FORM FOR PETITION TO DETERMINE INCAPACITY MODEL FORM FOR USE IN PETITION TO DETERMINE INCAPACITY PURSUANT TO FLORIDA PROBATE RULE 5.550

In the Circuit Court of the Judicial Circuit, in and for County, Florida Probate Division Case No. In Re: Guardianship of Respondent’s Name An Alleged Incapacitated Person PETITION TO DETERMINE INCAPACITY Petitioner, .....(name of petitioner)....., files this petition seeking a determination of incapacity of the respondent and states: 1. Petitioner’s name: Petitioner’s age: Petitioner’s home address and mailing address: Petitioner’s relationship to the respondent: 2. Respondent’s name: Respondent’s age: Respondent’s home address, mailing address, county of residence: Primary language of the respondent: 3. The factual basis for alleging incapacity: 4. List all persons, with their name and address, known to have information relating to the basis for alleging incapacity: 5. Which rights are being sought to be removed under section 744.3215, Florida Statutes? Indicate which rights that the petitioner requests be removed from the respondent, but not delegated to a guardian: ( ) a. to marry. If the right to enter into a contract has been removed, the right to marry is subject to court approval; ( ) b. to vote; ( ) c. to personally apply for government benefits; ( ) d. to have a driver license; ( ) e. to travel; and ( ) f. to seek or retain employment. Indicate which rights that the petitioner requests be removed from the respondent, but may be delegated to the guardian: ( ) a. to contract; ( ) b. to sue and defend lawsuits; ( ) c. to apply for government benefits; ( ) d. to manage property or to make any gift or disposition of property; ( ) e. to determine his or her residence; ( ) f. to consent to medical and mental health treatment; and ( ) g. to make decisions about his or her social environment or other social aspects of his or her life. If all of the above are checked a determination of plenary incapacity is requested. If only some of the above are checked a determination of limited incapacity is requested. 6. Is a guardianship being sought? Yes No Check any possible alternatives to guardianship: ( ) a. trust agreements; ( ) b. powers of attorney; ( ) c. designations of health care surrogates; ( ) d. other advance directives; or ( ) e. other If a guardianship is being sought, explain why the checked possible alternatives to guardianship are insufficient to meet the needs of the respondent: 7. List the names, addresses, phone numbers, and relationships of the living next of kin of the respondent, including date of birth if the person is a minor. If married, this includes the spouse and all of his or her children: Name Address Relationship 8. Name, address, and phone number of family physician, if known: WHEREFORE, this court is respectfully requested to determine incapacity of the respondent, award attorney’s fees and costs pursuant to Chapter 744, Florida Statutes, and grant such other relief as the court deems just and proper. Under penalties of perjury, I declare that I have read the foregoing, and the facts alleged are true, to the best of my knowledge and belief. Signed on .....(date)...... Petitioner’s Signature Petitioner’s Printed Name: Petitioner’s Address: Petitioner’s Phone Number: Petitioner’s E-mail Address: