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STATE OF MICHIGAN

PROBATE COURT
COUNTY

PETITION FOR
APPOINTMENT OF CONSERVATOR
PROTECTIVE ORDER

CASE NO. and JUDGE

Court address

Court telephone no.

In the matter of

First, middle, and last name

Last four digits of SSN

Petitioner’s name, address, and telephone no.

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

1. I,

Name

and make this petition as

2. The individual was born

, resides in

State interest/relationship
Put DOB in Ref. No.
row 1 on MC 97.
Date

, am interested in this matter

Address

City, state, zip

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

and has property in

County.

County

Court,

above individual has been previously filed in

Case Number

, was assigned to Judge

and

remains

is no longer

pending.

4. 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.)

a. The individual is an adult unable to manage his/her property and business affairs effectively because of

chronic use of drugs
chronic intoxication
detention by a foreign power

confinement
disappearance

Name and address

mental illness

mental deficiency
physical illness or disability

and either

the adult has property that will be wasted or dissipated unless proper management is provided, or
the adult or his/her dependents are in need of money for support, care, and welfare, and protection is

necessary to obtain or provide money.

b. The adult petitioner is mentally competent but because of age or physical infirmity is unable to manage his/her

property and affairs effectively, and recognizing the disability, requests appointment of a conservator.

Approved, SCAO
Form PC 639, Rev. 5/21
MCL 700.5104(2), MCL 700.5215(a), MCL 700.5314(b), MCL 700.5401,
MCL 700.5404, MCR 3.206(A)(4), MCR 5.105(C), MCR 5.125(C)(25)
Page 1 of 3

Put last 4 digits of SSN in Ref. No. row 2 on MC 97.XXX-XX-PCS Code: CSRTCS Code: CSVPetition for Appointment of Conservator and/or Protective Order
Page 2 of 3

(5/21)

Case No.

owns money or property that requires management or protection that cannot otherwise be provided.
has or may have business affairs that may be jeopardized or prevented by minority.
needs money for support and education, and protection is necessary or desirable to obtain or provide money.

d. I am the guardian of the ward and it is in the ward’s best interests to sell or otherwise dispose of the ward’s

c. The individual is a minor who

5. (continued)

6. The statements in item 5 are supported by the following facts:

real property or interest in real property.

(Attach a separate sheet if necessary.)

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

Real property

Personal property

Insurance

Monthly income

8. The individual to be protected is receiving the following benefits from governmental agencies:

Social Security $

SSI $

MDHHS $

Veterans Administration $

, claimant number

Other:

9. The individual to be protected has

below.

a spouse whose name and address are listed below.
child(ren) whose name(s) and address(es) are listed below.
descendants of deceased child(ren) whose name(s) and address(es) are listed below.
if no child(ren) or descendants of deceased child(ren), parents whose name(s) and address(es) are listed

if none of the above, presumptive heirs whose name(s) and address(es) are listed below.
none of the above (must notify the Attorney General - see instructions for the address of the Attorney General).

NAME

ADDRESS AND TELEPHONE NUMBER

RELATIONSHIP

AGE
(if minor)*

Street address

City

Street address

State

Zip

Telephone no.

State

Zip

Telephone no.

State

Zip

Telephone no.

State

Zip

Telephone no.

*If person is a minor, provide the date of birth on form MC 97a and put the Ref. No. from that form in the box above with the age.

Petition for Appointment of Conservator and/or Protective Order
Page 3 of 3

(5/21)

Case No.

10. None of the persons named above are under any legal incapacity except

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

11. The individual is currently found at

Address or location Telephone no.

12. It is necessary that a preliminary protective order be entered pending the regular hearing because

I REQUEST that the court:

13. Appoint

Name, address, and telephone no.

who has priority as

Priority relationship

14. Preserve and apply the individual's property pending the appointment of a conservator as follows:

, as conservator of the estate to be protected.

15. Enter a protective order that provides

or interest in real property.

16. Appoint the guardian as special conservator with authority to sell or otherwise dispose of the ward's real property

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

17. NOMINATION BY PERSON TO BE PROTECTED: I am 14 years of age or older. I nominate as my conservator

Date

Name, address, and telephone no.

