Guardianship 17-A Questionnaire

Please fill out the form below. If you would prefer to submit a paper copy you may print a pdf version of this form instead. Guardianship 17-A Questionnaire

REQUIRED CLIENT INFO FOR 17A PETITIONS
PLEASE COMPLETE THIS QUESTIONNAIRE TO THE BEST OF YOUR ABILITIES.
NOTE: Person Guardianship is for (hereinafter sometimes referred to as the “Respondent”):
Your Name*
First Last
Your Email Address*
Respondent's Name*
First Middle Last Suffix
As it appears on the Birth Certificate
Date of Birth*
Month
Day
Year
Marital Status*
Select*
- Intellectually Disabled
- Developmentally Disabled
Respondent is a Native American child under the Indian Child Welfare Act of 1978 (25 U.S.C. Sections 1901-1963):*
- Yes
- No
Domicile Street Address*
Street Address Address Line 2 City State ZIP Code
Is the Mailing address different?*
- Yes
- No
If the Respondent is employed, provide Employer Name and Address:
Employer Name
Employer Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
If the Respondent resides in a Group Home or Facility:
Group Home or Facility Name
Group Home or Facility Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Name of Director of Group Home or Facility:
Director Name
Director Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Medical Affidavits Are Required to Be Completed by Either the Primary Care Physician and Licensed Psychologist or 2 Examining Physicians:
Name of Certifying Physician/Primary Care Physician:*
Phone number of Certifying Physician/Primary Care Physician:
Address of Certifying Physician/Primary Care Physician:
Street Address Address Line 2 City State ZIP Code
Name of second Certifying Physician or Licensed Psychologist:*
Phone number of second Certifying Physician or Licensed Psychologist:
Address of second Certifying Physician or Licensed Psychologist:
Street Address Address Line 2 City State ZIP Code
If Primary care physician different from certifying physician:
Name
Address
Address

Street Address Address Line 2 City State ZIP Code
Can the Respondent attend the hearing to be scheduled by the court?*
- Yes
- No
If not, is it because Respondent is medically incapable of being present to the extent that attendance is likely to result in physical harm to respondent?*
- Yes
- No
OR is it for other reasons?
- Yes
- No
Person Seeking to Be Guardian And/Or Co-Guardians
Name of person seeking to be Guardian and/or Co-Guardians:*
First Last
Date of Birth*
Month
Day
Year
Street Address*
Street Address Address Line 2 City State ZIP Code
Interest/Relationship to Respondent:*
Education*
Qualifications*
Standby Guardian
Standby Guardian Name*
First Last
Date of Birth*
Month
Day
Year
Street Address*
Street Address Address Line 2 City State ZIP Code
Interest/Relationship to Respondent:*
Education*
Qualifications*
First Alternate Standby Guardian
First Alternate Standby Guardian Name
First Last
Date of Birth
Month
Day
Year
Street Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Interest/Relationship to Respondent:
Education
Qualifications
Information Regarding the Parents and Relatives of Respondent
Name of Respondent’s Father
First Last
Date of Birth
Month
Day
Year
Date of Death (if applicable)
Month
Day
Year
Street Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Mailing address is different:
- Yes
- No
Name of Respondent’s Mother
First Last
Date of Birth
Month
Day
Year
Date of Death (if applicable)
Month
Day
Year
Street Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Mailing address is different:
- Yes
- No
Name of Respondent’s Spouse
First Last
Date of Birth
Month
Day
Year
Date of Death (if applicable)
Month
Day
Year
Street Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Respondent’s Children and/or Siblings

Children and/or Siblings

Name(s), addresses, and ages of adult children and adult siblings (18 years of age or older) of the Respondent:

Name	Address	Date of Birth	Relationship to Respondent

Mailing address is different:
- Yes
- No
If parents, spouse, adult children, or adult siblings are living but not proposed to be appointed guardian, standby guardian, or alternate standby guardian, provide explanation.
Assets of the Respondent
BANK ACCOUNTS
Title of Bank Account
Account Number
Balance Amount - $
INSURANCE COMPANY
Insurance Policy Company
Policy Number
Amount Insured
Name of Insured
Relationship to Respondent
STOCK AND BOND INFORMATION
Stock Name
Number of Shares
Stock Value - $
REAL PROPERTY
Location of Real Property
Gross Value
Annual Income
Rental Income (if applicable)
Respondent's Interest
Property Is:
select all that apply
- Mortgaged
- Under a Lien
Amount
Is residence to be occupied by respondent?
- Yes
- No
Is sale of property contemplated?
- Yes
- No
ANNUAL INCOME OF RESPONDENT
Source of wages to be received
Amount
Source of pension to be received
Amount
Name of Trust from which income is received
Amount
Source of governmental entitlements
Amount
Source of other income
Amount
If the Respondent Is a Beneficiary of Someone’s Estate Please Provide:
Decedent Name
Relationship to Respondent
Date of Death
Month
Day
Year
Attach a copy of the Court appointment of representative of the estate
Accepted file types: pdf, doc, docx, Max. file size: 50 MB.
Phone
This field is for validation purposes and should be left unchanged.

Guardianship 17-A Questionnaire

Medical Affidavits Are Required to Be Completed by Either the Primary Care Physician and Licensed Psychologist or 2 Examining Physicians:

Person Seeking to Be Guardian And/Or Co-Guardians

Standby Guardian

First Alternate Standby Guardian

Information Regarding the Parents and Relatives of Respondent

Respondent’s Children and/or Siblings

Assets of the Respondent

If the Respondent Is a Beneficiary of Someone’s Estate Please Provide:

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