Under Oath, I petition the Court for:  Full Name of Ward:   Birth date:   --
        the appointment of the guardian of the  person  estate
        protective placement.

1. The petitioner is who resides at  .  Petitioner is is not an enrolled member of the Stockbridge-Munsee Tribe.
2. The proposed ward's
           post office address is
           residence is    
           telephone number is
   
           Tribal Affiliation: 
3. The proposed ward is in need of a guardian, of the type checked above, for the following reasons:
   
   
4. The Court has jurisdiction over this matter because:
   
   
5. The relationship of the proposed Guardian to the Ward is:     
6. The proposed ward has or is entitled to:
    

   personal property, value	$
   real estate, value	$
   social security	$
   Veterans Administration Benefits	$
   other claims, Income, compensation, rent,      pension, Insurance or allowances, value	$
   medical assistance

7. Of the present assets, $ were derived from the Veterans Administration.  The additional information required by the Uniform Veterans Act.  If applicable, is .
8. The present guardian is (if none, so state):
   name:   telephone number:
   post office address: 
9. The person nominated as guardian of:
   person is:  telephone number:
   estate is:   telephone number:
   post office address: 
10. The person nominated as a standby guardian is:
    name:   telephone number:
    post office address: 
11. The person or institution having the care and custody of the proposed ward is:
    name:   telephone number:
    post office address: 
12. The names and post office addresses of the spouse, presumptive or apparent adult heirs of proposed ward, and all other interested persons are:

    Name	Relationship	Post Office Address

13. The petitioner believes that the proposed ward should retain the following power(s), if any:
    vote   marry   contract   hold or convey property obtain a motor vehicle operator's license or other state license
    other