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Here is the text we could read:

In the matter of

First, middle, and last name

Petitioner’s name, address, and telephone no.

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

1. The individual named above, age

, is a resident of

County

Michigan, and presently lives with/at

Name of person or center or facility

Address City State Zip Telephone no.

Put DOB in box 1 on MC 97.
Date of birth

XXX-XX- Put SSN in box 2 on MC 97.
Last four digits of SSN

The individual is a citizen of the following foreign country:

2. His/her presumptive heirs are as follows: (Attach additional page if needed.)

NAME

AGE

RELATIONSHIP

ADDRESS AND TELEPHONE NUMBER

Street address

City

Street address

State

Zip

Telephone no.

State

Zip

Telephone no.

State

Zip

Telephone no.

State

Zip

Telephone no.

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

individual has been previously filed in

Court, Case Number

, was

, and

remains

is no longer

pending.

assigned to Judge

Approved, SCAO
Form PC 658, Rev. 9/20
MCL 330.1100a, MCL 330.1609
Page 1 of 3

STATE OF MICHIGANPROBATE COURTCOUNTYPETITION FOR APPOINTMENT OFGUARDIAN, INDIVIDUAL WITH ALLEGED DEVELOPMENTAL DISABILITYCASE NO. and JUDGECourt address Court telephone no.JIS Code: PEGPetition for Appointment of Guardian, Individual with Alleged Developmental Disability
Page 2 of 3

(9/20)

Case No.

4. I,

Name (type or print)

State your interest/relationship

, am interested in this matter and make this petition as

5. A report and evaluation required by law

accompanies

does not accompany

the petition.

6. The individual has a developmental disability described as a severe, chronic condition that meets all the following:
1) it is attributable to a mental or physical impairment or a combination of mental and physical impairments;
2) it was manifested before the individual was 22 years old;
3) it is likely to continue indefinitely; and
4) it results in substantial functional limitations in major life activities of

and it reflects the individual’s need for a combination and sequence of special, interdisciplinary, or generic care,

7. The specific nature and extent of the disability is:

(A minimum of three of the following options must apply and be checked.)

self-care,
mobility,
economic self-sufficiency,

receptive and expressive language,

self-direction,

treatment, or other services that are lifelong or for an extended duration and are individually planned and coordinated.

learning,
capacity for independent living,

8. A guardian is needed to assist the individual with the following responsibilities and duties:

9. The estimated value of the individual’s estate and income are:

Real estate:

Yearly income:

Personal property:

Source of yearly income:

I REQUEST THAT:
10. If a report does not accompany this petition, the court order evaluations to be performed and a report to be prepared.

11. The court determine that the individual requires guardianship as an individual with a developmental disability.

12. The court determine and appoint

Name

Address City State Zip Telephone no.

or appoint some other suitable individual or entity as

a. plenary (full) guardian of the
b. partial guardian of the

individual
individual

estate
estate

with the following powers:

The proposed guardian is a current service provider. No other individual or agency is suitable to serve as guardian.

Petition for Appointment of Guardian, Individual with Alleged Developmental Disability
Page 3 of 3

(9/20)

Case No.

13. The court authorize the guardian to execute an application for admission to

Name of facility

located at

Address

14. Pending the appointment of a guardian, the court appoint a temporary guardian or exercise its emergency powers

because

Describe emergency situation

15. The court appoint

Name

Address

as standby guardian.

City State Zip Telephone no.

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’s signature

Attorney’s signature

Date

PC 658, Petition for Appointment of Guardian, Individual with Alleged Developmental Disability

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): 103
Average fields per page: 34
Reading Level: Grade 12
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.

