700-00074 – Petition to Appoint Guardian for an Adult (Voluntary) (08/2018) Page 1 of 1
PETITION TO APPOINT GUARDIAN FOR AN ADULT
(Voluntary)
I, _________________________________ request the Court to appoint a guardian pursuant to 14 V.S.A. §2671 to
Name of Petitioner
assist me in the management of my affairs. In support of this petition, I state:
1. I am 18 years old or older. My date of birth is _______________;
2. I understand the nature, extend and consequences of the guardianship;
3. I understand how the guardianship can be ended;
4. I ask that _______________________________|__________________________ be appointed to act as my
Name of Proposed Guardian Name of Proposed Co-Guardian
gu
ardian with the following powers
(check all that apply):
☐ to have general supervision over me, including my care, habilitation, education, employment and
choosing or changing where I live, subject to the requirements of 14 V.S.A. §§2691, 3073 and 3074;
☐ to seek, approve or refuse medical or dental treatment, subject to the provisions of 14 V.S.A. §3075
and any constitutional right of mine to refuse treatment;
☐ to supervise my income and resources;
☐
to approve or withhold approval of any contract I wish to make, except a contract for my basic
needs;
☐ to approve or withhold approval of the sale, lease or encumbrance of my real property subject to the
provisions of 14 V.S.A. §2881 – 2891;
☐ to seek legal advice and to start or defend against a court action in my name.
5. I am
(check one):
☐ physically able to appear before the court at a hearing on this petition; OR
☐ not physically able to appear before the Court at a hearing on this petition for the following reason:
_______________________________________________________________________________
I
voluntarily request the appointment of a guardian. This request is not made in response to coercion or duress.
_________________ ______________________________________________
Date Signature of Petitioner
______________________________________ ______________________________________________
Petitioner’s Mailing Address Petitioner’s Phone/Email
GUARDIAN’S CONSENT
I consent to be appointed guardian of: _________________________________________________________________
_________________ ___________________________________|______________________________
Date Signature of Guardian Signature of Co-Guardian, if any
___________________________________|______________________________
Guardian’s Mailing Address Co-Guardian’s Mailing Address
___________________________________|______________________________
Guardian’s Phone/Email Co-Guardian’s Phone/Email
