Nebraska State Court Form REQUIRED

CC 16:2.5 Rev. 04/2020 Neb. Ct. R. § 6-1443(A)(1) Neb. Rev. Stat. § 30-2601(10)

ADDRESS INFORMATION FOR GUARDIANSHIPS/

CONSERVATORSHIPS

IN THE MATTER OF Case No.

ADDRESS INFORMATION FOR GUARDIANSHIPS/CONSERVATORSHIPS

Name Address Phone number Email Address

Mother Address Phone number Email AddressFather Address Phone number Email Address

Name Address Phone number Email Address

Name Age Address Phone number Email AddressName Age Address Phone number Email Address

Name Relation

Address Phone number Email Address

Name Relation Address Phone number Email Address

War d/Minor Ward/Protected Person.

WARD/MINOR WARD/ PROTECTED PERSON:

PARENTS:

SPOUSE:

CHILDREN:

OTHER:

Page 1 of 3 Address Information for Guardianships/Conservatorships CC 16:2.5 Rev.04/2020

,

OTHER INTERESTED PERSON(S)*: List the name(s) and address(es) of all interested persons of the ward/minor ward/protected person that are not listed above.

Name Address

Phone number Email Address Name Address

Phone number Email AddressName

Address Phone number Email Address

OTHER PERSON authorized to manage the ward’s/minor ward’s/protected person’s financial resources, if other than the guardian(s)/conservator(s):

Relation Name Address Nature of power Phone number Email Address

See attached (more names and addresses than above)

Date Signature of Guardian and/or Conservator

Print or Type Name of Guardian and/or Conservator Street Address/P.O. Box of Guardian and/or Conservator

Bar Number and Firm Name (attorneys only) City/State/ZIP Code of Guardian and/or Conservator

Page 2 of 3 Address Information for Guardianships/Conservatorships CC 16:2.5 Rev. 04/2020

Phone Email Address

* Pursuant to Neb. Rev. Stat. § 30-2601, interested persons are defined as:• children and spouses;• future heirs if the ward/incapacitated person/protected person would die without leaving a valid

will (brothers and sisters who are adults, grandparents, etc.);• a trustee of any trust executed by the ward/incapacitated person/protected person;• if there are no individuals defined as “interested persons” above, include any person or

organization named as a “devisee” in the ward’s/incapacitated person’s/protected person’smost recent will;

• after death of the ward/incapacitated person/protected person, interested person also includesthe personal representative of a deceased ward’s/incapacitated person’s/protected person’sestate, the deceased ward’s/incapacitated person’s/protected person’s heirs in an intestateestate, and the deceased ward’s/incapacitated person’s/protected person’s devisees in atestate estate;

• any governmental agency paying benefits on behalf of the ward/incapacitated person/protectedperson; and

• any person designated by order of the court to be an interested person.

If there are no interested persons identified for a ward/incapacitated person/protected person, the court may appoint a guardian ad litem (Nebraska Supreme Court Rule § 6-1449(B)). The cost of the guardian ad litem may be taken from the assets of the ward/incapacitated person/protected person.

Page 3 of 3 Address Information for Guardianships/Conservatorships CC 16:2.5 Rev. 04/2020