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A In the matter of STATE OF MICHIGAN (Michigan)

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STATE OF MICHIGAN
PROBATE COURT
COUNTY
PETITION FOR
APPOINTMENT OF GUARDIAN
OF INCAPACITATED INDIVIDUAL
CASE NO. and JUDGE
Court address Court telephone no.
In the matter of
First, middle, and last name
Last four digits of SSN
Approved, SCAO
Form PC 625, Rev. 5/21
MCL 700.1105(a), MCL 700.5303, MCR 5.125(C)(23), MCR 5.402(A)
Page 1 of 3
A
B
PCS Code: PEG
TCS Code: PGII
Petitioner’s name, address and telephone no. Petitioner’s attorney, bar no., address, and telephone no.
Date of birth Race Sex Address of alleged incapacitated individual where now found
Put DOB in Ref. No.
row 1 on MC 97.
Put last 4 digits of SSN in
Ref. No. row 2 on MC 97.
XXX-XX-
1. I,
Name (type or print)
, am interested in this
matter and make this petition as
State interest/relationship
.
2. An action within the jurisdiction of the family division of circuit court involving the family or family members of the
person named above has been previously filed in
Court, Case Number
,
was assigned to Judge
, and remains is no longer pending.
3. The adult is a resident of
City, village, or township
,
County State
and has a home address and telephone number of
Address
City State Zip Telephone no.
.
The individual is a citizen of the following foreign country:
.
4. The adult has a patient advocate/power of attorney for health care. (Specify name and address below.)
a power of attorney. (Specify name and address below.)
a conservator. (Specify name and address below.)
Name and address
5. The patient advocate designation was not executed in compliance with MCL 700.5506.
The patient advocate is not complying with the terms of the designation or of MCL 700.5506 to MCL 700.5512.
The patient advocate is not acting consistent with the ward’s best interests.
6. The adult lacks sufficient understanding or capacity to make or communicate informed decisions because of
mental illness. mental deficiency. physical illness or disability.
chronic intoxication. chronic drug use.
.
C
D
E
F
G
H
Petition for Appointment of Guardian of Incapacitated Individual (5/21)
Page 2 of 3
Case No.
7. Specific facts about the adult’s recent condition or conduct that lead me to believe the adult needs a guardian are
(Attach a separate sheet if more space is needed.)
8. The name, address, and telephone number of the person/agency (if any) who currently has care and custody of the
adult are
.
9. The adult is is not entitled to receive Veterans Administration benefits. The Veterans Administration
claimant number is
.
10.The alleged incapacitated individual has
a spouse whose name and address are listed below.
adult child(ren) whose name(s) and address(es) are listed below.
living parent(s) whose name(s) and address(es) are listed below.
no spouse, adult child(ren), or parent(s). The names and addresses of presumptive heirs are listed below.
none of the above (must notify Attorney General - see instructions for the address of the Attorney General).
NAME
RELATIONSHIP ADDRESS AND TELEPHONE NUMBER
Street address
City State Zip Telephone No.
Street address
City State Zip Telephone No.
Street address
City State Zip Telephone No.
Street address
City State Zip Telephone No.
Nominated
guardian
Street address
City State Zip Telephone No.
11. None of the adults named above is under any legal incapacity except
Give name, legal incapacity, and representative of the person, if any
.
I
J
K
L
M
Petition for Appointment of Guardian of Incapacitated Individual (5/21)
Page 3 of 3
Case No.
12. I REQUEST that the court determine the adult is an incapacitated individual and appoint
Name
,
Address City, state, zip Telephone No.
who has priority as
Priority relationship
, full guardian with all powers provided by statute.
limited guardian with the following powers:
13. No other person appears to have authority to act in the circumstances. I request that a temporary guardian be
appointed pending a hearing on this petition because of the following emergency:
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.
Date
Petitioner signature
Date
Attorney signature
14. NOMINATION BY THE ALLEGED INCAPACITATED INDIVIDUAL
In the event the court finds that I require a guardian, I nominate
Name
Address, city, state, zip Telephone no.
Date
Signature of alleged incapacitated individual
O
P
Q
N
INSTRUCTIONS FOR COMPLETING
"PETITION FOR APPOINTMENT OF GUARDIAN OF INCAPACITATED INDIVIDUAL"
Please type or print neatly using black or blue ink.
Items A through Q 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
Enter the name of the individual who you believe needs a guardian.
B
Enter the date of birth of the individual named in
A
in Ref. No. row 1 on form MC 97, then fill in the race, and sex of the
individual. Enter the address where the individual is currently located. This address may or may not be the home of the
individual. For example, if the individual is currently in the hospital, enter the address of the hospital.
C
Enter your name in the first line and your relationship to the individual (or your interest) on the second line.
D
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 personal protection, abuse or neglect, or a name change. 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 that case. Then place a check in the box indicating whether that case is still pending or not.
E
Enter the city, village, or township and county and state the individual is a resident of and the full home address and
telephone number of the individual.
F
Check the boxes that apply and provide the name(s) and address(es).
G
If the individual has a patient advocate and you believe there is a problem, check only the boxes that apply.
H
Check the boxes that you believe apply to the individual.
I
Explain in as much detail as possible specific examples of the individual's conduct that lead you to believe he or she
needs a guardian. Give specific examples of his or her conduct that supports what you checked in
H
and that
demonstrate the need for a guardian. This information is extremely important for the court in making a decision
about the need to appoint a guardian. Use additional sheets of paper if needed.
J
Enter the name, address, and telephone number of the person or agency who currently has care and custody of the
individual. If there is no one, leave blank.
K
Check whether the individual is or is not entitled to receive Veterans Administration benefits. If you checked that the
individual is entitled to benefits, enter his or her VA claimant number.
L
-
M
Check all the boxes that apply and enter the names, relationships, addresses and telephone numbers of each
relative of the individual. Presumptive heirs includes minor children, if any. If any of the adults named in
L
are under legal incapacity, enter the names in
M
. If you check the last box in
L
(item 10), you must notify
the Attorney General by sending a copy of this form to: Attorney General, Public Administration, PO Box 30755,
Lansing, Michigan 48909.
N
Enter the name, address, and telephone number of the person you want to be appointed as guardian of the individual.
Enter the relationship, if any, that this person has to the individual. Check the box for either a full guardian or a limited
guardian.
O
Check the box if there is an emergency requiring the appointment of a temporary guardian before the hearing on this
petition is held.
P
Enter today's date and sign your name.
Q
If the individual wants to nominate someone to be his/her guardian, check the box and enter the name, address, and
telephone number of the person the individual is nominating. The individual must sign and date the form.
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A In the matter of STATE OF MICHIGAN (Michigan)

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Completed 1 December 2021

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