PAG94 – Motion for Emergency Temporary Guardian (09/2014) Page 1 of 2

STATE OF VERMONT

SUPERIOR COURT PROBATE DIVISION

Unit Docket No.:

In re Guardianship of :

MOTION FOR EMERGENCY TEMPORARY GUARDIAN

I ask the Court to appoint an emergency temporary guardian for ____________________________________ Name of Respondent

The nature of the emergency guardianship is: (check one)

☐ Financial

☐ Medical

☐ Other:

In support of this request, I state:

1. The respondent’s mental state is:

2. Because of Respondent’s present mental state, Respondent is unable at this time to make the following decisions: (check all boxes that apply)

☐ Medical

☐ Financial

☐ Other decisions related to Respondent’s well-being: (explain below)

3. The following serious and irreparable harm to respondent’s physical health or financial interests will

result if an emergency temporary guardian is not appointed.

PAG94 – Motion for Emergency Temporary Guardian (09/2014) Page 2 of 2

I request: (check one)

☐ A temporary emergency order with notice and hearing I have filed a guardianship petition and request a hearing on the petition at the earliest date after appointment of an attorney for the respondent and after notice of the petition has been given to the respondent. I attach a sworn statement that I am unable to serve notice of the petition as required by the Rules of Probate Procedure due to the emergency need for guardianship.

☐ A temporary emergency order without notice and hearing I have filed a guardianship petition and request appointment of an emergency temporary guardian without notice to the respondent and the opportunity for hearing. I attach a sworn statement with specific facts showing that immediate, serious, and irreparable harm will result to the respondent before a hearing on the appointment of an emergency temporary guardian can be held.

Date Signature of Petitioner

Petitioner’s Mailing Address

Petitioner’s Phone Number

Attachments: Petition for Adult Guardianship (Form no. PAG72 ) if not previously filed List of Interested Persons (Form no. PG 73) if not previously filed Statement of Respondent’s assets and income (Form no. PG 72) if not previously filed