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STATE OF MICHIGAN

PROBATE COURT
COUNTY

PETITION FOR
APPOINTMENT OF GUARDIAN
OF INCAPACITATED INDIVIDUAL

CASE NO. and JUDGE

Court address

Court telephone no.

In the matter of

First, middle, and last name

Last four digits of SSN

1. I,

Name (type or print)

matter and make this petition as

State interest/relationship

, am interested in this

2. An action within the jurisdiction of the family division of circuit court involving the family or family members of the

person named above has been previously filed in

Court, Case Number

was assigned to Judge

3. The adult is a resident of

City, village, or township

County State

, and

remains

is no longer pending.

and has a home address and telephone number of

Address

City State Zip Telephone no.

The individual is a citizen of the following foreign country:

a patient advocate/power of attorney for health care. (Specify name and address below.)
a power of attorney. (Specify name and address below.)
a conservator. (Specify name and address below.)

4. The adult has

Name and address

The patient advocate designation was not executed in compliance with MCL 700.5506.
The patient advocate is not complying with the terms of the designation or of MCL 700.5506 to MCL 700.5512.
The patient advocate is not acting consistent with the ward’s best interests.

Approved, SCAO
Form PC 625, Rev. 5/22
MCL 700.1105(a), MCL 700.5303, MCR 5.125(C)(23), MCR 5.402(A)
Page 1 of 3

ABPCS Code: PEGTCS Code: PGIIPetitioner’s name, address and telephone no.Petitioner’s attorney, bar no., address, and telephone no.Date of birthPut DOB in Ref. No. row 1 on MC 97Driver’s license number Put DLN on Ref. No. row 3 on MC 97RaceSexAddress of alleged incapacitated individual where now foundPut last 4 digits of SSN in Ref. No. row 2 on MC 97.XXX-XX-

Petition for Appointment of Guardian of Incapacitated Individual
Page 2 of 3

(5/22)

Case No.

6. The adult lacks sufficient understanding or capacity to make or communicate informed decisions because of

physical illness or disability.

mental illness.

mental deficiency.

chronic intoxication.

chronic drug use.

7. Specific facts about the adult’s recent condition or conduct that lead me to believe the adult needs a guardian are

(Attach a separate sheet if more space is needed.)

8. The name, address, and telephone number of the person/agency (if any) who currently has care and custody of the

9. The adult

is not

entitled to receive Veterans Administration benefits. The Veterans Administration

10.The alleged incapacitated individual has

a spouse whose name and address are listed below.
adult child(ren) whose name(s) and address(es) are listed below.
living parent(s) whose name(s) and address(es) are listed below.
no spouse, adult child(ren), or parent(s). The names and addresses of presumptive heirs are listed below.
none of the above (must notify Attorney General - see instructions for the address of the Attorney General).

NAME

RELATIONSHIP

ADDRESS AND TELEPHONE NUMBER

adult are

claimant number is

Street address

City

State

Zip

Telephone No.

State

Zip

Telephone No.

State

Zip

Telephone No.

State

Zip

Telephone No.

Nominated
guardian

State

Zip

Telephone No.

Petition for Appointment of Guardian of Incapacitated Individual
Page 3 of 3

(5/22)

Case No.

11. None of the adults named above is under any legal incapacity except

Give name, legal incapacity, and representative of the person, if any

12. I REQUEST that the court determine the adult is an incapacitated individual and appoint

Address City, state, zip Telephone no.

who has priority as
,

Priority relationship

full guardian with all powers provided by statute.
limited guardian with the following powers:

13. No other person appears to have authority to act in the circumstances. I request that a temporary guardian be
appointed pending a hearing on this petition because of the following emergency:

I declare under the penalties of perjury that this petition has been examined by me and that its contents are true to the
best of my information, knowledge, and belief.

Petitioner signature

Attorney signature

14. NOMINATION BY THE ALLEGED INCAPACITATED INDIVIDUAL

In the event the court finds that I require a guardian, I nominate

Name

Address, city, state, zip

Telephone no.

Signature of alleged incapacitated individual

Name

ate

Date

PC 625, Petition For Appointment of Guardian of Incapacitated Individual

This info page is part of the LIT Lab's Form Explorer project. It is not associated with the Michigan state courts. To learn more about the project, check out our about page.

Downloads: You can download both the original form (last checked 2023-03) and the machine-processed form with normalized data fields.

About This Form:

Sourced from www.courts.michigan.gov/guardianship (2023-03)
Page(s): 3
Fields(s): 109
Average fields per page: 36
Reading Level: Grade 10
LIST Grouping(s): Unknown

Use our Rate My PDF tool to learn more. Go beyond the above insights and learn more about this or any pdf form at RateMyPDF.com, includes: counts of difficult words used, passive voice decetion, and suggestions for how to make the form more usable.

