FORM MH-109 Gc Letters & Acceptance

• Legal Form Number: FORM MH-109
• Date: 01 January 2024
• Section: Az Mh Forms Annotated

FORM MH-109

(Attorney's name, State Bar No.)

(Attorney's law firm name)

(Law firm bar number)

(Address)

(Phone number)

(Attorney or firm's e-mail address)

Attorney for: __________

SUPERIOR COURT OF ARIZONA, __________ COUNTY

In the Matter of the Guardianship of and Conservatorship for: an Adult. NO. __________ LETTERS OF Guardian WITH MENTAL HEALTH POWERS and CONSERVATOR, AND ACCEPTANCE OF APPOINTMENT

LETTERS OF GUARDIAN AND CONSERVATOR

1. __________ is appointed guardian of (subject person's name) and granted the general powers of a guardian pursuant to A.R.S. §§ 14-5312 and -5312.01, including but not limited to the power to consent for (subject person's name) to receive inpatient mental health care and treatment and be placed in a level one behavioral health facility licensed by the Arizona Department of Health Services for medical, psychiatric, and psychological treatment, subject to the following restrictions: .

2. __________ is appointed conservator for (subject person's name) and is granted the general powers of a conservator pursuant to A.R.S. §§ 14-5424 and -5425.

3. Unless modified by subsequent court order, Guardian's authority to consent to inpatient mental health care and treatment shall expire on __________. The expiration of these mental health powers shall not terminate Guardian's appointment as guardian or conservator and shall not affect Guardian's general powers under A.R.S. §§ 14-5312 and -5312.01(A), including the power to consent for (subject person's name) to receive psychiatric and psychological care, including the administration of psychotropic medications, that takes place outside a level one behavioral health facility licensed by the Arizona Department of Health Services, or Conservator's powers under A.R.S. §§ 14-5424 and -5425.

4. Conservator's powers are subject to the following restrictions:

a. (Identify the funds or accounts to be deposited into a newly created restricted account and the restrictions) shall be deposited into an interest bearing, federally insured restricted account at a financial institution engaged in business in Arizona. No withdrawals of principal or interest may be made without certified order of the superior court. Unless otherwise ordered, reinvestment may be made without further court order so long as funds remain insured and restricted in this institution at this branch.

b. The following (identify the securities, brokerage or investment accounts) are...