In the intricate landscape of legal forms that navigate the protection and management of an individual’s assets, the PC 639 form from the State of Michigan serves a crucial role. Tasked with the solemn duty of petitioning for the appointment of a conservator or the issuance of a protective order, this document is vital in circumstances where an individual is deemed unable to competently manage their property and affairs due to reasons spanning mental illnesses, chronic intoxication, physical disabilities, and more. The form thoughtfully inquires about the necessary specifics: the petitioner’s relationship to the individual alleged to need protection, the current situation regarding the individual’s residence, property, and any existing legal actions that might be affecting them. Further detail is demanded regarding the necessity of a conservator, supported by concrete facts and the involved parties' detailed descriptions. Not stopping at just financial aspects, the form takes into account the individual's familial connections and existing legal representatives or powers of attorney, painting a holistic picture crucial for court decisions. By facilitating the protection of vulnerable individuals' assets and ensuring their welfare, the PC 639 form embodies a structured approach toward a sensitive issue, balancing between legal formality and the inherent need to safeguard the well-being of citizens within Michigan’s jurisdiction.
| Question | Answer |
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| Form Name | Pc 639 Form |
| Form Length | 3 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 45 sec |
| Other names | mi appointment protective online, pc protective order form, pc 639, michigan conservator |
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PCS CODE: CSR |
Approved, SCAO |
TCS CODE: CSV |
STATE OF MICHIGAN PROBATE COURT COUNTY OF
PETITION FOR
APPOINTMENT OF CONSERVATOR PROTECTIVE ORDER
FILE NO.
A Estate of |
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Individual alleged to need protection (irst, middle, and last name) |
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Last four digits of SSN |
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B 1. |
I, |
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, am interested in this matter |
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Name |
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and make this petition as |
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State interest/relationship |
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C 2. |
The individual was born |
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County |
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Date |
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at |
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Address |
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and has property in |
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County. |
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City, state, zip |
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D 3. An action within the jurisdiction of the family division of circuit court involving the family or family members of the above
individual has been previously iled in |
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Court, Case Number |
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assigned to Judge |
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remains |
is no longer |
pending. |
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E 4. The individual has |
a power of attorney. (Specify name and address below.) |
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a guardian. (Specify name and address below.) |
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a representative payee for social security. (Specify name and address below.) |
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Name and address
F5. a. The individual is an adult unable to manage his/her property and business affairs effectively because of
mental illness |
chronic use of drugs |
detention by a foreign power |
mental deiciency |
chronic intoxication |
disappearance |
physical illness or disability |
coninement |
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and either
the adult has property that will be wasted or dissipated unless proper management is provided, or
the adult or his/her dependents are in need of money for support, care, and welfare, and protection is necessary to obtain or provide money.
b. The adult petitioner is mentally competent but because of age or physical inirmity is unable to manage his/her property and affairs effectively, and recognizing the disability, requests appointment of a conservator.
c. The individual is a minor who
owns money or property that requires management or protection that cannot otherwise be provided.
has or may have business affairs that may be jeopardized or prevented by minority.
needs money for support and education, and protection is necessary or desirable to obtain or provide money. d. I am the guardian of the ward and it is in the ward's best interests to sell or otherwise dispose of the ward's real
property or interest in real property.
G6. The statements in item 5 are supported by the following facts: (Attach a separate sheet.)
(SEE SECOND PAGE)
USE NOTE: If this form is being iled in the circuit court family division, please enter the court name and county in the upper
Do not write below this line - For court use only
MCL 700.5104(2), MCL 700.5215(a), MCL 700.5314(b), MCL 700.5401, MCL 700.5404, MCR 3.206(A)(4), MCR 5.105(C),
PC 639 (9/16) PETITION FOR APPOINTMENT OF CONSERVATOR AND/OR PROTECTIVE ORDER |
MCR 5.125(C)(24) |
H7. The individual to be protected has an estate approximately valued at:
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$ |
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$ |
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$ |
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Real property |
Personal property |
Insurance |
Monthly income |
I8. The individual to be protected is receiving the following beneits from governmental agencies:
Social Security $ |
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SSI $ |
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MDHHS $ |
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Veterans Administration $ |
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, claimant number |
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Other: |
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$ |
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J9. The individual to be protected has
a spouse whose name and address are listed below.
child(ren) whose name(s) and address(es) are listed below.
descendants of deceased child(ren) whose name(s) and address(es) are listed below.
if no child(ren) or descendants of deceased child(ren), parents whose name(s) and address(es) are listed below.
if none of the above, presumptive heirs whose name(s) and address(es) are listed below.
none of the above (must notify the Attorney General - see instructions for the address of the Attorney General).
