Arizona Probate Form pbgca11fz

Petition For Permanent Appointment Of Guardian And Conservator For An Adult (Or Minor At Least 17.5 Years Of Age, To Become Effective At Age 18)

Everything you need to know about Arizona Form pbgca11fz, including helpful tips, fast facts & deadlines, how to fill it out, where to submit it and other related AZ probate forms.

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About Petition For Permanent Appointment Of Guardian And Conservator For An Adult (Or Minor At Least 17.5 Years Of Age, To Become Effective At Age 18)

There are all sorts of forms executors, beneficiaries, and probate court clerks have to fill out and correspond with during probate and estate settlement, including affidavits, letters, petitions, summons, orders, and notices.

Petition For Permanent Appointment Of Guardian And Conservator For An Adult (Or Minor At Least 17.5 Years Of Age, To Become Effective At Age 18) is a commonly used form within Arizona. Here’s an overview of what the form is and means, including a breakdown of the situations when (or why) you may need to use it:

Atticus Fast Facts About Petition For Permanent Appointment Of Guardian And Conservator For An Adult (Or Minor At Least 17.5 Years Of Age, To Become Effective At Age 18)

Sometimes it’s tough to find a quick summary— here’s the important details you should know about Petition For Permanent Appointment Of Guardian And Conservator For An Adult (Or Minor At Least 17.5 Years Of Age, To Become Effective At Age 18):

  • This form pertains to the State of Arizona

Government forms are not typically updated often, though when they are, it often happens rather quietly. While Atticus works hard to keep this information about Arizona’s Form pbgca11fz - Petition For Permanent Appointment Of Guardian And Conservator For An Adult (Or Minor At Least 17.5 Years Of Age, To Become Effective At Age 18) up to date, certain details can change from time-to-time with little or no communication.

How to file Form pbgca11fz

Step 1 - Download the correct Arizona form based on the name and ID if applicable

Double check that you have both the correct form name and the correct form ID. Some Arizona probate forms can look remarkably similar, so it’s best to double, even triple-check that you’re using the right one! Keep in mind that not all States have a standardized Form ID system for their probate forms.

Step 2 - Complete the Document

Fill out all relevant fields in Form pbgca11fz, take a break, and then review. Probate and estate settlement processes in AZ are long enough to begin with, and making a silly error can push your timeline even farther back. No thank you!

Note: If you don’t currently know all of the answers and are accessing Form pbgca11fz online, be sure to avoid closing the browser tab and potentially losing all your progress (or use a platform like Atticus to help avoid making mistakes).

Step 3 - Have Form pbgca11fz witnessed or notarized (if required)

Some States and situations require particular forms to be notarized. If you have been instructed to get the document notarized or see it in writing on the document, then make sure to hire a local notary. There are max notary fees in the United States that are defined and set by local law. Take a look at our full guide to notary fees to make sure you aren’t overpaying or getting ripped off.

Step 4 - Submit Petition For Permanent Appointment Of Guardian And Conservator For An Adult (Or Minor At Least 17.5 Years Of Age, To Become Effective At Age 18) to the relevant office

This is most often the local probate court where the decedent (person who passed away) is domiciled (permanently resides) or the institution involved with this particular form (e.g. a bank). Some offices allow you to submit forms online, other’s don’t, and we while we generally recommend going in-person to expedite the process, sometimes that simply isn’t an option.

It’s also a generally good idea to establish a positive working relationship with any probate clerk (unfortunately there’s enough people & process out there making things more difficult and unnecessarily confusing for them), so a best practice is to simply ask the probate clerk proactively exactly how and where they’d prefer you to submit all forms.

Need help getting in touch with a local probate court or identifying a domicile probate jurisdiction?

👉 Find and Contact your Local Probate Court

👉 What is a Domicile Jurisdiction?

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When Petition For Permanent Appointment Of Guardian And Conservator For An Adult (Or Minor At Least 17.5 Years Of Age, To Become Effective At Age 18) is due

Different probate forms or processes can require different deadlines or response times for completing the appropriate form.

While some steps in the process are bound to specific deadlines (like petitioning for probate, having to submit an inventory of assets, or filing applicable notices to creditors and beneficiaries), many probate forms or processes are not tied to a specific deadline since the scope of work can vary based on situational factors or requirements involved.