Identified Data Fields:

We have done our best to automaticly identify and name form fields according to our naming conventions. When possible, we've used names tied to our question library. See e.g., user1_name. If we think we've found a match to a question in our library, it is highlighted in green. Novel names are auto generated. So, you will probably need to edit some of them if you're trying to stick to the convention.

Here are the fields we could identify.

first_middle_last_name was First middle and last name (0.58 conf)
petitioners_name_address was Petitioners name address and telephone no (0.40 conf)
petitioners_attorney_address was Petitioners attorney bar no address and telephone no (0.52 conf)
race was Race (0.41 conf)
sex was Sex (0.38 conf)
address_alleged_individual was Address of alleged incapacitated individual where now found (0.39 conf)
name_type_print was Name type or print (0.45 conf)
state_interestrelationship was State interestrelationship (0.46 conf)
action_division_involving was 2 An action within the jurisdiction of the family division of circuit court involving the family or family members of the (0.42 conf)
court_case_number was Court Case Number (0.46 conf)
undefined__1 was undefined (0.38 conf)
and was and (0.41 conf)
remains was remains (0.32 conf)
longer was is no longer (0.37 conf)
city_village_township was City village or township (0.33 conf)
users1_address_state was State (1.00 conf)
users1_address_line_one__1 was Address (1.00 conf)
users1_address_city was City (1.00 conf)
telephone__1 was Telephone no (0.44 conf)
individual_following_foreign was The individual is a citizen of the following foreign country (0.35 conf)
undefined__2 was undefined_2 (0.39 conf)
patient_health_address was a patient advocatepower of attorney for health care Specify name and address below (0.42 conf)
attorney_specify_name_address was a power of attorney Specify name and address below (0.39 conf)
conservator_specify_name_address was a conservator Specify name and address below (0.42 conf)
name_address was Name and address (0.37 conf)
unknown__1 was 5 (0.38 conf)
patient_advocate_compliance was The patient advocate designation was not executed in compliance with MCL 7005506 (0.49 conf)
patient_advocate_complying_terms was The patient advocate is not complying with the terms of the designation or of MCL 7005506 to MCL 7005512 (0.47 conf)
patient_consistent_best was The patient advocate is not acting consistent with the wards best interests (0.38 conf)
county__1 was County (0.39 conf)
judge was Judge (0.39 conf)
court_telephone was Court telephone no (0.51 conf)
court_address was Court address (0.42 conf)
county__2 was County2 (0.35 conf)
mental_illness was mental illness (0.38 conf)
mental_deficiency was mental deficiency (0.43 conf)
chronic_intoxication was chronic intoxication (0.38 conf)
chronic_drug_use was chronic drug use (0.37 conf)
undefined__3 was undefined_4 (0.39 conf)
unknown__2 was 1 (0.38 conf)
unknown__3 was 2 (0.38 conf)
unknown__4 was 3 (0.38 conf)
adult was adult are (0.43 conf)
is was is (0.32 conf)
is_not was is not (0.34 conf)
claimant_number was claimant number is (0.37 conf)
spouse_whose_name_address was a spouse whose name and address are listed below (0.38 conf)
adult_whose_addresses was adult children whose names and addresses are listed below (0.48 conf)
living_whose_addresses was living parents whose names and addresses are listed below (0.43 conf)
spouse_presumptive_heirs was no spouse adult children or parents The names and addresses of presumptive heirs are listed below (0.47 conf)
must_see_address was none of the above must notify Attorney General see instructions for the address of the Attorney General (0.36 conf)
name_row__1 was NAMERow1 (0.43 conf)
relationship_row__1 was RELATIONSHIPRow1 (0.39 conf)
users1_address_line_one__2 was Street address (1.00 conf)
city__1 was City_2 (0.39 conf)
state__1 was State_3 (0.39 conf)
zip__1 was Zip_2 (0.36 conf)
telephone__2 was Telephone No (0.44 conf)
name_row__2 was NAMERow2 (0.43 conf)
relationship_row__2 was RELATIONSHIPRow2 (0.39 conf)
street_address__1 was Street address_2 (0.43 conf)
city__2 was City_3 (0.39 conf)
state__2 was State_4 (0.39 conf)
zip__2 was Zip_3 (0.36 conf)
telephone__3 was Telephone No_2 (0.45 conf)
name_row__3 was NAMERow3 (0.43 conf)
relationship_row__3 was RELATIONSHIPRow3 (0.39 conf)
street_address__2 was Street address_3 (0.43 conf)
city__3 was City_4 (0.39 conf)
state__3 was State_5 (0.39 conf)
zip__3 was Zip_4 (0.36 conf)
telephone__4 was Telephone No_3 (0.45 conf)
name_row__4 was NAMERow4 (0.43 conf)
relationship_row__4 was RELATIONSHIPRow4 (0.39 conf)
street_address__3 was Street address_4 (0.43 conf)
city__4 was City_5 (0.39 conf)
state__4 was State_6 (0.39 conf)
zip__4 was Zip_5 (0.36 conf)
telephone__5 was Telephone No_4 (0.45 conf)
name_row__5 was NAMERow5 (0.43 conf)
street_address__4 was Street address_5 (0.43 conf)
city__5 was City_6 (0.39 conf)
state__5 was State_7 (0.39 conf)
zip__5 was Zip_6 (0.36 conf)
telephone__6 was Telephone No_5 (0.45 conf)
physical_illness_disability was physical illness or disability (0.45 conf)
checkbox was checkbox1 (0.35 conf)
none_adults_named_except was 11 None of the adults named above is under any legal incapacity except (0.35 conf)
give_representative_person was Give name legal incapacity and representative of the person if any (0.33 conf)
users1_name was Name (1.00 conf)
address was Address_2 (0.35 conf)
telephone__7 was Telephone no_2 (0.45 conf)
priority_relationship was Priority relationship (0.48 conf)
guardian_powers_provided was full guardian with all powers provided by statute (0.38 conf)
limited_guardian_powers was limited guardian with the following powers (0.37 conf)
person_appears_authority was 13 No other person appears to have authority to act in the circumstances I request that a temporary guardian be (0.38 conf)
pending_hearing_following__1 was appointed pending a hearing on this petition because of the following emergency 1 (0.42 conf)
pending_hearing_following__2 was appointed pending a hearing on this petition because of the following emergency 2 (0.42 conf)
pending_hearing_following__3 was appointed pending a hearing on this petition because of the following emergency 3 (0.42 conf)
signature_date__1 was Date (1.00 conf)
signature_date__2 was Date_2 (1.00 conf)
q was Q (0.34 conf)
name was Name_2 (0.30 conf)
address_city_state_zip was Address city state zip (0.32 conf)
telephone__8 was Telephone no_3 (0.45 conf)
signature_date__3 was Date_3 (1.00 conf)
text__1 was Text4 (0.35 conf)
text__2 was Text5 (0.35 conf)
text__3 was Text6 (0.35 conf)
text__4 was Text7 (0.35 conf)

