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STATE OF SOUTH CAROLINA COUNTY OF: IN THE MATTER OF:

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IN THE PROBATE COURT PETITION FOR FINDING CASE NUMBER:

INCAPACITY APPOINTMENT OF GUARDIAN SUCCESSOR GUARDIAN Applicant/Petitioner: Address: Telephone: I. ALL PETITIONERS MUST COMPLETE THIS SECTION. 1. 2. Nature of interest of undersigned: Information -- Allegedly Incapacitated Person Name: Date of Birth
Address:
City/State/Zip:
Telephone:
To my knowledge, above named To my knowledge, above named 3. DOES DOES Age:


DOES NOT have a health care power of attorney. DOES NOT have a living will (Declaration of a Desire for a Natural Death.)

Venue for this proceeding in this county because the subject: resides in this county.
is present in this county.
is admitted to an institution pursuant to an order of a court of competent jurisdiction in this county.


4.

Information--Family of allegedly incapacitated person, including dates of birth of minors. If there are no minors, so state. Relationship to Name Date of Birth Address Incapacitated Person

(use additional sheet if necessary)

FORM #530PC (2/2004) 62-5-301, 62-5-302, 62-5-303, 62-5-304, 62-5-305 62-5-307, 62-5-309, 62-5-310, 62-5-311

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5.

The nature and degree of incapacity is as follows:

II.

COMPLETE THIS SECTION IF APPOINTMENT IS SOUGHT. 1. Is it your belief that the allegedly incapacitated person is in need of a guardian/successor guardian as a means of providing continuing care and supervision of the person of said incapacitated person? YES NO If no, please explain.

2.

The extent to which the guardian should be permitted to give consents or approvals that may be necessary to enable the allegedly incapacitated person to receive medical or other professional care, counsel, treatment or services is as follows:

3.

The nature and extent of the care, assistance, protection, or supervision which is necessary or desirable for the allegedly incapacitated person under the circumstances is as follows:

4.

Has a guardian appointed by a Will accepted such appointment? NO YES If yes, please explain.

5.

I request the appointment of: Name: Address: Telephone (O):
(H):
E-mail:
whose priority for appointment as guardian for the subject is as follows: a person nominated to serve as guardian by the allegedly incapacitated person an attorney-in-fact appointed by the allegedly incapacitated person pursuant to Section 62-5-501 spouse of the allegedly incapacitated person adult child of the allegedly incapacitated person parent of the allegedly incapacitated person other relative of the allegedly incapacitated person (Specify): nominated by the person who is caring for the allegedly incapacitated person or paying benefits to him/her Other (specify)

6. Is it necessary to appoint a temporary guardian for the subject until a hearing can be held on this Petition? NO YES If yes, please state reasons.

FORM #530PC (2/2004)

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III.

ALL PETITIONERS MUST COMPLETE THIS SECTION.
1. 2. I request that the Court set a time and place of hearing on this Petition and that the Court determine that the above person is incapacitated. I request that the Court determine that the need for the appointment of a guardian is proper, and that the Court appoint as the guardian for the above person: and that Letters of Guardianship be issued to the guardian.

3. The following persons are required by statute to be given notice of the time and place of hearing on this Petition: (SCPC 5-309)

Name

Address

Relationship

VERIFICATION The undersigned, being sworn states: That the facts set forth in the foregoing statement are true to the best of the undersigned's knowledge, information and belief. SWORN to before me this , 20 day of Signature: Name: Address: E-mail: Telephone (O): (H): Attorney: Address: E-mail: Telephone (O):

Notary Public for South Carolina My Commission Expires:

QUALIFICATION AND STATEMENT OF ACCEPTANCE I accept this appointment and agree to perform the duties and discharge the trust of the office of Guardian of the incapacitated person of . SWORN to before me this , 20 day of Signature: Name: Address: E-mail: Telephone (O): (H):

Notary Public for South Carolina My Commission Expires:

FORM #530PC (2/2004)

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