Either way, there are a bunch of practical reasons why personal representatives should work to complete each step as thoroughly and quickly as possible when completing probate in Arizona.

5 reasons you should submit pbgca11fz as quickly as possible:

  1. The sooner you begin, the faster Arizona can allow heirs and beneficiaries to get their share of assets subject to probate. Acting promptly can also decrease the costs & overall mental fatigue through an otherwise burdensome process.

    Helpful Context: What’s the Difference Between Probate and Non-Probate Assets?

  2. In general, creditors of an estate usually have around 3-6 months from the time you file notice to creditors to file any claims for debt against the deceased’s assets. If they don’t, then that debt is forfeited (and more importantly, the executor won’t be held personally responsible). So doing this sooner means you have a better idea of who is owed what and ensures you won’t get a surprise collector months later.

  3. Not filing a will within 30 days (on average) could mean that the probate process proceeds according to intestate laws (laws that govern what happens to someone's stuff without a will) or is subject to unnecessary supervision by the probate court. And if you aren't directly related to the deceased (a.k.a. next of kin), this could also mean you lose your inheritance.

  4. It’s important to file any necessary state tax returns on behalf of the deceased or estate by the following tax season in Arizona. If you don’t, you could owe penalties and interest. This also includes any necessary federal tax returns such as Forms 1040, 1041, or even a Form 706 estate tax return.

  5. If a house in the State of Arizona is left empty (or abandoned) for a while, insurance can get dicey. For example, if the house burns down and no one has been there for a year, an insurance company may get out of paying your claim.

If you’re not using Atticus to get specific forms, deadlines, and timelines for Arizona probate, then try and stay as organized as possible, pay close attention to the dates mentioned in any correspondence you have with the State’s government officials, call the local Arizona probate clerk or court for exact answers regarding Form pbgca11fz, and when in doubt— consult a qualified trust & estates lawyer for that area.

How to Download, Open, and Edit Form pbgca11fz Online

Petition For Permanent Appointment Of Guardian And Conservator For An Adult (Or Minor At Least 17.5 Years Of Age, To Become Effective At Age 18) is one of the many probate court forms available for download through Atticus.

It may also be available through some Arizona probate court sites, such as . In order to access the latest version, be updated with any revisions, and get full instructions on how to complete each form, check out the Atticus Probate & Estate Settlement software or consider hiring a qualified legal expert locally within Arizona.

While Atticus automatically provides the latest forms, be sure to choose the correct version of Form pbgca11fz - Petition For Permanent Appointment Of Guardian And Conservator For An Adult (Or Minor At Least 17.5 Years Of Age, To Become Effective At Age 18) f using any other site or resource in order to avoid having to re-complete the form process and/or make another trip to the Arizona probate court office.

Petition For Permanent Appointment Of Guardian And Conservator For An Adult (Or Minor At Least 17.5 Years Of Age, To Become Effective At Age 18) is a .pdf, so opening it should be as simple as clicking “View Form” from within the Atticus app or by clicking the appropriate link found on any Arizona-provided government platform. Once you’ve opened the form, you should be able to directly edit the form before saving or printing.

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Did you know?

  • Form pbgca11fz - Petition For Permanent Appointment Of Guardian And Conservator For An Adult (Or Minor At Least 17.5 Years Of Age, To Become Effective At Age 18) is a probate form in Arizona.

  • Arizona has multiple types of probate and the necessary forms depend on the unique aspects of each estate, such as type and value of assets, whether there was a valid will, who is serving as the personal representative or executor, and even whether or not they also live in Arizona.

  • During probate, all personal representatives and executives in are required to submit a detailed inventory of assets that must separate non-probate assets from probate assets.

  • Probate in Arizona, especially without guidance, can take years to finish and cost upwards of $14,000.

Frequently Asked Questions about Petition For Permanent Appointment Of Guardian And Conservator For An Adult (Or Minor At Least 17.5 Years Of Age, To Become Effective At Age 18)

Probate is the government’s way of making sure that when a person dies, the right stuff goes to the right people (including the taxes the government wants).

All of that stuff is collectively known as someone’s “estate”, and it’s the job of the executor or personal representative to fill out all the forms and complete all the required steps to formally dissolve the estate. 

To get instant clarity on the entire probate process and get an idea of the steps, timeline, and best practices, read the Atticus Beginner’s Guide to Probate

The best place? Create an account in Atticus to start getting estate-specific advice. 