We've done our best to group similar variables togther to avoid overwhelming the user.

Suggested Screen 0:

race
action_division_involving

Suggested Screen 1:

sex

Suggested Screen 2:

and

Suggested Screen 3:

remains
is
is_not

Suggested Screen 4:

longer

Suggested Screen 5:

undefined__1
users1_address_state
users1_address_line_one__1
users1_address_city
undefined__2
unknown__1
undefined__3
unknown__2
unknown__3
unknown__4
users1_address_line_one__2
street_address__1
street_address__2
street_address__3
street_address__4
users1_name
signature_date__1
signature_date__2
signature_date__3

Suggested Screen 6:

petitioners_name_address
petitioners_attorney_address
address_alleged_individual
attorney_specify_name_address
conservator_specify_name_address
name_address
court_address
spouse_whose_name_address
adult_whose_addresses
must_see_address
give_representative_person
address
person_appears_authority
name

Suggested Screen 7:

patient_advocate_compliance
patient_advocate_complying_terms
patient_consistent_best
chronic_drug_use
physical_illness_disability

Suggested Screen 8:

judge

Suggested Screen 9:

patient_health_address
mental_illness
mental_deficiency
chronic_intoxication

Suggested Screen 10:

adult

Suggested Screen 11:

court_case_number
individual_following_foreign
claimant_number
living_whose_addresses

Suggested Screen 12:

spouse_presumptive_heirs

Suggested Screen 13:

first_middle_last_name
name_type_print
name_row__1
relationship_row__1
name_row__2
relationship_row__2
name_row__3
relationship_row__3
name_row__4
relationship_row__4
name_row__5
none_adults_named_except

Suggested Screen 14:

city_village_township
county__1
county__2
city__1
city__2
city__3
city__4
city__5

Suggested Screen 15:

zip__1
zip__2
zip__3
zip__4
zip__5

Suggested Screen 16:

telephone__1
court_telephone
telephone__2
telephone__3
telephone__4
telephone__5
telephone__6
telephone__7
telephone__8

Suggested Screen 17:

state_interestrelationship
state__1
state__2
state__3
state__4
state__5
address_city_state_zip

Suggested Screen 18:

checkbox

Suggested Screen 19:

priority_relationship

Suggested Screen 20:

guardian_powers_provided
limited_guardian_powers

Suggested Screen 21:

pending_hearing_following__1
pending_hearing_following__2
pending_hearing_following__3

Suggested Screen 22:

Suggested Screen 23:

text__1
text__2
text__3
text__4

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The Legal Innovation & Technology Lab's Form Explorer Beta @ Suffolk Law School Last updated 2023-04-02

PC 625, Petition For Appointment of Guardian of Incapacitated Individual

About This Form:

Identified Data Fields:

Create an Interactive Version of this Form:

The Legal Innovation & Technology Lab's Form Explorer ^Beta @ Suffolk Law School Last updated 2023-04-02