Fillable Mpc130 Petition For Appt Of Conservator For Disabled Person Fill (Commonwealth of Massachusetts)

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Mpc130 Petition For Appt Of Conservator For Disabled Person Fill (Commonwealth of Massachusetts)

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MPC 130 (1/1/15)
page
of
PETITION FOR APPOINTMENT
OF CONSERVATOR FOR
DISABLED PERSON
OR FOR SINGLE TRANSACTION
Commonwealth of Massachusetts
The Trial Court
Probate and Family Court
Docket No.
In the Interests of:
Last Name
Middle Name
Person to be Protected/Respondent
The Court, whenever feasible, shall grant to a Conservator only those powers necessary based on the
Protected Person's limitations and demonstrated needs and will issue orders that will encourage the
development of the Protected Person's maximum self-reliance and independence.
Minor
Adult
Division
1.
Information about Respondent:
If the residence and current address are outside of the Commonwealth, state the location of Respondent's property within
the county:
(Address)
(State)
(Zip)
(Apt, Unit, No. etc.)
Principal Residence:
Primary Language:
English
Other
Last Name
Name:
First Name
M.I.
Date Residence was established:
Current Address:
Same as Above or
the following address:
If this appointment is made, Respondent's dwelling will be
Principal Residence
Current Address
the following address:
Primary Phone #:
(Address)
(State)
(Zip)
(Apt, Unit, No. etc.)
(Address)
(State)
(Zip)
(Apt, Unit, No. etc.)
(Address)
(State)
(Zip)
(Apt, Unit, No. etc.)
Date of Birth:
Age:
Gender:
2.
Information about the Petitioner:
Name:
First Name
M.I.
Last Name
(Address)
(State)
(Zip)
Primary Phone #:
Relationship to Respondent:
(Apt, Unit, No. etc.)
State your interest in the appointment:
An attachment to this petition provides information on co-petitioners.
3.
Petitioner is requesting:
to be appointed
that some suitable person be appointed
the following person be appointed:
Name:
(Address)
(City/Town)
(State)
(Zip)
(Apt, Unit, No. etc.)
Primary Phone #:
First Name
M.I.
Last Name
Relationship to Respondent:
An attachment to this petition provides additional information.
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MPC 130 (1/1/15)
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He or she has priority of appointment because the nominee is:
4.
.
5.
This is a Petition for:
The appointment of a Limited Conservator
With limitations as follows:
The appointment of a Conservator
State why a limited conservator is inappropriate:
Authorization of the following protective arrangement or single transaction:
The appointment of a Special Conservator to assist in the accomplishment of the above-stated protective
arrangement or other authorized single transaction.
6.
Unless the Respondent is a minor, a Medical Certificate dated with an examination having taken place within 30 days
of the filing of the petition or, if Respondent is alleged to be Intellectually Disabled, a Clinical Team Report dated with
an examination having taken place within 180 days of the filing of the petition:
is not filed with this Petition and is not on file with the Court.
is filed with this Petition or is on file with the Court (Docket No. ); OR
If a Medical Certificate or Clinical Team Report is not filed with this Petition, or on file with this Court, you must immediately
file and present a motion requesting that the Court permit it to be filed late or waive the filing requirement. An affidavit must
accompany the motion explaining why it is impossible to file a Medical Certificate or Clinical Team Report with this Petition.
7.
A conservator is necessary and in the best interest of Respondent because Respondent is:
a minor; OR
alleged disabled for reasons other than minority. A description of the nature and extent of the Respondent's
alleged incapacity is detailed in the most recent Medical Certificate or Clinical Team Report filed with this Petition or
is described as follows:
OR
detained or otherwise unable to return to the United States. State the relevant circumstances, including the time
and nature of detention or inability to return and a description of any search or inquiry concerning the person's
whereabouts:
AND
Respondent has property which will be wasted or dissipated unless proper management is provided;
Respondent or persons entitled to Respondent's support require money for support, care, and welfare, and
protection is necessary or desirable to obtain or provide money.
AND/OR
8.
Respondent
is
is not
alleged to be Intellectually Disabled.
MPC 130 (1/1/15)
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9.