You may need a lawyer, you may not, and paying for one when you didn’t need it really hurts. Atticus makes sure you make  the best decisions (plus you can write it off as an executor expense).

We’ve also created a list of other probate services. Be sure to check it out!

An executor is named in someone’s will, and if the deceased didn’t have a will, then the spouse or other close family relative usually steps up to fulfill the role. If no one wants to do it, then a judge will appoint someone. 

The executor is responsible for the complete management of the probate process, including major responsibilities such as:

  • Creating an inventory of all probate assets.

  • Filling out all necessary forms

  • Paying off all estate debts and taxes

  • Submitting reports to the court and beneficiaries as requested

And much more. This process often stretches longer than a year. 

For an idea of what separates executors who succeed from those who make this way harder than it should be, visit our article, Executors of an Estate:
What they do & secrets to succeeding
.

The Exact Text on Form pbgca11fz

Here’s the text, verbatim, that is found on Arizona Form pbgca11fz - Petition For Permanent Appointment Of Guardian And Conservator For An Adult (Or Minor At Least 17.5 Years Of Age, To Become Effective At Age 18). You can use this to get an idea of the context of the form and what type of information is needed.

© Superior Court of Arizona in Maricopa County PBGCA11f - 080816 ALL RIGHTS RESERVED Page 1 of 10 APE Person Filing: Address (if not protected): City, State, Zip Code: Telephone: Email Address: Lawyer’s Bar Number: Licensed Fiduciary Number: ___________________________________ Representing Self, without a Lawyer or Attorney for Petitioner OR R espondent SUPERIOR COURT OF ARIZONA IN ____________ COUNTY In the Matter of Case Number PB: Guardianship and Conservatorship of: PETITION FOR PERMANENT APPOINTMENT OF GUARDIAN and CONSERVATOR FOR AN ADULT, or a Minor at least 17.5 years of age, to become effective at age 18 Name of Person to be Protected UNDER OATH OR BY AFFIRMATION: INFORMATION REQUIRED BY ARIZONA LAW (A.R.S. § 14- 5303 and 5404) 1.INFORMATION ABOUT THE PETITIONER (the person filing this petition) (My) Name: Address: Telephone: Date of Birth: My interest in or relationship to the person to be protected is: (examples: mother, father, sister, brother, grandparent, legal guardian) FOR CLERK’S USE ONLY Case No. ___________________ © Superior Court of Arizona in Maricopa County PBGCA11f - 080816 ALL RIGHTS RESERVED APE Page 2 of 10 2. INFORMATION ABOUT THE PERSON TO BE PROTECTED (also known as “the proposed protected person” or “the ward”) Name: Address: Telephone: Date of Birth: 3. INFORMATION ABOUT THE PROPOSED GUARDIAN AND CONSERVATOR: (Complete this only if the proposed guardian/ conservator is someone other than Petitioner.) Name: Address: Telephone: Date of Birth: Relationship to the person to be protected is: (examples: mother, father, sister, brother, grandparent, legal guardian) A. The proposed guardian and conservator has priority for appointment as a conservator under Arizona law A.R.S. § 14-5410, because he or she is: (Already) A conservator, guardian of property or other similar fiduciary appointed or recognized by the appropriate court of any other jurisdiction in which the person to be protected resides. An individual or corporation nominated by the protected person if the protected person is at least fourteen years of age and has, in the opinion of the court, sufficient mental capacity to make an intelligent choice. The person nominated to serve as conservator in the protected person's most recent durable power of attorney. The spouse of the protected person. An adult child of the protected person. A parent of the protected person, or a person nominated by the will of a deceased parent. Any relative of the protected person with whom the protected person has resided for more than six months before the filing of the petition. The nominee of a person who is caring for or paying benefits to the protected person. If the protected person is a veteran, the spouse of a veteran or the minor child of a veteran, the department of veterans' services. A fiduciary who is licensed pursuant to Arizona law, A.R.S. § 14-5651, other than a public fiduciary. Case No. ___________________ © Superior Court of Arizona in Maricopa County PBGCA11f - 080816 ALL RIGHTS RESERVED APE Page 3 of 10 A public fiduciary who is licensed pursuant to Arizona law A.R.S. § 14- 5651. OTHER. Explain: B. The proposed guardian and conservator named above has priority for appointment as a guardian under Arizona law A.R.S. § 14-5 311, because he or she is: The spouse of the incapacitated person; An individual nominated by the incapacitated person to be the guardian; An adult child of the incapacitated