STATE OF SOUTH CAROLINA COUNTY OF: ___________________________ ) ) ) ) IN THE PROBATE COURT IN THE MATTER OF: _____________________ CASE NUMBER: _______________________________ _______________________________________ Petitioner PETITION FOR: MINOR ADULT vs. PROTECTIVE ORDER APPOINTMENT OF CONSERVATOR __________________________________________ Respondent(s) Petitioner: _______________________________________________________________________________________ 1. Give your relationship to the alleged incapacitated person, if any, and your interest in this proceeding. __________________________________________________________________________________________ 2. Information Minor/Allegedly Incapacitated Person Name: Date of Birth: Last Four Digits of Social Security Number: Address: City/State/Zip: Telephone (Home): Age: XXX-XX- (Office/other): DOES DOES DOES NOT have a Will DOES NOT have a Power of Attorney To my knowledge, the above-named To my knowledge, the above-named 3. Jurisdiction and Venue South Carolina has jurisdiction over the allegedly incapacitated adult because: South Carolina is the "Home State" because the allegedly incapacitated person has been physically present in South Carolina for the six month period immediately preceding the filing of this petition or for at least six consecutive months ending within the six month period immediately preceding the filing of this petition; or If the allegedly incapacitated person has not been physically present in South Carolina for that period, set forth on an additional sheet sufficient information on which the court may make a determination that it has initial jurisdiction pursuant to Section 62-5-707. A. FORM #540GC (10/13) 62-5-401, 62-5-404, 62-5-407, 62-5-410, 62-5-411, 62-5-412, 62-5-413, 62-5-414 Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Special jurisdiction is appropriate, if South Carolina does not have jurisdiction pursuant to Sections 62-5-707(1) through (3), to: (1) appoint a guardian in an emergency pursuant to this article for a term not exceeding ninety days for a respondent who is physically present in this State; (2) issue a protective order with respect to real or tangible personal property located in this State; or (3) appoint a guardian or conservator for an incapacitated or protected person for whom a provisional order to transfer the proceeding from another state has been issued pursuant to procedures similar to Section 62-5-714. B. Venue for this proceeding is proper in this county because the above minor/alleged incapacitated person: resides in this county does not reside in this county but has property in this county 4. The name and address of the above person's guardian, if any, is: ___________________________________________________________________________________________ 5. Information -- Family (list nearest relative first) of minor/alleged incapacitated person, including dates of birth of minors: Name Date of Birth Address Relationship (use additional sheet if necessary) 6. The following is a general statement of the property, assets, and income of the above person, together with an estimate of the value thereof: (A full inventory, Form #550PC, shall be completed and filed with the Court within thirty days of appointment.) Description Value 7. The appointment of a conservator for the above person is necessary because (state reasons justifying appointment): ____________________________________________________________________________________________ 8. I request the appointment of: Name: Address: Telephone (O): Telephone (H): Email: whose priority for appointment as conservator for the above person is as follows: fiduciary appointed or recognized by the appropriate court of any other jurisdiction in which the minor/alleged FORM #540GC (10/13) Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com incapacitated person resides individual or corporation nominated by the minor/alleged incapacitated person (if fourteen or more years of age and deemed mentally capable of making such a choice) attorney-in-fact appointed by protected person (Pursuant to S.C. Code Ann. Section 62-5-501) spouse of protected person adult child of protected person parent of protected person or person nominated by will of deceased parent other relative of protected person (specify): ______________________________________________________________________________________ person nominated by the person who is caring for protected person or paying benefits to him/her nominated by one with priority to serve in his/her stead (specify): _______________________________________________________________________ ______________________________________________________________________________________ o other (specify) __________________________________________________________________________ 9. The following persons are required by statute to be given notice of the time and place of hearing on this Petition: Name Address Relationship 10. I request that the Court set a time and place of hearing on this Petition; that the Court determine that the above person is a person for whom appointment of a conservator is proper; that the Court appoint ___________ as the conservator for the above minor/incapacitated person; and, that Letters of Conservatorship be issued to the conservator. Executed this _________day of ____________, 20_________. Signature: VERIFICATION The undersigned, being sworn, states: That the facts set forth in the foregoing statement are true to the best of the undersigned's knowledge, information and belief. SWORN to before me this day of Signature: , 20 Name: Address: Notary Public for South Carolina My Commission Expires: E-mail: Telephone (O): (H): Signature: Name: Address: E-mail: Telephone (O): (H): FORM #540GC (10/13) Page 3 of 4 American LegalNet, Inc. www.FormsWorkFlow.com QUALIFICATION AND STATEMENT OF ACCEPTANCE I accept this appointment and agree to perform the duties and discharge the trust of the office of Conservator of the conservatorship of ____________________________________________________________________________. Executed this __________ day of _________, 20____________. SWORN to before me this , 20 day of Signature: Name: Address: E-mail: Telephone (O): (H): Signature: Name: Address: E-mail: Telephone (O): (H): Notary Public for South Carolina My Commission Expires: FORM #540GC (10/13) Page 4 of 4 American LegalNet, Inc. www.FormsWorkFlow.com
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