Verified Motion For Appointment Of Temporary Guardian For Adult {MPC 320}

VERIFIED MOTION FOR APPOINTMENT OF Docket No. TEMPORARY GUARDIAN FOR AN INCAPACITATED PERSON PURSUANT TO G.L. c.190B, § 5-308 In the Interests of: First Name Middle Name Last Name Commonwealth of Massachusetts The Trial Court Probate and Family Court Division Alleged Incapacitated Person/Respondent on Petition filed The court shall encourage the development of maximum self-reliance and independence of the Incapacitated Person and make appointive and other orders only to the extent necessitated by the Incapacitated Person's limitations or other conditions warranting the guardianship. Now comes the moving party First Name M.I. Last Name who states as follows: 1. An emergency exists requiring the appointment of a Temporary Guardian as any delay in the appointment will cause immediate and substantial harm to the health, safety or welfare of the Respondent, and no other person has authority to act in the circumstances. 2. The nature of the circumstances requiring the appointment of a Temporary Guardian are: 3. The particular harm sought to be avoided is: 4. The actions which need to be taken by a Temporary Guardian to avoid the harm are: 5. Respondent: Does (See Petition) does not have a Health Care Agent in the Commonwealth or elsewhere or attached already filed with the Court unavailable. Uncertain. A copy of the Health Care Proxy is 6. Respondent: Does (See Petition) Uncertain. A copy of the Durable Power of Attorney is The within Motion hereby is Date does not have a Durable Power of Attorney/Agent in the Commonwealth or elsewhere or attached already filed with the Court unavailable. DENIED. ALLOWED (see Order Appointing Temporary Guardian). JUSTICE OF THE PROBATE AND FAMILY COURT American LegalNet, Inc. www.FormsWorkFlow.com MPC 320 (5/30/11) page 1 of 2 WHEREFORE, PETITIONER REQUESTS THAT THIS HONORABLE COURT: Appoint The Petitioner(s) or or First Name M.I. Last Name Some suitable person. as Temporary Guardian(s) of the Respondent to serve with without sureties for the following reasons: The moving party further seeks specific court authorization: to admit Respondent to a nursing facility; to treat Respondent with antipsychotic medication in accordance with a treatment plan; for the following treatment or action for which a substituted judgment determination may be required: to revoke the Health Care Proxy of the Incapacitated Person; to apply for health insurance benefits including MassHealth on behalf of the Respondent. In addition, I request that the Court: SIGNED UNDER THE PENALTIES OF PERJURY I affirm or swear under oath that I have read the foregoing Motion and that the statements set forth therein are true and correct to the best of my knowledge. Date Signature of Moving Party Date Signature of Attorney for Moving Party (Print name) (Address) (City/Town) (Apt, Unit, No. etc.) (State) (Zip) Primary Phone #: B.B.O. # MPC 320 (5/30/11) page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com