person; The parent of the incapacitated person; A relative of the incapacitated person and has lived with the person more than six months before filing this petition; Nominated by someone who is caring for or is paying benefits for the incapacitated person; Is a private fiduciary, a professional guardian, conservator, or the Arizona Veterans' Service Commission. Other (explain): 4. REASONS FOR GUARDIANSHIP : The person to be protected needs a guardian because he or she is incapacitated as defined by Arizona Law, A.R.S. §14-5101(1), to the extent that he or she lacks sufficient understanding or capacity to make or communicate responsible decisions concerning his or her own self-interests. Appointment of a guardian is necessary or desirable to provide continuing care and supervision of the person, and is in his or her best interests . THE PERSON TO BE PROTECTED IS INCAPACITATED AND IN NEED OF CONTINUING CARE AND SUPERVISION DUE TO: (C heck all that apply): Mental illness, mental deficiency, mental disorder; Chronic use of drugs; Physical illness or disability; Chronic intoxication; Other (explain): Case No. ____________________ © Superior Court of Arizona in Maricopa County PBGCA11f - 080816 ALL RIGHTS RESERVED APE Page 4 of 10 5.TYPE OF GUARDIANSHIP: LIMITED OR GENERAL: (A.R.S. § 14-5303(B)(8)) A. A LIMITED GUARDIANSHIP is requested with the following specific powers: 1. Authority for the guardian to: Consent to Medical Treatment Consent to Make Living Arrangements Arrange Education or Training Consent to Marriage Apply for Public Assistance or Social Services Consent to Outpatient Mental Health Care and Treatment 2. INPATIENT Mental Health Powers: The ward is incapacitated as a result of mental health disorder as defined in A.R.S. § 36-501. Authority is requested for the Guardian to place the ward in an Inpatient Psychiatric Facility for inpatient mental health care and treatment. This request is supported by the opinion of a licensed psychiatrist or psychologist, included and made part of this document. 3. OTHER LIMITED POWERS REQUESTED: (List and Describe) Continues on attachment “Powers Requested”, made part of this document. (OR) B. GENERAL GUARDIANSHIP is requested. As required by Arizona law, A.R.S. §14- 5303(B)(8) , less restrictive alternatives to “general” guardianship, including technological assistance, have been considered, however: ( Check the box if true*) The proposed ward is incapacitated in a manner or to an extent that a limited guardianship would not adequately protect and provide for the proposed ward’s care and well-being. (Optional additional information) *For the court to order a general guardianship, you must check the box and be prepared to offer clear and convincing evidence that less restrictive means of meeting the proposed ward’s demonstrated needs would not be sufficient. (A.R.S. § 14-5304(B)) NOTE: A general or “non-limited” guardianship includes authority to consent to outpatient mental health treatment but the Court must specifically grant authority to place the ward in an inpatient mental health facility. Check the box below if the best interests of the incapacitated person require the Guardian to have this authority. INPATIENT Mental Health Powers: Authority is requested for the Guardian to place the ward in an Inpatient Psychiatric Facility for inpatient mental health care and treatment. This request is supported by the opinion of a licensed psychiatrist or psychologist, included with and made part of this document. Case No. ____________________ © Superior Court of Arizona in Maricopa County PBGCA11f - 080816 ALL RIGHTS RESERVED APE Page 5 of 10 C.(Limited or General) DRIVING PRIVILEGES AND VOTING RIGHTS: (A.R.S. §§14- 5304) 1. The proposed ward’s incapacity does not prevent or interfere with safe operation of a motor vehicle. Petitioner requests that the court not suspend the ward’s privilege to obtain or retain a driver’s license. Medical or other evidence will be presented in support of this statement and request. 2. The Petitioner believes the proposed ward has sufficient capacity and understanding to exercise the right to vote. On behalf of the proposed ward, the Petitioner hereby petitions the court to consider the issue and hold a hearing at the same time as this Petition. Clear and Convincing evidence will be presented that the proposed ward has sufficient understanding to exercise the right to vote. 6.REASONS FOR CONSERVATORSHIP: In accord with Arizona Law, A.R.S. §14-5401, the person to be protected needs a conservator because he or she has property which will be wasted or used up unless proper management is provided, AND : (Check all that apply) Funds are needed for the support, care and welfare of the protected person; Funds are needed for the support, care and welfare of others who are entitled to receive support from the