Fillable PETITION TO APPOINT GUARDIAN FOR AN ADULT (Involuntary) (Vermont Judiciary)

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PETITION TO APPOINT GUARDIAN FOR AN ADULT (Involuntary) (Vermont Judiciary)

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PAG72 – Petition to Appoint Guardian for an Adult (Involuntary) (10/2014) Page 1 of 5
STATE OF VERMONT
SUPERIOR COURT
PROBATE DIVISION
Unit
Docket No.:
In re Guardianship of :
PETITION TO APPOINT GUARDIAN FOR AN ADULT
(Involuntary)
I ask the court to appoint a guardian or a limited guardian for
Name of Respondent
In support of this request, I state:
1. Information about the person in need of a guardian:
Name of Respondent
DOB
Age
1
Street Address
Town
State
Zip
Mailing Address if different
Phone Number
Current Location of Respondent if Different from Above
2. Reason for Guardianship
A guardianship is necessary because Respondent is unable to manage, without the supervision of a
guardian, some or all aspects of his or her personal or financial affairs as a result of:
Significantly sub-average intellectual functioning which exists concurrently with deficits in adaptive
behavior; and/or
A physical or mental condition that results in significantly impaired cognitive functioning which grossly
impairs judgment, behavior, or the capacity to recognize reality.
Under Vermont law, guardianship shall be utilized only as necessary to promote the well-being of the
individual and to protect the individual from violations of his or her human and civil rights. It shall be
designed to encourage the development and maintenance of maximum self-reliance and
independence in the individual and only the least restrictive form of guardianship shall be ordered to
the extent required by the individual’s actual mental and adaptive limitations. The State of Vermont
recognizes the fundamental right of an adult with capacity to determine the extent of health care the
individual will receive. 14 V.S.A.
§
3060
1
Respondent must be at least 18 years old or within four months of his/her 18
th
birthday.
PAG72 – Petition to Appoint Guardian for an Adult (Involuntary) (10/2014) Page 2 of 5
3. Existing or Pending Guardianships
There is no guardian, limited guardian or pending guardianship proceeding for the Respondent in this
state or any other state.
There is an existing guardian or limited guardian for the Respondent.
Please provide
the following
information
Name of Guardian
Type of Guardianship
Mailing Address
County and State where case was filed
Copy of Appointment is attached
There is a pending guardianship proceeding.
Please provide the
following information
County and State where action is filed
Docket Number
4. Advance Directives and Powers of Attorney
To my knowledge, Respondent does not have an advance directive.
Respondent has an advance directive
Please provide the
following information
Name of Agent
Mailing Address
Copy of Directive is attached
To my knowledge Respondent does not have a power of attorney
Respondent has a power of attorney
Please provide the
following information
Name of Agent
Mailing Address
Copy of Power of Attorney is attached
5. Relationship of Petitioner to Respondent
My relationship to the Respondent is:
Relative __________________
Social Worker
Physician
Friend/Neighbor
Public Official
Other ________________________________
6. Reason to Appoint a Guardian
The specific reasons that I am seeking a guardianship for the Respondent are as follows:
Describe your reasons. Please be specific about the facts that support your request.
PAG72 – Petition to Appoint Guardian for an Adult (Involuntary) (10/2014) Page 3 of 5
7. Nomination of Guardian
I ask that the Court appoint me as guardian
I ask that the Court appoint another person as guardian
Please provide the
following information.
If you are proposing
more than one
guardian, provide
information about the
co-guardian in 7A
below.
Name of proposed guardian
Mailing Address
Relationship between proposed guardian and Respondent:
Relative __________________
Social Worker
Physician
Friend/Neighbor
Public Official
Other ____________________________
7A. Nomination of Co-Guardian
I am not requesting a co-guardian.
I am requesting a co-guardian whose information is below.
Please provide
the following
information
about the
proposed co-
guardian.
Name of proposed co-guardian
Mailing Address
Relationship between proposed co-guardian and Respondent:
Relative __________________
Social Worker
Physician
Friend/Neighbor
Public Official
Other ____________________________
8. Proposed Guardianship Powers
I ask that the Guardian be given the following powers:
to have general supervision over the Respondent, including care, habilitation, education, employment
and choosing or changing where the Respondent lives, 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 the Respondent to refuse treatment;
to supervise Respondent’s income and resources;
to approve or withhold approval of any contract Respondent wishes to make, except a contract for
basic needs;
to approve or withhold approval of the sale, lease or encumbrance of Respondent’s 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 Respondent’s name.
9. Alternatives to Guardianship
I have considered the following alternatives to guardianship:
Describe each alternative (e.g. power of attorney, representative payee, etc.) you have considered and
explain why it is unsuitable.
PAG72 – Petition to Appoint Guardian for an Adult (Involuntary) (10/2014) Page 4 of 5
10. Evaluation of Respondent
I understand that the Court must order an evaluation of the Respondent at the Respondent’s expense
unless the Respondent is indigent. The evaluation must be performed by someone who has specific
training and demonstrated competence to evaluate a person in need of guardianship. The evaluation
shall be completed within 30 days of the filing of the petition with the court unless the time period is
extended by the court for cause.
I propose that the following person perform the evaluation of the Respondent:
Please provide
the following
information
Name of Proposed Evaluator
Mailing Address
Phone Number
11. Attorney for Respondent
I understand that the Court must appoint an attorney to represent the respondent in this proceeding.
Respondent does not have an attorney
Respondent is currently represented by an attorney whose name and contact information are as
follows:
Please provide
the following
information
Name of Proposed Attorney
Mailing Address
Phone Number
Date
Signature of Petitioner
Petitioner’s Mailing Address
Petitioner’s Phone Number
GUARDIAN’S CONSENT
I consent to be appointed guardian of :
Date
Signature of Proposed Guardian
Guardian’s Mailing Address
Guardian’s Telephone Number
PAG72 – Petition to Appoint Guardian for an Adult (Involuntary) (10/2014) Page 5 of 5
CO-GUARDIAN’S CONSENT
I consent to be appointed co-guardian of :
Date
Signature of Proposed Guardian
Guardian’s Mailing Address
Guardian’s Telephone Number
Attachments:
Filing fee payable to the Vermont Superior Court, Probate Division
List of Interested Persons (Form no. PG 73)
Statement of Respondent’s Assets and Income (Form no. PG 72)
Copy of advance directive, power of attorney or appointment of guardian
A consent signed by the proposed guardian sufficient to allow a background check.
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PETITION TO APPOINT GUARDIAN FOR AN ADULT (Involuntary) (Vermont Judiciary)

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Completed 30 July 2020

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