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Here is the text we could read:

STATE OF MICHIGAN

PROBATE COURT
COUNTY

APPLICATION FOR
APPOINTMENT OF
OUT-OF-STATE CONSERVATOR

CASE NO. and JUDGE

Court address

Court telephone no.

In the matter of

First, middle, and last name

Last 4 digits of SSN

Applicant’s name, address, and telephone no.

Applicant’s attorney, bar no., address, and telephone no.

, am interested in this matter and

1. I,

Name

make this application as the individual’s conservator appointed, qualified, and serving in good standing in another state.

2. I am not aware of any conservatorship or pending petitions in this state for a conservatorship of the protected individual.

3. The individual was born

Put DOB in Ref. No.
row 1 on MC 97.
Date

, resides in

County at

Address City, state, zip

and has property in

County and state or other jurisdiction

The individual is a citizen of the following foreign country:

child(ren)

4. The protected individual has: (These are interested persons who have a right to receive a copy of this application.)

a spouse
if no child(ren) or descendants of deceased child(ren), parents whose name(s) and address(es) are listed below.
if none of the above, presumptive heirs whose name(s) and address(es) are listed below.
none of the above. (Notify the Attorney General by sending a copy of this form to: Attorney General, Public Administration, PO Box 30755,

whose name(s) and address(es) are listed below.

descendants

Lansing, MI 48909.)

NAME

RELATIONSHIP

ADDRESS AND TELEPHONE NUMBER

Street address

City

State

Zip

Telephone no.

State

Zip

Telephone no.

State

Zip

Telephone no.

Approved, SCAO
Form PC 683m, Rev. 5/21
MCL 700.5104(2), MCL 700.5404, MCL 700.5409, MCL 700.5433,
MCR 3.206(A)(4), MCR 5.107, MCR 5.125(C)(25)
Page 1 of 2

JIS Code: AOVXXX-XX-Put last 4 digits of SSN in Ref. No. row 2 on MC 97. ,

Application for Appointment of Out-Of-State Conservator
Page 2 of 2

(5/21)

Case No.

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

above individual has been previously filed in

Court, Case Number

was assigned to Judge

, and

remains

is no longer

pending.

6. The individual has

a power of attorney. (Specify name and address below.)
a guardian. (Specify name and address below.)
a representative payee for social security. (Specify name and address below.)

Name and address

7. None of the persons named above is under any legal incapacity except

Name, incapacity, and representative of the person, if any

8. The individual is currently found at

Address or location Telephone no.

9. The individual

is not

entitled to receive Veterans Administration benefits.

Claimant number

10. The individual to be protected has an estate approximately valued at:

Real property

Personal property

Insurance

Monthly income

11. The individual to be protected is receiving the following income:

Social Security $

Retirement $

Veterans Administration $

Other

Specify

Name of court that appointed conservator State Telephone no.

appointed the conservator for the following reason(s):

13. I REQUEST that the court of this state appoint me conservator of the individual in accordance with the laws of this state.

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

Applicant signature

Attorney signature

12.

Date

PC 683m, Application for Appointment of Out-Of-State Conservator

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/conservatorship-protected-individuals (2023-03)
Page(s): 2
Fields(s): 79
Average fields per page: 39
Reading Level: Grade 10
LIST Grouping(s): ES-02-00-00-00, ES-00-00-00-00.

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.

stat_e_f_michiga_n_probat_cour_county was STATE OF MICHIGAN PROBATE COURT COUNTY (0.62 conf)
court_address was Court address (0.42 conf)
first_middle_last_name was First middle and last name (0.37 conf)
applicants_address_telephone was Applicants name address and telephone no (0.42 conf)
applicants_attorney_address was Applicants attorney bar no address and telephone no (0.51 conf)
users1_name was Name (1.00 conf)
county was County at (0.29 conf)
users1_address_line_one__1 was Address (1.00 conf)
users1_address_line_two was City state zip (1.00 conf)
county_state_jurisdiction was County and state or other jurisdiction (0.39 conf)
individual_following_foreign was The individual is a citizen of the following foreign country (0.35 conf)
undefined__1 was undefined (0.38 conf)
spouse was a spouse (0.35 conf)
children_whose_addresses was if no children or descendants of deceased children parents whose names and addresses are listed below (0.44 conf)
presumptive_heirs_addresses was if none of the above presumptive heirs whose names and addresses are listed below (0.37 conf)
notify_general_form_public was none of the above Notify the Attorney General by sending a copy of this form to Attorney General Public Administration PO Box 30755 (0.48 conf)
children was children (0.34 conf)
descendants was descendants (0.33 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)
users1_address_city was City (1.00 conf)
users1_address_state was State (1.00 conf)
users1_address_zip was Zip (1.00 conf)
telephone__1 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__1 was City_2 (0.39 conf)
state__1 was State_2 (0.39 conf)
zip__1 was Zip_2 (0.36 conf)
telephone__2 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__2 was City_3 (0.39 conf)
state__2 was State_3 (0.39 conf)
zip__2 was Zip_3 (0.36 conf)
telephone__3 was Telephone no_3 (0.45 conf)
judge was Judge (0.39 conf)
text__1 was Text8 (0.35 conf)
action_division_involving was 5 An action within the jurisdiction of the family division of circuit court involving the family or family members of the (0.42 conf)
individual_previously_filed was above individual has been previously filed in (0.34 conf)
court_case_number was Court Case Number (0.46 conf)
assigned_judge was was assigned to Judge (0.41 conf)
remains was remains (0.32 conf)
longer was is no longer (0.37 conf)
attorney_specify_name_address was a power of attorney Specify name and address below (0.39 conf)
guardian_specify_name was a guardian Specify name and address below (0.41 conf)
security_specify_address was a representative payee for social security Specify name and address below (0.36 conf)
name_address was Name and address (0.37 conf)
name_representative_person was Name incapacity and representative of the person if any (0.34 conf)
individual_currently_found was 8 The individual is currently found at (0.39 conf)
is was is (0.32 conf)
is_not was is not (0.34 conf)
claimant_number was Claimant number (0.39 conf)
undefined__2 was undefined_2 (0.39 conf)
undefined__3 was undefined_3 (0.39 conf)
undefined__4 was undefined_4 (0.39 conf)
undefined__5 was undefined_5 (0.39 conf)
individual_receiving_income was 11 The individual to be protected is receiving the following income (0.38 conf)
undefined__6 was undefined_6 (0.39 conf)
social_security was Social Security (0.40 conf)
retirement was Retirement (0.44 conf)
undefined__7 was undefined_7 (0.39 conf)
veterans_administration was Veterans Administration (0.41 conf)
other was Other (0.43 conf)
specify was Specify (0.36 conf)
undefined__8 was undefined_8 (0.39 conf)
appointed_following_reasons__1 was appointed the conservator for the following reasons 1 (0.36 conf)
appointed_following_reasons__2 was appointed the conservator for the following reasons 2 (0.36 conf)
signature_date__1 was Date (1.00 conf)
signature_date__2 was Date_2 (1.00 conf)
text__2 was Text9 (0.35 conf)
text__3 was Text10 (0.35 conf)
text__4 was Text11 (0.35 conf)
text__5 was Text12 (0.35 conf)
text__6 was Text13 (0.35 conf)
text__7 was Text14 (0.35 conf)

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

PC 683m, Application for Appointment of Out-Of-State Conservator

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