protected person. THE PERSON TO BE PROTECTED CANNOT PROVIDE PROPER MANAGEMENT DUE TO: (Check all that apply): Mental illness, mental deficiency, or mental disorder Physical illness or disability Chronic use of drugs Chronic intoxication Confinement Detention by a foreign power Disappearance (The person whose property needs protection cannot be found at this time.) 7.LIMITED OR SINGLE TRANSACTION CONSERVATORSHIP (Check box if applicable). Conservatorship is needed for only a single transaction or for only the following limited purposes: (Explain in detail) Case No. ____________________ © Superior Court of Arizona in Maricopa County PBGCA11f - 080816 ALL RIGHTS RESERVED APE Page 6 of 10 8. INFORMATION ABOUT OTHER CONSERVATOR OR GUARDIAN: To the best of my knowledge: (Check one box.) No Guardian or Conservator has been appointed in any other court, and no court proceedings are pending for such appointment; OR Someone has been appointed Guardian and/or Conservator, or court proceedings are pending. (If “yes”, provide details below.) Name: Address: Telephone: Date of Birth: Relationship to the person to be protected is: Was appointed GUARDIAN CONSERVATOR for the ward named in #2 above in: Name of Court: Located in: City and State: Date Appointed: Other Details: 9. INFORMATION ABOUT OTHER COURT or AGENCY INVOLVEMENT A. Other Court Cases (Mark the box beside the statements below that are TRUE.) 1. Divorce, Legal Separation, or Paternity cases with court orders  There are NO Divorce, Legal Separation, or Paternity court orders or cases, that include legal decision-making (custody) or parenting time (visitation) matters for the alleged incapacitated person.  YES, a Court Order exists for a Divorce, Legal Separation, or Paternity case involving the alleged incapacitated person. ● The name of Arizona or other state Court where the above case is located:______________. ● The name of the Arizona or other state case number for the above case is ______________.  The above case involved legal decision-making (legal custody) or parenting time (visitation). ●The petitioner or proposed guardian in the above-named case is:  A parent of the alleged incapacitated person – or  A non-parent who has been awarded legal decision-making for the alleged incapacitated person.  I attached a copy of the most recent court order regarding legal decision-making (legal custody) or parenting time (visitation) from the (Divorce, Legal Separation or Paternity) mentioned above. (On the top margin of the attached court order copy, write “Attachment for Question 2.A.) Case No. ____________________ © Superior Court of Arizona in Maricopa County PBGCA11f - 080816 ALL RIGHTS RESERVED APE Page 7 of 10 2. Other Guardianship or Conservatorship cases with court orders No Guardian or Conservator was appointed by court order in any other court, and no Guar dianship and/or Conservatorship court proceedings are pending for such appointment; Someone was appointed Guardian and/or Conservator, or Guardianship and/or Conservatorship court proceedings are pending. (If “yes”, provide details below.) Name:__________________________________ Address:______________________________________________________________ Telephone:________________________ Date of Birth:_________________________ Relationship to the person to be protected is:_________________________________ Was appointed  GUARDIAN or  CONSERVATOR for the alleged incapacitated. Name of Court:___________________________________________________________________ Located in: City and State:________________________________________________________ Date Appointed:__________________________ Other Details: ______________________________________________________________________________ B.Age ncy Involvement (Place a check mark beside the statements below that are true.) A state or local agency is, or has NOT been involved or concerned with the alleged incapacitated person. Yes, a state or local agency is, or has been involved or concerned with the alleged incapacitated person. The following state or local agency has a case with or has checked on the alleged incapacitated person: (Mark the box beside the agency involved, and write in the date of involvement) Division of Aging and Adult Services ________________________________ Department of Child Safety Division of Developmental Disabilities Police Other Agency: ____________________________ 10.INFORMATION ABOUT NEAREST RELATIVE: The nearest known relative is the p etitioner the proposed conservator or NEITHER. Name: Address: Telephone: Relationship to the person to be protected is: 11.ASSETS OF THE PROPOSED PROTECTED PERSON (“the ward”): (Check one box) The ward has no substantial assets or income. No bond is required; OR Case No. ____________________ © Superior Court of Arizona in Maricopa County PBGCA11f - 080816 ALL RIGHTS RESERVED APE