Fillable A C B FILE NO. 2. An action (Michigan)

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A C B FILE NO. 2. An action (Michigan)

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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 Court, Case Number , was
assigned to Judge , and remains is no longer pending.
1. I, , am interested in this matter and make this petition as
.
3
. The individual named above, born , is a resident of ,
Michigan, and presently lives with/at at
.
The individual is a citizen of the following foreign country:
4. His/her presumptive heirs are as follows: (
Attach additional page if needed.)
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:
(PLEASE SEE OTHER SIDE)
In the matter of , an individual with an alleged developmental disability
PC 658 (9/12) PETITION FOR APPOINTMENT OF GUARDIAN, INDIVIDUAL WITH ALLEGED DEVELOPMENTAL DISABILITY
JIS CODE: PEGApproved, SCAO
FILE NO.
Name (type or print)
PETITION FOR APPOINTMENT OF
GUARDIAN, INDIVIDUAL WITH ALLEGED
DEVELOPMENTAL DISABILITY
MCL 330.1100a, MCL 330.1609
State your interest/relationship
Do not write below this line - For court use only
NAME AGE RELATIONSHIP ADDRESS AND TELEPHONE NUMBER
County
Name of person or center or facility
Address City State Zip Telephone no. Last four digits of SSN
Date
A
B
C
D
E
F
G
H
XXX-XX-
STATE OF MICHIGAN
PROBATE COURT
COUNTY OF
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.
Street address
City
State
Zip
Telephone no.
Street address
City
State Zip Telephone no.
Form Instructions
9. The estimated value of the individual's estate and income are:
Real estate: $ Personal property: $
Yearly income: $ Source of yearly income:
I REQUEST THAT:
10. If a report does not accompany this petition, the court order evaluations to be performed and a report to be prepared.
11. The court determine that the individual requires guardianship as an individual with a developmental disability.
12. The court determine and appoint of
or appoint some other suitable individual or entity as
a. plenary (full) guardian of the individual estate
b. partial guardian of the individual estate with the following powers:
The proposed guardian is a current service provider. No other individual or agency is suitable to serve as guardian.
13. The court authorize the guardian to execute an application for admission to
located at .
14. Pending the appointment of a guardian, the court appoint a temporary guardian or exercise its emergency powers
because
.
15. The court appoint of
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.
Address City State Zip Telephone no.
Name
AddressName
Address
Name of facility
Describe emergency situation
Address
Signature of petitioner
City, state, zip
Address
Name (type or print)
City, state, zip Telephone no.
Telephone no.
Bar no.
DateSignature of attorney
8. A guardian is needed to assist the individual with the following responsibilities and duties:
I
J
K
L
M
N
Telephone no.
City State Zip
/s/
/s/
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A C B FILE NO. 2. An action (Michigan)

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Completed 30 August 2020

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