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PETITION FOR APPOINTMENT OF [DocketNo. | Commonwealth of MassachusettsThe Trial CourtGUARDIAN FOR AN ; , Probate and Family CourtINCAPACITATED PERSON BL DaPIRG IGIn the Interests of:Jermaine LOUIS COO 0 oat Wig f DY (hy FLED DivisionJUL 22 2022PROBATE COURTThe Court shall encourage the development of maximum self-reliance and independence=dflthe GHcapbdiatéd\Person andmake appointive and other orders only to the extent necessitated by the Incapacitated Person's limitations or other conditionswarranting the procedure.1. Information about the Respondent:none: Je(MIGUNE Loujs — Collare Redi-guerPrimary Language: [[] English Other: fants Primary "ee # (74- 6 BU? gy >Date of Birth: {2-07-20} Age: 20 Gender: qPrincipal Residence: {) 2 la aacurcy IPs) uct NW bedlod — Hel oz HKress} + UNDate Residence was established: 9 Antos (20 144 >Current Address: [same as Above or [] the following address: Alleged Incapacitated Person/Respondent “tadaressy"———— «Tt, Unit, No. ete.) ___{cityTowny ——_ 7tatey- appIf this appointment is made, Respondent will reside at [_] Principal Residence [] Current Address _[[ the following address:SS) (Apt, Unit, No. etc.) (CityiTowny ‘Gtatey (ZipyRespondent is [is not alleged intellectually disabled.2, Information about the Petitioner:Name: Madeline L . Bode (Gven KoclriqveFirst Name MI Ti UTS wT13 h ress) “Cpt Unit, No. ety . ‘own} 9BPrimary Phone #: 2 4G-b 3ef- 2443 Relationship to Respondent: U oO WYE-mail: hade ommy Ser nh ayamail. Com -State your interest in the appointment: .Jermaine needs agsistanee W/ all SAtcty, Madi C4t,heath , aCKvikes of daily (iving.CD An attachment to this petition provides information on co-petitioner(s).3. The Petitioner is requesting: :to be appointed CU that some suitable person be appointed + [_] that the person named below be appointed:\4MPC 120 (10/8/19) page 1 of |Name: \ , : “ A Fst Name MA. “ 5 Tast Name(Address) Apt Unit, No. etc) ( iyTowny Ctatey TZipyPrimary Phone #: Relationship to Respondent:E-mail:——(0 An attachment to this petition provides information on co-Guardian(s).4. He or she has priority of appointment because the nominee is (choose one):(1 Nominated in a durable power of attorney by Respondent; wh Respondent's parent or a parental nominee; OR(J Respondent's spouse or a spousal nominee; [1 None of the above.State the reason the proposed guardian(s) should be appointed:Jevinains necds aistance in all areas ys oychy ; Melt CLNth , OL aCrVitres of alaiuy OVing5. This is a Petition for appointment of a (choose one):© Limited Guardian. State the powers being sought:O to apply for health insurance benefits including MassHealth on behalf of Respondent;(2 to obtain copies of statements or any other records from banks, insurance companies, or other financialinstitutions verifying balances and transactions of accounts standing in the name of the Incapacitated Person,individually or jointly with another.(J Other:ORdb General Guardian. State the reasons why a Limited Guardianship is inappropriate:Termaine has Pown Syndrome ) ine llechialAis abi iy and need& GSdistance ‘in all ATeA® of med cat,. GY eeriimal Care. . .6. A Medical Certificate dated With an examination having taken place within 30 days of the filing of the petition or, ifRespondent is alleged to be intellectually disabled, a Clinical Team Report dated with an examination having takenplace within 180 days of the filing of the petition:mt is filed with this Petition or is on file with the Court (Docket No. );ORCO is not filed with this Petition and is not on file with this Court.If a Medical Certificate or Clinical Team Report is not filed with this Petition, or on file with this Court, you must immediatelfile and present a motion requesting that the Court permit it to be filed late or waive the filing requirement. An affidavit musaccompany the motion explaining why it is impossible to file a Medical Certificate or Clinical Team Report with this Petition. 