Signature of person to be protected

P Q

Date

PC 639, Petition for Appointment of Conservator and/or Protective Order

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): 3
Fields(s): 121
Average fields per page: 40
Reading Level: Grade 9
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)
appointmen_f_conservator was APPOINTMENT OF CONSERVATOR (0.43 conf)
protectiv_e_order was PROTECTIVE ORDER (0.45 conf)
court_address was Court address (0.42 conf)
first_middle_last_name was First middle and last name (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)
users1_name was Name (1.00 conf)
interested_matter was am interested in this matter (0.44 conf)
county__1 was County (0.39 conf)
signature_date__1 was Date (1.00 conf)
users1_address_line_one__1 was Address (1.00 conf)
county__2 was County_2 (0.37 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)
undefined__1 was undefined (0.38 conf)
individual_previously_filed was above individual has been previously filed in (0.34 conf)
remains was remains (0.32 conf)
longer was is no longer (0.37 conf)
court was Court (0.45 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)
manage_business_affairs was a The individual is an adult unable to manage hisher property and business affairs effectively because of (0.46 conf)
physical_unable_manage was b The adult petitioner is mentally competent but because of age or physical infirmity is unable to manage hisher (0.39 conf)
mental_illness was mental illness (0.38 conf)
mental_deficiency was mental deficiency (0.43 conf)
physical_illness_disability was physical illness or disability (0.45 conf)
chronic_use_drugs was chronic use of drugs (0.36 conf)
chronic_intoxication was chronic intoxication (0.38 conf)
detention_foreign_power was detention by a foreign power (0.46 conf)
confinement was confinement (0.30 conf)
undefined__2 was undefined_3 (0.39 conf)
unless_proper_provided was the adult has property that will be wasted or dissipated unless proper management is provided or (0.38 conf)
money_support_care was the adult or hisher dependents are in need of money for support care and welfare and protection is (0.37 conf)
judge was Judge (0.39 conf)
text__1 was Text2 (0.35 conf)
disappearance was disappearance (0.38 conf)
checkbox was checkbox2 (0.35 conf)
c_individual_minor was c The individual is a minor who (0.35 conf)
best_otherwise_dispose was d I am the guardian of the ward and it is in the wards best interests to sell or otherwise dispose of the wards (0.28 conf)
money_cannot_provided was owns money or property that requires management or protection that cannot otherwise be provided (0.45 conf)
may_business_affairs was has or may have business affairs that may be jeopardized or prevented by minority (0.43 conf)
necessary_desirable_obtain was needs money for support and education and protection is necessary or desirable to obtain or provide money (0.48 conf)
statements_following_facts was 6 The statements in item 5 are supported by the following facts (0.38 conf)
attach_separate_necessary__1 was Attach a separate sheet if necessary 1 (0.38 conf)
attach_separate_necessary__2 was Attach a separate sheet if necessary 2 (0.38 conf)
undefined__3 was undefined_4 (0.39 conf)
undefined__4 was undefined_5 (0.39 conf)
undefined__5 was undefined_6 (0.39 conf)
undefined__6 was undefined_7 (0.39 conf)
individual_receiving was 8 The individual to be protected is receiving the following benefits from governmental agencies (0.36 conf)
undefined__7 was undefined_8 (0.39 conf)
ssi was SSI (0.45 conf)
mdhhs was MDHHS (0.35 conf)
undefined__8 was undefined_9 (0.39 conf)
social_security was Social Security (0.40 conf)
veterans_administration was Veterans Administration (0.41 conf)
other was Other (0.43 conf)
undefined__9 was undefined_10 (0.39 conf)
claimant_number was claimant number (0.39 conf)
undefined__10 was undefined_11 (0.39 conf)
undefined__11 was undefined_12 (0.39 conf)
spouse_whose_name_address was a spouse whose name and address are listed below (0.38 conf)
children_whose_addresses__1 was children whose names and addresses are listed below (0.45 conf)
children_whose_addresses__2 was descendants of deceased children whose names and addresses are listed below (0.42 conf)
children_whose_addresses__3 was if no children or descendants of deceased children parents whose names and addresses are listed (0.45 conf)
presumptive_heirs_addresses was if none of the above presumptive heirs whose names and addresses are listed below (0.37 conf)
must_see_address was none of the above must notify the Attorney General see instructions for the address of the Attorney General (0.36 conf)
name_row__1 was NAMERow1 (0.43 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)
relationship_row__1 was RELATIONSHIPRow1 (0.39 conf)
ag_e_minor_row__1 was AGE if minorRow1 (0.45 conf)
name_row__2 was NAMERow2 (0.43 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)
relationship_row__2 was RELATIONSHIPRow2 (0.39 conf)
ag_e_minor_row__2 was AGE if minorRow2 (0.45 conf)
name_row__3 was NAMERow3 (0.43 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)
relationship_row__3 was RELATIONSHIPRow3 (0.39 conf)
ag_e_minor_row__3 was AGE if minorRow3 (0.45 conf)
name_row__4 was NAMERow4 (0.43 conf)
street_address__3 was Street address_4 (0.43 conf)
city__3 was City_4 (0.39 conf)
state__3 was State_4 (0.39 conf)
zip__3 was Zip_4 (0.36 conf)
telephone__4 was Telephone no_4 (0.45 conf)
relationship_row__4 was RELATIONSHIPRow4 (0.39 conf)
ag_e_minor_row__4 was AGE if minorRow4 (0.45 conf)
name_representative_person was Name incapacity and representative of the person if any (0.34 conf)
address_location was Address or location (0.39 conf)
telephone__5 was Telephone no_5 (0.45 conf)
necessary_preliminary_pending was 12 It is necessary that a preliminary protective order be entered pending the regular hearing because (0.38 conf)
undefined__12 was undefined_13 (0.39 conf)
name_address_telephone__1 was Name address and telephone no (0.37 conf)
appoint was 13 Appoint (0.38 conf)
apply_pending_appointment was 14 Preserve and apply the individuals property pending the appointment of a conservator as follows (0.41 conf)
enter_protective_provides was 15 Enter a protective order that provides (0.39 conf)
authority_otherwise_real was 16 Appoint the guardian as special conservator with authority to sell or otherwise dispose of the wards real property (0.44 conf)
priority_relationship was Priority relationship (0.48 conf)
undefined__13 was undefined_14 (0.39 conf)
signature_date__2 was Date_2 (1.00 conf)
signature_date__3 was Date_3 (1.00 conf)
n_years_age_older was 17 NOMINATION BY PERSON TO BE PROTECTED I am 14 years of age or older I nominate as my conservator (0.43 conf)
name_address_telephone__2 was Name address and telephone no_2 (0.39 conf)
signature_date__4 was Date_4 (1.00 conf)
text__2 was Text3 (0.35 conf)
text__3 was Text4 (0.35 conf)
text__4 was Text5 (0.35 conf)
text__5 was Text6 (0.35 conf)

