Guardianship/Conservatorship Intake Form

GUARDIANSHIP/CONSERVATORSHIP INTAKE FORM

1. Full name of person seeking guardianship/conservatorship:

______

1. Address: ______
2. Date of Birth: ______
3. Social security number: ______
4. Phone number(s):______
5. Your employer:______
6. Your employer’s address:______
7. Ever pled guilty of convicted of misdemeanor or felony? If so, explain:______

______

______

______

1. Your Spouse’s Name and Address:______

______

1. Will your spouse join you as Petitioner? ______
2. Please list your spouse’s date of birth and social security number:______
3. Has your spouse ever pled guilty or been convicted of misdemeanor or

felony? If so, explain:______

______

______

1. Your Spouse’s Employer:______

Employer’s Address:______

1. Full name of person who needs a guardian/conservator: ______

______

1. His/her address: ______

______

1. His/her age: ______
2. His/her date of birth:______
3. His/her mailing address:______
4. His/her social security number:______

PLEASE COMPLETE THE BELOW INFORMATION FOR THE PERSON NEEDING A GUARDIANSHIP/CONSERVATOR:

1. PARENTS
2. Full name of Mother:______
3. Address of Mother: ______
4. Full name of Father:______
5. Address of Father:______
6. SPOUSE, if any
7. Full name Spouse:______
8. Address of spouse:______
9. CHILDREN, if any
10. Full name(s) of children:______
11. Address of his/her children: ______
12. Age(s) of his/her children:______
13. GRANDPARENTS:
14. Full Name of Maternal Grandmother:______
15. Address:______
16. Full Name of Maternal Grandfather:______
17. Address:______
18. Full Name of Paternal Grandmother:______
19. Address:______
20. Full Name of Paternal Grandfather:______
21. Address:______
22. OTHER CLOSE RELATIVE (aunts, uncles, etc.)
23. Name:______
24. Address:______
25. Relationship:______
26. Name:______
27. Address:______
28. Relationship:______
29. Name:______
30. Address:______
31. Relationship:______

1. Residence for past 6 months of person who needs a guardian/conservator and who resided with them:______

______

1. Reason(s) why a guardian should be appointed:

1. Name and address of person’s current guardian or conservator appointed in this or any other state:______

______

______

1. Any pending custody, guardianship, or conservatorship proceedings in this or any other state? If so, list the details:______

______

1. Are you a guardian and/or conservator for any other person(s)?______

1. If so, list the full names of other individuals of whom you are the guardian and/or conservator? ______

______

1. Full name of physician and physician’s address of the physician treating the person who needs a guardianship/conservatorship: ______

______

______

1. If the proposed guardian is not a Missouri resident then specify a person in Missouri who can act as the agent in the State of Missouri: ______

______

1. If applicable, list the agent in Missouri’s residential address and phone number:

______

______

1. List the names and addresses of all interested persons who will need notice of the pending guardianship/conservatorship, if not already listed as relatives above: ______

______

______

1. List names and addresses of three people who will always know your whereabouts:
2. Name:______
3. Address:______
4. Name:______
5. Address:______
6. Name:______
7. Address:______

1. Complete listing of assets for person who needs guardianship/conservator:

1. Real estate: (include address & legal description)______

______

______

1. Bank and Savings Accounts: (include location of bank account, address, and current balance of account) ______

______

1. Certificates of Deposit: ______
2. Stocks and Bonds: ______
3. Vehicles: ______
4. Household goods and furnishings: ______

______

1. Other: ______

1. Income of person who needs guardianship/conservator assets:

1. Social Security: ______
2. Supplemental Security Income: ______
3. Veterans Administration Benefits: ______
4. Company Pension: ______
5. Interest:______
6. Other:______