Haw. Prob. R. Flag Sheet 1-C-CG

CG. No.

(Attorney for Petitioner or Pro Se Petitioner)

Tel. No. Name of Respondent

I. Respondent

1. The Respondent is an adult: Yes Age

2. Has the Respondent's attendance/participation been excused? Yes No

(HRS §560:5-308(a), -408(a))

II. Appointment of Conservator and Guardian

A. Proposed Conservator

1. State the relationship of the proposed Conservator to the Respondent.

2. Is there any person who has higher priority to be appointed Conservator?

Yes No

3. If “Yes,” list the name(s) of the person(s) who have higher priority, and whether waiver(s) of their right to be appointed Conservator have been filed.

Waiver Filed?

Name Yes No

4. Has the proposed Conservator's attendance been excused? Yes No

(HRS §560:5-408(a))

B. Proposed Guardian

1. State the relationship of the proposed Guardian to the Respondent.

2. Is there any person who has higher priority to be appointed Guardian?

Yes No

3. If “Yes,” list the name(s) of the person(s) who have higher priority, and

whether waiver(s) of their right to be appointed Guardian have been filed.

Waiver Filed?

Name Yes No

4. Has the proposed Guardian's attendance been excused? Yes No

(HRS §560:5-308(a))

III. The Respondent's Assets

1. Estimated dollar value of property

a. Real Property $

b. Personal Property $

Total Value $

2. If the Respondent has a claim for damages, describe the nature of the claim, the

amount of the settlement offer, and whether the offer is fair and reasonable in light

of all the circumstances of the claim.

IV. Deposit

1. Deposit of the property shall be in accordance with Rule 107(c) of the Hawaii Probate Rules. Yes No

2. If “No,” state the method of deposit.

V. Withdrawals

1. State the amount requested, if any, for the support

and maintenance of the Respondent: $ per month

2. State the amount requested, if any, for extraordinary

withdrawals, and the reason therefor: $

VI. Accounting Period Requested

Check one of the following:

(1) Annual; (2) Biennial; (3) Triennial; (4) Other.

State the accounting period:

VII. Proof of Service

1. List or attach a list of all interested persons who are entitled to notice of hearing,

and their relationship to the Respondent.

Name Relationship

2. Was the petition and notice personally served on the Respondent?

(HRS §560:5-309; 5-404; 5-406(b)) Yes No

3. Was notice served on all interested persons?

(HRS §560:5-309; 5-404; 1-401) Yes No

4. If “No,” were waivers of notice obtained and filed for all

interested persons other than those served under 3 above? Yes No

5. If “No,” list the names of all interested persons who have not been served and

have not waived notice.

VIII. Limitations on Conservatorship and/or Guardianship

A. Conservatorship

1.Is Limited or Unlimited Conservatorship requested?

(HRS § 560:5-403(c)(3), 5-409(b)) Limited Unlimited

2. Explain:

B. Guardianship

1.Is Limited or Unlimited Guardianship requested?

(HRS § 560:5-304(b)(9), 5-311(b)) Limited Unlimited

2. Explain:

IX. Recommendation of Kokua Kanawai

(Applicable; Not applicable.)

The Kokua Kanawai's specific recommendations are:

(a) Need for a Guardian and Conservator exists? Yes No

(b) Should a Guardian ad Litem be appointed? Yes No

(c)Appointment of Petitioner?

1. As Conservator? Yes No

2.As Guardian?Yes No

(d) Accounting period (specify) (e) Limited or Unlimited?

1. Conservatorship? Limited Unlimited 2. Guardianship? Limited Unlimited

(f) Other:

X. Estimated Fees

1. Kokua Kanawai $

2. Attorney for Petitioner $

3. Attorney or Guardian ad Litem for Respondent $

XI. Bond

1. Is the appointment of the Guardian with bond? Yes No

2. If “Yes,” state the amount of the bond requested. $

3. Is the appointment of the Conservator with bond? Yes No

4. If “Yes,” state the amount of the bond requested. $

XII. Objection or Opposition

1. Are you aware of any opposition or objection to this petition? Yes No

2. If “Yes,” state by whom (include the relationship of the objector to the

Respondent or proposed Conservator and/or Guardian) and the grounds for the

objection, if known.

THE UNDERSIGNED HEREBY CERTIFIES THAT TO THE BEST OF SAID INDIVIDUAL’S KNOWLEDGE AND BELIEF ALL OF THE FOREGOING FACTS

AND FIGURES ARE TRUE AND CORRECT.

Attorney for Petitioner or Pro Se Petitioner

Hearing Date: