Adult Conservatorship Petition Template
[Name of Court]
[County / District]
[State]
In the Matter of the Petition for Conservatorship of:
[Proposed Conservatee Full Name]
Case No.: [Case Number, if known]
Petitioner: [Petitioner Full Name]
ADULT CONSERVATORSHIP PETITION
1. Petitioner Information
I, [Petitioner Full Name], state as follows:
Address: [Street Address]
City, State, ZIP Code: [City, State, ZIP Code]
Phone Number: [Phone Number]
Email Address: [Email Address]
My relationship to the proposed conservatee is:
[Spouse / Child / Parent / Sibling / Relative / Friend / Professional / Other]
2. Proposed Conservatee Information
The adult for whom conservatorship is requested is:
Full Name: [Proposed Conservatee Full Name]
Date of Birth: [Date of Birth]
Current Address: [Street Address]
City, State, ZIP Code: [City, State, ZIP Code]
The proposed conservatee currently resides at:
☐ Private residence
☐ Assisted living facility
☐ Nursing facility
☐ Hospital
☐ Other: [Describe]
3. Type of Conservatorship Requested
I request appointment of a conservator for:
☐ The person
☐ The estate
☐ Both the person and the estate
If conservatorship of the person is requested, the conservator will need authority relating to:
[Personal care, housing, meals, medical care, safety, daily needs, or other matters]
If conservatorship of the estate is requested, the conservator will need authority relating to:
[Income, bank accounts, bills, property, investments, benefits, debts, or other financial matters]
4. Proposed Conservator Information
The person proposed to serve as conservator is:
Full Name: [Proposed Conservator Full Name]
Address: [Street Address]
City, State, ZIP Code: [City, State, ZIP Code]
Phone Number: [Phone Number]
Email Address: [Email Address]
Relationship to proposed conservatee:
[Relationship]
The proposed conservator is:
☐ Willing to serve
☐ An adult with capacity to serve
☐ Not disqualified to serve to the best of petitioner’s knowledge
5. Reason for Petition
This petition is being filed because the proposed conservatee is unable to adequately manage personal care, financial affairs, or both, for the following reasons:
[Describe the physical, mental, cognitive, medical, or functional limitations]
Examples of current concerns include:
[Missed medications, inability to manage bills, confusion, self-neglect, unsafe living conditions, exploitation risk, or other issues]
6. Need for Court Appointment
Court appointment is necessary because:
[Explain why legal authority is needed now]
The proposed conservatee needs help with:
[Daily living, health care decisions, finances, housing, protection from harm, or other needs]
Without the requested conservatorship, the proposed conservatee may face the following risks:
[Financial loss, neglect, inability to obtain care, unsafe living conditions, missed treatment, or other risks]
7. Less Restrictive Alternatives Considered
The following less restrictive alternatives have been considered, attempted, or are not sufficient:
☐ Durable power of attorney
☐ Health care directive
☐ Supported decision-making
☐ Representative payee
☐ Informal family assistance
☐ Trust administration
☐ Other: [Describe]
These alternatives are not sufficient for the following reasons:
[Explain]
8. Interested Persons
The following persons may be entitled to notice of this petition or may have a significant interest in the matter:
Name: [Full Name]
Relationship: [Relationship]
Address: [Address]
Name: [Full Name]
Relationship: [Relationship]
Address: [Address]
Name: [Full Name]
Relationship: [Relationship]
Address: [Address]
Add additional persons if needed.
9. Medical or Functional Information
To the best of my knowledge, the proposed conservatee has the following diagnosis, condition, or limitations:
[Describe condition or write “Unknown at this time”]
Supporting evaluation, report, or statement:
☐ Attached
☐ Will be filed separately
☐ Not yet available
Name of physician, evaluator, or care provider, if applicable:
[Name and contact information]
10. Property and Financial Information
Complete this section if conservatorship of the estate is requested.
The proposed conservatee’s known income, assets, or property include:
[Bank accounts, benefits, pension, home, vehicle, investments, personal property, or other assets]
The proposed conservatee’s known debts, bills, or financial obligations include:
[Rent, mortgage, utilities, medical bills, loans, taxes, or other obligations]
11. Special Requests
I request that the court grant the following authority or orders, if permitted:
[Specific powers, restrictions, protective orders, authority to access records, authority to manage benefits, or other requested relief]
If temporary or emergency relief is also requested, describe it here:
[Describe urgent need or write “None”]
12. Supporting Documents
The following documents are attached or will be filed separately, if required:
☐ Medical declaration or evaluation
☐ Notice documents
☐ Confidential information sheet
☐ Proposed order
☐ Screening or background form
☐ Additional declarations
☐ Other: [Describe]
13. Request for Relief
I respectfully ask the court to:
appoint [Proposed Conservator Full Name] as conservator of the ☐ person ☐ estate ☐ both for [Proposed Conservatee Full Name];
grant the powers requested in this petition, as allowed by law;
set the matter for hearing and provide any appropriate notice; and
grant any further relief the court finds proper.
14. Declaration and Signature
I declare under penalty of perjury under the laws of [State] that the foregoing is true and correct to the best of my knowledge.
Date: [Date]
Signature: __________________________
Name: [Petitioner Full Name]
If there is more than one petitioner, each petitioner should sign below:
Signature: __________________________
Name: [Petitioner Full Name]
Date: [Date]
15. Proposed Conservator Acknowledgment
I, [Proposed Conservator Full Name], state that I am willing to serve as conservator if appointed by the court and will perform the required duties according to law and court order.
Signature: __________________________
Name: [Proposed Conservator Full Name]
Date: [Date]
16. Attorney Information, if Any
Attorney Name: [Attorney Full Name]
Bar Number: [Number]
Law Firm: [Law Firm Name]
Address: [Address]
Phone Number: [Phone Number]
Email Address: [Email Address]
Attorney for: [Petitioner / Proposed Conservator / Other]
