiction of the family division of circuit court involving the family or family members of the individual has been previously filed in assigned to Judge Court, Case Number , and , is a resident of Date County Name of person or center or facility State Zip Telephone no. , was is no longer pending. , at . XXX-XXLast four digits of SSN remains D 3. The individual named above, born Michigan, and presently lives with/at Address City E The individual is a citizen of the following foreign country: 4. His/her presumptive heirs are as follows: (Attach additional page if needed.) NAME AGE RELATIONSHIP ADDRESS F G 5. A report and evaluation required by law accompanies does not accompany the petition. 6. The individual has a developmental disability described as a severe, chronic condition that meets all the following: 1) it is attributable to a mental or physical impairment or a combination of mental and physical impairments; 2) it was manifested before the individual was 22 years old; 3) it is likely to continue indefinitely; and 4) it results in substantial functional limitations in major life activities of (A minimum of three of the following options must apply and be checked.) self-care, receptive and expressive language, learning , mobility, self-direction, capacity for independent living, economic self-sufficiency, and it reflects the individual's need for a combination and sequence of special, interdisciplinary, or generic care, treatment, or other services that are lifelong or for an extended duration and are individually planned and coordinated. 7. The specific nature and extent of the disability is: H (PLEASE SEE OTHER SIDE) USE NOTE: If this form is being filed in the circuit court family division, please enter the court name and county in the upper left-hand corner of the form. Do not write below this line - For court use only MCL 330.1100a, MCL 330.1609 PC 658 (9/11) PETITION FOR APPOINTMENT OF GUARDIAN, INDIVIDUAL WITH ALLEGED DEVELOPMENTAL DISABILITY American LegalNet, Inc. www.FormsWorkFlow.com I 8. A guardian is needed to assist the individual with the following responsibilities and duties: J 9. The estimated value of the individual's estate and income are: Real estate: Yearly income: I REQUEST THAT: 10. 11. If a report does not accompany this petition, the court order evaluations to be performed and a report to be prepared. The court determine that the individual requires guardianship as an individual with a developmental disability. The court determine and appoint Address Name City State Zip $ $ Personal property: $ Source of yearly income: K 12. of Telephone no. or appoint some other suitable individual or entity as a. plenary (full) guardian of the b. partial guardian of the individual individual estate estate with the following powers: The proposed guardian is a current service provider. No other individual or agency is suitable to serve as guardian. L 13. The court authorize the guardian to execute an application for admission to located at Address Name of facility . M 14. Pending the appointment of a guardian, the court appoint a temporary guardian or exercise its emergency powers because Describe emergency situation . N 15. The court appoint Name of Address as standby guardian. I declare under the penalties of perjury that this petition has been examined by me and that its contents are true to the best of my information, knowledge, and belief. Signature of attorney Name (type or print) Address City, state, zip Telephone no. Bar no. Date Signature of petitioner Address City, state, zip Telephone no. American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS FOR COMPLETING "PETITION FOR APPOINTMENT OF GUARDIAN, INDIVIDUAL WITH ALLEGED DEVELOPMENTAL DISABILITY" Please type or print neatly using black or blue ink. Items A through N must be read and filled in (when required) before your petition can be filed with the court. Please read the instruction for each item. Then fill in the correct information for that item on the form. A B C Enter the name of the individual whom you believe needs a guardian. Enter your name on the first line and your relationship to the individual (or your interest) on the second line. Check this box if there is or has been a case in the family division of the circuit court involving the individual in "A." Examples of a family division case are a personal protection, abuse or neglect, adoption, name change, or divorce or support action. If the individual is under the age of 19½, the individual may be the subject of a support order if the parents are divorced or a support order was entered. If you have checked this box, enter the name of the court, the case number of the action, the name of the judge assigned to the case. Place a check in the box indicating whether the case is still pending or not. Enter the date of birth of the individual on the first line, the name of the county the person resides in on the second line, and the name, address, and telephone number of the person, center or facility where the person is currently located. This address and telephone number may or may not be the home of the individual. List the presumptive heirs of the individual. If the individual has a spouse or minor or adult children, list those individuals' names, addresses, ages, relationships and current addresses. If the individual does not have a spouse or children, list the parents of the individual and if there are no living parents, then the siblings of the individual, with their ages, relationship and current addresses. If the individual doesn't have any siblings, list any other presumptive heirs. If the individual has no presumptive heirs, you must notify the Attorney General by sending a copy of this form to: Attorney General, Public Administration, PO Box 30736, Lansing, MI 48909. Indicate whether a report and evaluation required by law accompanies or does not accompany the petition. Check the appropriate boxes under this item (not less than three). Indicate the specific nature and extent of the disability. Explain in detail, giving specific examples why a gua
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