Kentucky > Statewide > Hospitalization-Disability
Petition To Determine If Disabled AOC-740 - Kentucky
| Petition To Determine If Disabled Form. This is a Kentucky form and can be used in Hospitalization-Disability Statewide . |
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AOC-740 Doc. Code: PDD Case No._____________________Rev. 5-00 Page 1 of 2 Court________________________Commonwealth of Kentucky Court of Justice PETITION TO DETERMINE County_______________________KRS 387.530 IF DISABLED COMMONWEALTH OF KENTUCKY, ) PETITIONER ) ) VS. ) ) ) _____________________________________________ ) RESPONDENT ) * * * * * * * * * * * * Petitioner, ____________________________________________________________, states that he/she has rea-sonable grounds or knowledge to lead him/her to believe that the Respondent named herein appears to be unableto provide for his/her physical health and safety and/or manage his/her financial resources effectively and submitsto the Court the following facts upon which he/she bases this belief: 1. Name of the Respondent:_______________________________________________________________________ Address:_____________________________________________________________________________________2. Birthdate of Respondent, if known:________________________________________________________________3. The nature of the Respondents disability and the facts or reasons supporting the need for a determination of disability are: ____________________________________________________________________________________________ ____________________________________________________________________________________________ 4. The Respondent owns the following estate, including government benefits, insurance entitlements, and anticipated yearly income (state if none or unknown): ESTATE VALUE Real Property $_____________________ Personal Property _____________________ Yearly Income _____________________ Source of Yearly Income _____________________ 5. Respondents next of kin are: NAME ADDRESS RELATIONSHIP______________________________ ______________________________ _____________________________ ______________________________ ______________________________ _____________________________ ______________________________ ______________________________ _____________________________ <<<<<<<<<********>>>>>>>>>>>>> 2AOC-740 Doc. Code: PDD Rev. 5-00 Page 2 of 2 6. The person or facility having custody of the Respondent is: ____________________________________________________________________________________________ Address:_____________________________________________________________________________________ 7. The Respondents ? Durable Power of Attorney ? Health Care Surrogate is: _________________________________________ _____________________________________________ Name Address _____________________________________________ _____________________________________________ WHEREFORE, Petitioner requests that the Court inquire into the ability of the Respondent to care for himself/herself and to manage his/her financial resources. Petitioner further requests: 1. Trial by jury; 2. Counsel to represent the Respondent; and 3. A physician, psychologist and social worker be appointed by the Court to evaluate the Respondent as provided by law unless the evaluation report is filed with this Petition. In support of this Petition, the application for appointment of fiduciary is attached. _________________________________________ _____________________________________________ DATE SIGNATURE OF PETITIONER_________________________________________ _____________________________________________ PETITIONERS RELATIONSHIP TO ADDRESS OF PETITIONER RESPONDENT ______________________________________________________________________________________ PETITIONERS TELEPHONE NUMBER * * * * * * * * * * * * SUBSCRIBED AND SWORN TO before me this___________day of____________________________, _________. My commission expires: _________________________________________________________________________ NAME/TITLE _____________________________________________ COUNTY, KENTUCKYTo be completed if Petitioner is represented by counsel: _____________________________________________ SIGNATURE OF ATTORNEY _____________________________________________ ADDRESS OF ATTORNEY _____________________________________________ TELEPHONE NUMBER
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