stat_e_f_michiga_n_probat_cour_county was STATE OF MICHIGAN PROBATE COURT COUNTY (0.62 conf)
first_last_name_individual was First middle and last name of the individual (0.37 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)
county__1 was County (0.39 conf)
name_person_center_facility was Name of person or center or facility (0.43 conf)
individual_following_foreign was The individual is a citizen of the following foreign country (0.35 conf)
name_row__1 was NAMERow1 (0.43 conf)
age_row__1 was AGERow1 (0.36 conf)
relationship_row__1 was RELATIONSHIPRow1 (0.39 conf)
users1_address_line_one__1 was Street address (1.00 conf)
users1_address_city was City (1.00 conf)
state__1 was State_2 (0.39 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)
age_row__2 was AGERow2 (0.36 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__2 was State_3 (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)
age_row__3 was AGERow3 (0.36 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__3 was State_4 (0.39 conf)
zip__2 was Zip_3 (0.36 conf)
telephone__3 was Telephone no_3 (0.45 conf)
name_row__4 was NAMERow4 (0.43 conf)
age_row__4 was AGERow4 (0.36 conf)
relationship_row__4 was RELATIONSHIPRow4 (0.39 conf)
street_address__3 was Street address_4 (0.43 conf)
city__3 was City_4 (0.39 conf)
state__4 was State_5 (0.39 conf)
zip__3 was Zip_4 (0.36 conf)
telephone__4 was Telephone no_4 (0.45 conf)
action_division_involving was 3 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)
was was was (0.41 conf)
individual_previously_filed was individual has been previously filed in (0.40 conf)
remains was remains (0.32 conf)
longer was is no longer (0.37 conf)
judge was Judge (0.39 conf)
text__1 was Text2 (0.35 conf)
text__2 was Text3 (0.35 conf)
age was age (0.36 conf)
phone was phone no (0.35 conf)
users1_address_line_one__2 was address (1.00 conf)
county__2 was county2 (0.35 conf)
4_i was 4 I (0.32 conf)
state_interestrelationship was State your interestrelationship (0.48 conf)
accompanies was accompanies (0.28 conf)
accompany was does not accompany (0.46 conf)
selfcare was selfcare (0.35 conf)
mobility was mobility (0.38 conf)
economic_selfsufficiency was economic selfsufficiency (0.44 conf)
receptive_expressive_language was receptive and expressive language (0.45 conf)
selfdirection was selfdirection (0.35 conf)
learning was learning (0.43 conf)
capacity_independent_living was capacity for independent living (0.31 conf)
specific_extent_disability was 7 The specific nature and extent of the disability is (0.40 conf)
needed_assist_individual was 8 A guardian is needed to assist the individual with the following responsibilities and duties (0.34 conf)
unknown__1 was 1 (0.38 conf)
unknown__2 was 2 (0.38 conf)
undefined__1 was undefined (0.38 conf)
undefined__2 was undefined_2 (0.39 conf)
undefined__3 was undefined_3 (0.39 conf)
source_yearly_income was Source of yearly income (0.34 conf)
court_determine_appoint was 12 The court determine and appoint (0.42 conf)
users1_address_line_one__3 was Address (1.00 conf)
telephone__5 was Telephone no_5 (0.45 conf)
plenary_full_guardian was a plenary full guardian of the (0.38 conf)
b_partial_guardian was b partial guardian of the (0.38 conf)
current_individual_agency was The proposed guardian is a current service provider No other individual or agency is suitable to serve as guardian (0.36 conf)
individual__1 was individual (0.38 conf)
individual__2 was individual_2 (0.36 conf)
estate__1 was estate (0.47 conf)
estate__2 was estate_2 (0.39 conf)
following_powers was with the following powers (0.37 conf)
1_2 was 1_2 (0.38 conf)
2_2 was 2_2 (0.38 conf)
unknown__3 was 3 (0.38 conf)
text__3 was Text4 (0.35 conf)
name_facility was Name of facility (0.41 conf)
court_authorize_admission was 13 The court authorize the guardian to execute an application for admission to (0.43 conf)
pending_guardian_powers was 14 Pending the appointment of a guardian the court appoint a temporary guardian or exercise its emergency powers (0.46 conf)
court_appoint was 15 The court appoint (0.37 conf)
located was located at (0.37 conf)
address__1 was Address_2 (0.35 conf)
describe_emergency_situation was Describe emergency situation (0.34 conf)
undefined__4 was undefined_4 (0.39 conf)
users1_name was Name (1.00 conf)
address__2 was Address_3 (0.35 conf)
city__4 was City_6 (0.39 conf)
telephone__6 was Telephone no_6 (0.45 conf)
signature_date__1 was Date (1.00 conf)
signature_date__2 was Date_2 (1.00 conf)
text__4 was Text5 (0.35 conf)
text__5 was Text6 (0.35 conf)
text__6 was Text7 (0.35 conf)

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

Suggested Screen 0:

petitioners_name_address
petitioners_attorney_address
court_authorize_admission
court_appoint

Suggested Screen 1:

first_last_name_individual
name_person_center_facility
receptive_expressive_language
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Suggested Screen 2:

individual_following_foreign
current_individual_agency

Suggested Screen 3:

county__1
city__1
city__2
city__3
county__2
individual__1
individual__2
city__4

Suggested Screen 4:

telephone__1
telephone__2
telephone__3
telephone__4
telephone__5
telephone__6

Suggested Screen 5:

age_row__1
relationship_row__1
age_row__2
relationship_row__2
age_row__3
relationship_row__3
age_row__4
relationship_row__4

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state__1
state__2
state__3
state__4
state_interestrelationship
source_yearly_income
estate__1
estate__2

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action_division_involving

Suggested Screen 8:

court_case_number
was
individual_previously_filed
specific_extent_disability
court_determine_appoint

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remains

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longer

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judge

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zip__1
zip__2
zip__3
text__1
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text__6

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age

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phone

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stat_e_f_michiga_n_probat_cour_county
name_row__1
users1_address_line_one__1
users1_address_city
users1_address_zip
name_row__2
street_address__1
name_row__3
street_address__2
name_row__4
street_address__3
users1_address_line_one__2
4_i
selfcare
selfdirection
unknown__1
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users1_address_line_one__3
b_partial_guardian
unknown__3
address__1
users1_name
address__2
signature_date__1
signature_date__2

Suggested Screen 16:

accompanies
accompany
needed_assist_individual

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mobility

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economic_selfsufficiency
describe_emergency_situation

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learning

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capacity_independent_living

Suggested Screen 21:

undefined__1
undefined__2
undefined__3
undefined__4

Suggested Screen 22:

1_2
2_2

Suggested Screen 23:

plenary_full_guardian
following_powers
pending_guardian_powers

Suggested Screen 24:

located

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

PC 658, Petition for Appointment of Guardian, Individual with Alleged Developmental Disability

About This Form:

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