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

Suggested Screen 0:

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appointmen_f_conservator
protectiv_e_order
court_address
first_middle_last_name
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petitioners_attorney_address
users1_name
interested_matter
county__1
signature_date__1
users1_address_line_one__1
county__2
action_division_involving
undefined__1
individual_previously_filed
remains
longer
court
attorney_specify_name_address
guardian_specify_name
security_specify_address
name_address
manage_business_affairs
physical_unable_manage
mental_illness
mental_deficiency
physical_illness_disability
chronic_use_drugs
chronic_intoxication
detention_foreign_power
confinement
undefined__2
unless_proper_provided
money_support_care
judge
text__1
disappearance
checkbox
c_individual_minor
best_otherwise_dispose
money_cannot_provided
may_business_affairs
necessary_desirable_obtain
statements_following_facts
attach_separate_necessary__1
attach_separate_necessary__2
undefined__3
undefined__4
undefined__5
undefined__6
individual_receiving
undefined__7
ssi
mdhhs
undefined__8
social_security
veterans_administration
other
undefined__9
claimant_number
undefined__10
undefined__11
spouse_whose_name_address
children_whose_addresses__1
children_whose_addresses__2
children_whose_addresses__3
presumptive_heirs_addresses
must_see_address
name_row__1
users1_address_line_one__2
users1_address_city
users1_address_state
users1_address_zip
telephone__1
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ag_e_minor_row__1
name_row__2
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zip__1
telephone__2
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name_row__4
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zip__3
telephone__4
relationship_row__4
ag_e_minor_row__4
name_representative_person
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telephone__5
necessary_preliminary_pending
undefined__12
name_address_telephone__1
appoint
apply_pending_appointment
enter_protective_provides
authority_otherwise_real
priority_relationship
undefined__13
signature_date__2
signature_date__3
n_years_age_older
name_address_telephone__2
signature_date__4
text__2
text__3
text__4
text__5

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

PC 639, Petition for Appointment of Conservator and/or Protective Order

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