STATE OF VERMONT SUPERIOR COURT PROBATE DIVISION …PG73 – List of Interested Persons (09/2014) Page 1 of 2 STATE OF VERMONT SUPERIOR COURT PROBATE DIVISION Unit Docket No.: In re

PG73 – List of Interested Persons (09/2014) Page 1 of 2

STATE OF VERMONT

SUPERIOR COURT PROBATE DIVISION

Unit Docket No.:

In re Guardianship of :

LIST OF INTERESTED PERSONS Under 14 V.S.A. 3061(5), an interested person in an adult guardianship proceeding is a responsible adult who has a direct interest in a person in need of guardianship and includes: the person in need of guardianship (the respondent); the spouse of the respondent; the parents of the respondent; the adult children of the respondent; a proposed guardian; an agent for the respondent named in a power of attorney and/or advance directive; a person nominated as guardian in an advance directive. For each person listed, specify the person’s relationship to or interest in the Respondent.

Respondent

Name

Address

E-Mail Address (if known)

Telephone Number

Proposed Guardian

Name

Address

E-Mail Address (if known)

Telephone Number

OTHER INTERESTED PERSONS Name Relationship to/ Interest in Respondent

Address

E-Mail Address (if known)

Telephone Number

Name Relationship to/ Interest in Respondent

Address

E-Mail Address (if known)

Telephone Number

I declare that the list of persons above (with additional sheets, if any, attached) is complete and accurate to the best of my knowledge, information, and belief, after diligent inquiry.

Date Petitioner’s Signature

Subscribed and sworn before me, this _________day of_______________________

Notary Public

List of Interested Persons Sheet 1_ of ____.

PG73 – List of Interested Persons (09/2014) Page 2 of 2

ADDITIONAL SHEET – if required (List of Interested Persons)

Name Relationship to/ Interest in Respondent

Address

E-Mail Address (if known)

Telephone Number

Name Relationship to/ Interest in Respondent

Address

E-Mail Address (if known)

Telephone Number

Name Relationship to/ Interest in Respondent

Address

E-Mail Address (if known)

Telephone Number

Name Relationship to/ Interest in Respondent

Address

E-Mail Address (if known)

Telephone Number

Name Relationship to/ Interest in Respondent

Address

E-Mail Address (if known)

Telephone Number

Name Relationship to/ Interest in Respondent

Address

E-Mail Address (if known)

Telephone Number

Name Relationship to/ Interest in Respondent

Address

E-Mail Address (if known)

Telephone Number

Name Relationship to/ Interest in Respondent

Address

E-Mail Address (if known)

Telephone Number

List of Interested Persons Sheet of ____.