NAME |
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ADDRESS AND TELEPHONE NUMBER |
RELATIONSHIP |
AGE/DOB |
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(if minor) |
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Street address |
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Telephone no. |
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Street address |
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K10. None of the persons named above are under any legal incapacity except
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Name, incapacity, and representative of the person, if any |
Telephone no. . |
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11. The individual is currently found at |
Address or location |
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M 12. It is necessary that a preliminary protective order be entered pending the regular hearing because
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I REQUEST that the court:
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13. Appoint |
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Name, address, and telephone no. |
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who has priority as |
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, as conservator of the estate to be protected. |
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Priority relationship |
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O 14. Preserve and apply the individual's property pending the appointment of a conservator as follows:
15. Enter a protective order that provides |
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P 16. Appoint the guardian as special conservator with authority to sell or otherwise dispose of the ward's real property or
Qinterest in real property.
I declare under the penalties of perjury that this petition has been examined by me and that its contents are true to the best of my information, knowledge, and belief.
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Attorney signature |
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Date |
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Attorney name (type or print) |
Bar no. |
Petitioner signature |
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Attorney address |
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Petitioner address |
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City, state, zip |
Telephone no. |
City, state, zip |
Telephone no. |
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17. NOMINATION BY PERSON TO BE PROTECTED: I am 14 years of age or older. I nominate as my conservator
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Name, address, and telephone no.
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Signature of person to be protected |
INSTRUCTIONS FOR COMPLETING
"PETITION FOR APPOINTMENT OF CONSERVATOR"
Please type or print neatly in black or blue ink. Items A through S must be read and illed in (when required) before your petition can be iled with the court. Please read the instruction for each item. Then ill in the correct information for that item on the form.
AEnter the name of the individual who you believe needs a conservator.
BEnter your name in the irst line. Enter your relationship to the individual (or your interest) in the second line.
CEnter the date the individual was born, what county the individual is a resident of, the address of the place where the individual normally lives, and the county the individual's property is in.
DCheck this box if there is or has been a case in the family division of the circuit court involving the individual in A . Examples of a family division case are personal protection, abuse or neglect, or a name change. If you have checked this box, enter the name of the court, the case number of the action, the name of the judge assigned to that case. Then place a check in the box indicating whether that case is still pending or not.
ECheck the boxes that apply and provide the name(s) and address(es). If the individual has a power of attorney and you have a copy of the document, make a copy for the court.
FCheck the boxes that you believe apply to the individual.
GExplain in as much detail as possible the speciic facts about the individual's conduct or condition that lead you to believe he or she needs a conservator. Give speciic examples of his or her conduct that supports what you checked in F and that demonstrate the need for a conservator. This information is extremely important for the court in making a decision about the need to appoint a conservator. If you are the guardian asking for authority to sell or otherwise dispose of your ward's real property, state the reasons why it is in the ward's best interest to do so.
HSpecify the approximate value of any real property, personal property, insurance, and monthly income of the individual. An example of real property is a house. Examples of personal property are home furnishings, bank accounts, and checking accounts.
ICheck whether the individual is currently receiving beneits from governmental agencies and the amount(s).
J - K |
Check all the boxes that apply and enter the names, relationships, addresses and telephone numbers of each |
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relative of the individual. If any of the adults named in J are under legal incapacity, enter the names in K . If you |
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check the last box in J (item 9), you must notify the Attorney General by sending a copy of this form to: |
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Attorney General, Public Administration, PO Box 30755, Lansing, Michigan 48909. |
LEnter the address and telephone number where the individual is currently located. This address and telephone number may or may not be the home of the individual. For example, if the individual is currently in the hospital, enter the name, address, and telephone number of the hospital.
MIf there is an emergency that requires that a preliminary protective order be entered before the hearing, check the box and state the reason(s).
NEnter the name, address, and telephone number of the person you want to be appointed as conservator of the individual. Enter the relationship, if any, that this person has to the individual. If you are the guardian asking for authority to sell or otherwise dispose of your ward's real property, leave this blank and complete Q .
OCheck this box only if you checked M .
PCheck this box if you want the individual's property protected but you do not want a conservator appointed.
QCheck this box if you want the the guardian appointed special conservator to dispose of real property.
REnter today's date, sign your name, and enter your address and telephone number.
SIf the individual wants to nominate someone to be the conservator, check the box and enter the name, address, and telephone number of the person the individual is nominating. The individual must sign and date the form.