List Respondent's:
A.
Spouse and Children. If none, list parents and brothers and sisters or, if none, list heirs apparent or presumptive.
B.
Current Guardian in the Commonwealth or elsewhere;
C.
Nominated Guardian in the Commonwealth or elsewhere;
D.
Current Conservator in the Commonwealth or elsewhere;
E.
Health Care Agent;
F.
Durable Power of Attorney/Agent;
G.
Representative Payee; and/or
H.
Caretaker in the last 60 days.
Name
Primary Address
Primary Phone
Relationship
(Check all that apply)
Indicate if this
person is:
Spouse
Child
Guardian
Nominated Guardian
Conservator
Relative:
(relationship)
Had care & custody in the last
60 days.
Minor
Incompetent
Spouse
Child
Guardian
Nominated Guardian
Conservator
Relative:
(relationship)
Had care & custody in the last
60 days.
Minor
Incompetent
Spouse
Child
Guardian
Nominated Guardian
Conservator
Relative:
(relationship)
Had care & custody in the last
60 days.
Minor
Incompetent
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MPC 130 (1/1/15)
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10. Does the Respondent have, in the
Commonwealth or elsewhere:
If yes, a copy of the
document is:
Information/Explanation:
(If a Petition has been filed but not
allowed, please list Court and
Docket Number of pending case)
A current Guardian?
Yes and the person's information is listed at Q.9
No
Uncertain
Attached
Unavailable
A document nominating a Guardian?
Yes and the person's information is listed at Q.9
No
Uncertain
Attached
Unavailable
A current Conservator?
Yes and the person's information is listed at Q.9
No
Uncertain
Attached
Unavailable
A Representative Payee?
Yes and the person's information is listed at Q.9
No
Uncertain
Attached
Unavailable
A Health Care Agent?
Yes and the person's information is listed at Q.9
No
Uncertain
Attached
Unavailable
A Durable Power of Attorney/Agent?
Yes and the person's information is listed at Q.9
No
Uncertain
Attached
Unavailable
MPC 130 (1/1/15)
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11.
Respondent:
Uncertain.
does not
Does
have a Representative Payee, Trustee or Custodian of a Trust of Custodianship in the
Commonwealth or elsewhere or
Information about the
Trustee or
Custodian of a Trust of Custodianship:
Name:
(Address Line 1)
(State)
(Zip)
(Apt, Unit, No. etc.)
Primary Phone #:
First Name
M.I.
Last Name
An attachment to this petition provides additional information.
12.
Respondent:
entitled to benefits from the Department of Veterans Affairs or
is
is not
Uncertain.
13.
Does Respondent have any assets, e.g. bank accounts, property?
Yes
No
Uncertain.
If Yes, identify:
Description of Assets, e.g. Bank Accounts, Property, Insurance, Pensions
DO NOT INCLUDE NAMES OF INSTITUTIONS OR ACCOUNT NUMBERS
Estimated Value of
Property
Total
An attachment to this petition provides additional information.
14.
Does the Respondent have any anticipated income?
If Yes, identify:
Yes
No
Uncertain.
Description of Income, e.g. Social Security, Interest
DO NOT INCLUDE NAMES OF INSTITUTIONS OR ACCOUNT NUMBERS
Amount of Anticipated
Monthly Income or Receipts
Total
An attachment to this petition provides additional information.
WHEREFORE, PETITIONER REQUESTS THAT THIS HONORABLE COURT:
Appoint
Last Name
M.I.
First Name
or
with limitations as follows:
as:
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MPC 130 (1/1/15)
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Conservator;
Special Conservator to assist in the accomplishment of the protective arrangement or a single
transaction below.
In addition, I request that the Court grant the following specific powers sought pursuant to G.L. c. 190B,
§§ 5-407(c); 5-407(d)(1)-(7) (for which a substituted judgment must be made and Counsel appointed); 5-423
(8)-(13):
Authorize the following protective arrangement or single transaction:
Other:
SIGNED UNDER THE PENALTIES OF PERJURY
I affirm or swear under oath that I have read the foregoing Petition and that the statements set forth therein are true
and correct to the best of my knowledge.
Date:
Signature of Petitioner
Date:
Signature of Co-Petitioner (If applicable)
I assent to the foregoing Petition:
Date
Date
Date
Date
Print Name
Signature
Signature of Attorney for Petitioner
(Print name)
B.B.O. #
(Zip)
(State)
(City/Town)
(Address)
(Apt, Unit, No. etc.)
Attorney for Petitioner:
Primary Phone #:
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Mpc130 Petition For Appt Of Conservator For Disabled Person Fill (Commonwealth of Massachusetts)

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Completed 26 July 2020

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