7. The reason a guardianship Is necessary is detalled in the most recent Medical Certificate or Clinical Team Reportfiled with this petition or is described as follows:Dee Chinen Team KPT8. The nature and extent of Respondent's alleged incapacity is detailed in the Medical Certificate or Clinical TeamReport filed with this petition or is described as follows:See C$Kerecal Gearon KFT |MPC 120 (10/8/19) page 2 of 69, List Respondent's:A. Spouse, ifany,B. Children, any. lfnone, ist parents and brothers and sisters or, if none, list heirs apparent or presumptive,C. Current Guardian in the Commonwealth or elsewhereD. Nominated Guardian in the Commonwealth or elsewhere;E. Curent Conservator in the Commonwealth or elsewhere;F, Health Care Agent;G. Durable Power of Attorney/Agent;H. Representative Payee: andlor|. Caretaker in the last 60 days, Name Primary Address Primary Phone ( aT a tisit 11 Spouse f Representative Payee CMinori ‘lng (13 | 4 H-£34 Di chi [1] Heath Care Proxy 1] IncompetentNew f d i) Y YR (7 Guardian [ Durable Power Holder: Nominated Guardian [7] Had care & custody in the lastge, HA hoo 46 ae 60 days.chon cham SY\ Le fave | [1 Spouse [7 Representative Payee 1 Minor[ui 568 a0 g2- | cena [1 Heath Cae Proy C7 eanpeentCo [ h A} Q\ wor gS y i C7 Guardian [] Durable Power HolderPrarer® (ammo P E:00764[J] Nomingted Guardian ([] Had care & custody in the last[i Gonservator “Oday.Relative: Delii (relationship LI Spouse (7 Representative PayeeD child [J] Health Care ProxyL Guardian [J Durable Power Holder[]] Nominated Guardian [] Had care & custody in the last[J Conservator 60 days.L Relative:HONNNNNNN NINN NNN eeos69 NNN NNN NN C1 MinorL IncompetentInformation/Explanation: NoL Uncertain 10, Does the Respondent have, in the Ifyes, a copy of the | (Ifa Petition has been filed but notCommonwealth or elsewhere: document is; allowed, please list Court and 'Docket Number of pending case)Yes and the person's information is listed at 0.9 [AttachedA current Guardian? No LJ Unavailable(1 Uncertainve and the person's information is listed at Q.9 [Uf AtachedIA document nominating a Guardian? ONo [1 Unavailable ][J] Uncertaina Yes andthe person's information ised at 9 Cy Ateched1A current Conservator? ar LZ Unavailablemei AN\ Aive and the person's information is listed at Q.9 [statedIA Representative Payee? [No (1 Unavailable(] UncertainJ Yes and the person’ information is isted at 0.9 [7 Ateched_|AHealth Care Agent? a No [1 Unavailable MS[J UncertainYes and the person's information is listed at 0.9 (7 AttachedIA Durable Power of Attormey/Agent? (1) Unavailable44.Respondent [] has ahhes has not executed a MOLST (Medical Orders for the usta Treatment)12. Respondent [] Is d is not entitled to benefits from the Department of Veterans Affairs or [7] Uncertain.13. Does Respondent have any assets, e.g. bank accounts, property? 0 Yes df No [] Uncertain. If Yes, identify: Description of Assets, e.g. Bank Accounts, Property, Insurance, PensionsDO NOT INCLUDE NAMES OF INSTITUTIONS OR ACCOUNT NUMBERS Estimated Value of Property Total O (J An attachment to this petition provides additional information. 14. Does Respondent have any anticipated income? a Yes [] No [J Uncertain. If Yes, identify:Description of Income; e.g. Social Security, Interest Amount of Anticipated MonthlyDO NOT INCLUDE NAMES OF INSTITUTIONS OR ACCOUNT NUMBERS. Income or Receipts socal Security 6447 ob Vouk |Total | $ YU 2. TO/mo. ( An attachment to this Petition provides additional information.15. (] Petitioner seeks specific Court authorization:(1 to admit Respondent to a nursing facility;(7) to treat Respondent with antipsychotic medication in accordance with a treatment plan;tor the following treatment or action for which a substituted judgment determination may be required:Che DRC CAT? / [nee x teed(7 to revoke the Health Care Proxy of Respondent. WHEREFORE, PETITIONER REQUESTS THAT THIS HONORABLE COURT:Appoint af PetitionerOo First Name MI LastName(Some suitable personas [limited guardian(s) a general guardian(s) of Respondent, with any specific authorization as may be requested iparagraph 15 above.MPC 120 (10/8/19) | page 5 of 6fVo _. thhPetitioner requests the Court Waive sureties on the Bond for the following Teasons:The Respondent has minimal funds to be managed and requiring sureties Would place a financial burden on theRespondent. .[A Conservator is appointed or is being requested.(Other:(7 In addition, Petitioner requests that the Court:COALVE fOOVIACE fVotHE SIGNED UNDER THE PENALTIES OF PERJURY| affirm or swear under oath that | have read the foregoing Petition and that the statements set forth therein are true and correct tcthe best of my knowledge.soe 2 ]-2 B22 Hodeli Codys fsSignature of PetitionerDate: Signature of Co-petitioner (if applicable){assent to the foregoing Petition: Print Name SignatureDate .DateDateDateAttorney for PetitionerSignature of Attomey(Print name)Toss TBE Unt, No etey—TeiyrTawny Wiatey 2)Primary Phone:B.B.O. #E-mail:MPC 120 (10/8/19)page 6 of 6
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