Limited Conservatorship Petition

1. Petitioner Information

Name: Relationship to Proposed Conservatee: Address: Phone Number:

2. Proposed Conservatee Information

Name: Date of Birth: Address:

3. Nature of Disability

Specify the disability and describe its impact:

4. Limited Powers Requested

Power	Requested	Reason
Access to confidential records
Consent to medical treatment
Decide residence
Educational decisions
Financial decisions

5. Justification for Limited Conservatorship

Explain why a limited conservatorship is appropriate:

6. Additional Information

Other facts relevant to this petition:

7. Declaration

I declare under penalty of perjury under the laws of the State that the foregoing is true and correct.

Date: Signature: