In the matter of 

First, middle, and last name

 , alleged incapacitated individual  

1. I have been appointed by the court as guardian ad litem, and I accept this appointment.
2. I have performed the duties required by statute (see reverse side for list of duties).

3. I visited the alleged incapacitated individual on 

Date

 at 

Location

and,	to	the	extent	that	the	individual	could	comprehend,	explained	the	nature,	purpose,	and	legal	effects	of	a	guardian's

  appointment and otherwise complied with each provision of MCL 700.5305(1).

4. I report to the court as follows:
 
 
 
 
 

 a. the alleged incapacitated individual wishes to:
 
 
 
 

	have	limits	placed	on	the	guardian's	powers	

 do-not-resuscitate order. 

   contest the petition.

 
 
 
 

 

 

 object to the appointment of the nominated guardian.
 have an attorney appointed.

 

 

 POST (physician orders for scope of treatment) form. 

 

 other.

 b. There is a disagreement or dispute related to the guardianship, namely 

 
I believe it 

 
 
 c.  There is one or more appropriate alternative to a full guardianship, namely:
 

 1) appointment of a limited guardian with the following powers: 

 will not 

 might 

 

 

  be resolved through court-ordered mediation.

 

 

 

 

 
 2) appointment of a conservator or a written protective order.
 3) the alleged legally incapacitated individual executing one of the following:
 
 

 
 
 
 
 
 d. The alleged incapacitated individual wishes to be present at the hearing.

 a patient advocate designation. 
 a durable power of attorney. 

 
 

 a do-not-resuscitate declaration.
 a physician orders for scope of treatment (POST) form.

 e. I believe it is in the best interests of the individual to have legal counsel because 

 

 .

 .

 The individual will retain legal counsel. 

 I recommend the court appoint legal counsel.

 5. None of the items in item 4a above is demanded. My report to the court and recommendations are attached.

  	

 

 

 
 
 
 

 
 
 
 
 
 

 

 
 

 
 

 

 
 
 
 
 

 
 

 
 

 

Date

Signature

Address

 

 

Name (type or print)

City, state, zip                                                                              Telephone no.

Approved, SCAODo not write below this line - For court use onlySEE SECOND PAGE FOR DUTIES OF GUARDIAN AD LITEMUSE NOTE: If this form is being filed in the circuit court family division, please enter the court name and county in the upper left-hand corner of the form.STATE OF MICHIGANPROBATE COURTCOUNTY OF ACCEPTANCE OF APPOINTMENT ANDREPORT OF GUARDIAN AD LITEM OFALLEGED INCAPACITATED INDIVIDUALFILE NO.PC 627 (12/18) ACCEPTANCE OF APPOINTMENT AND REPORT OF GUARDIAN AD LITEM       OF ALLEGED INCAPACITATED INDIVIDUALMCL 700.5305, MCL 700.5306a(2), MCR 5.403(C)PCS CODE: AGL     TCS CODE: AGLYour duties as guardian ad litem include all the following:

  1. Visit the individual alleged to be incapacitated.

DUTIES OF GUARDIAN AD LITEM

	 2.	Explain	to	the	individual	the	nature,	purpose,	and	legal	effects	of	the	appointment	of	a	guardian.

  3. Give the individual form PC 626 that outlines the rights in MCL 700.5306a(1).

  4. Inform the individual that if a guardian is appointed, the guardian may have the power to execute a do-not-resuscitate  
 

  order and/or physician orders for scope of treatment (POST) form on behalf of the individual.

	 5.	Explain	to	the	individual	the	hearing	procedure	and	the	individual's	rights	in	the	hearing	procedure,	including	but	not
 

limited to: 

 

 

  a. the right to contest the petition.

	
  

	 b.	the	right	to	request	limits	on	the	guardian's	powers,	including	a	limitation	on	the	power	to	execute	a	do-not-resuscitate
 

  order and/or a physician orders for scope of treatment (POST) form on behalf of the individual.

  c.  the right to object to a particular person being appointed guardian.

  d. the right to be present at the hearing.

  e. the right to be represented by legal counsel and that legal counsel will be appointed for the person if s/he is unable to  
	

	 afford	legal	counsel.

  6. Inform the individual of the name of any person known to be seeking appointment as guardian.

  7. Ask the individual and the petitioner about the amount of cash and property readily convertible into cash that is in the  
	

individual's	estate.	

	

  8. Make determinations and inform the court of those determinations, on all the following:

  a. whether the individual alleged to be incapacitated wishes to be present at the hearing.

  b. whether the individual alleged to be incapacitated wishes to contest the petition.

	 c.	 whether	the	individual	alleged	to	be	incapacitated	wishes	limits	be	placed	on	the	guardian's	powers.

  d. whether the individual alleged to be incapacitated objec ts to having a do-not-resuscitate order and/or physician 
 

  orders for scope of treament (POST) form executed on his or her behalf.

  e. whether the individual alleged to be incapacitated objects to a particular person being appointed guardian.

f.  whether there is one or more appropriate alternatives to the appointment of a full guardian or whether other action  
  should be taken in addition to the appointment of a guardian after considering:

i.	 appointment	of	a	limited	guardian,	including	the	specific	powers	and	limitation	on	those	powers	the	guardian	ad
 

litem believes appropriate.

ii.  appointment of a conservator or another protective order under 700.5401 et seq.

iii. execution of a patient advocate designation, do-not-resuscitate declaration, physician orders for scope of treatment 
 

form, or durable power of attorney with or without limitations on purpose, authority, or duration.

iv. available support from family members. Family members may often take responsibility for the care of an individual. 
  Also, if  the individual should be diagnosed as having a reduced life expectancy because of an advanced illness,
	 state	law	allows	a	member	of	the	individual's	immediate	family	or	next	of	kin	to	make	informed	decisions	regarding
the individual receiving, continuing, discontinuing and refusing medical treatment and may choose palliative treatment
 
  and adequate and appropriate pain and symptom management.

In the report informing the court of the determinations, include an estimate of the amount of cash and property readily  

 
	 convertible	that	is	in	the	individual's	estate.

  g. whether a disagreement or dispute related to the guardianship petition might be resolved through court-ordered
 

  mediation.