Page 8 of 10 The ward has assets and/or annual income in the approximate amount of $ List/Describe: 12.APPOINTMENT OF PHYSICIAN (or other health professional authorized or required by A.R.S. § 14-5303(c) or § 14-5312(B): (Guardianship cannot be established for an adult unless the adult is examined by a medical doctor, registered nurse or psychologist, whose written report is filed with the court before the hearing. If authority to consent to inpatient mental health care is requested, the report or a separate report recommending such authority must be prepared by a licensed psychiatrist or psychologist.) The pr oposed protected person will be examined by a physician or other health professional authorized by Arizona law A.R.S. § 14-5303(C) or 5312 (B)), whose written report I will file with the court. The examiner will also indicate whether the protected person’s driving privileges should be suspended and whether inpatient mental health treatment is recommended. The person I say is in need of protection will be examined by: Name: Address: Telephone Number: Email: Professional Title: Medical Doctor Registered Nurse Psychologist 13.APPOINTMENT OF AN ATTORNEY (G uardianship or conservatorship cannot be established for an adult who does not have an attorney appointed by the Court to represent his or her interests in co urt.) (Check one box only and fill in the information requested): The person I say is incapacitated already has an attorney who I request be appointed to represent him or her in court regarding the proposed guardianship and conservatorship : Name of Attorney: Address: Telephone Number: Bar # Email Address: The prior relationship (if any) between the attorney and the Petitioner or the Ward consists of: (Explain) OR Case No. ____________________ © Superior Court of Arizona in Maricopa County PBGCA11f - 080816 ALL RIGHTS RESERVED APE Page 9 of 10 The incapacitated person does not have an attorney to represent him or her in court. I will contact the Office of Public Defense Services at (602) 506-7228, after I file this paperwork to arrange for a lawyer to be appointed by the court. REQUIRED STATEMENTS TO THE COURT: (Note: All of these statements must be true for this court to have the authority to grant your Petition.) 14. TRUE Venue (the court in which you are filing this Petition) is proper in this county because the proposed protected person lives in or is present in this county and has assets in this county. 15. TRUE The proposed guardian and conservator has completed the Affidavit of Person to be Appointed as Guardian and Conservator of an Adult and is filing that Affidavit with this Petition as required by Arizona law, A.R.S. § 14-5106. 16. TRUE I or the person I request to be appointed in section 3 is a suitable and proper person to act as guardian and conservator and is entitled to consideration for appointment under Arizona Law, A.R.S. § 14-5106, 5311, and/or 5410. 17.PERSONS ENTITLED TO NOTICE of this matter under Arizona law §14- 5405 and to whom I will give notice of this case: (See instructions.) Name Address Relationship to the Ward A. B. C. D. (17) Continues on attachment “Persons Entitled to Notice”, made part of this document. REQUESTS TO THE COURT: Petitioner asks the court to: 1.Appoint a lawyer to represent the proposed protected person’s interests, a physician or other health professional authorized by A.R.S. § 14-5303 or 5312 to report on his or her physical and mental condition, as well as a court investigator. 2.After Petitioner gives notice of the hearing to all interested persons and to those required by law, hold a hearing to determine if the Court should order a Guardianship and Conservatorship; 3.Make a finding that the person is incapacitated, needs a guardian, and if applicable, make a finding that the incapacitated person requires inpatient mental health care. 4.Make a finding that the person needs protection under law including a conservator; Case No. ____________________ © Superior Court of Arizona in Maricopa County PBGCA11f - 080816 ALL RIGHTS RESERVED APE Page 10 of 10 5. If a general guardianship is ordered, make a finding that less restrictive means, including technological assistance were considered, but not adequate or appropriate; 6. Appoint the person proposed in this petition as Guardian of the protected person and Conservator of his or her estate; 7. Make any other orders the Court decides are in the best interests of the proposed incapacitated and protected person. UNDER OATH OR AFFIRMATION I swear or affirm under penalty of perjury that the contents of this document are true and correct to the best of my knowledge and belief. Date Signature STATE OF COUNTY OF Subscribed and sworn to or affirmed before me this: (date) by . (notary seal) Deputy Clerk or Notary Public

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