Preview
60-PR-17-2571
Filed in Ninth Judicial District Court
12/7/2017 3:08 PM
Polk County, MN
STATE OF MINNESOTA DISTRICT COURT
COUNTY OF POLK PROBATE
I -
NINTH JUDICIAL DISTRICT
Court File No.
Cty. Atty. File No. G-17-016
IN RE: GUARDIANSHIP OF:
Gordon L. Johnson
Respondent.
PETITION FOR APPOINTMENT OF GUARDIAN OF THE PERSON
TO THE HONORABLE JUDGE OF THE DISTRICT COURT:
1. Petitioner's: Name: Kent Johnson
Address: 612 N. Broadway, Room 302
Crookston, MN
567 l 6
Telephone number: (21 8) 28 1—3 127
Interest in this matter: Director ofPolk County Social Services
2. Respondent's: Name: Gordon L. Johnson
Address: 608 5th Ave. NW
East Grand Forks, MN 56721
Telephone number: (21 8) 773-6648
Age/Date ofbirth: 4/23/1 932 / 85
The names and addresses of the Respondent's spouse and kindred are:
Relationshin Name Address
a) Spouse (include an adult with whom Respondent has resided for six months or more): None.
b) Kindred: (adult children, parents and adult brothers and sisters; ifnone ofthese, then list the nearest adult kin; See M.S. §
524.5-102 subd. 7)
Sister Bev Dewey 1802 S. 20"“ St., Apt. #8, Grand Forks, ND 58201
C) Administrator (if Respondent is in a hospital, VA, unit, nursing home, home care agency or other institution):
Edgewood Vista 608 5‘“
Ave. NW, East Grand Forks, MN 56721
d) Legal Representative (guardian/conservator, representative payee, trustee or custodian of property): None.
e) Persons nominated, proposed, or confirmed by prior order, as guardian or conservator (file applicable
document with petition Including a prior order, health care directive or related document): None.
A Guardian for the person of Respondent should be appointed because:
A. The Respondent is an incapacitated person in that Respondent lacks sufficient understanding or
capacity to make or communicate responsible decisions concerning Respondent's person
60-PR-17-2571
Filed in Ninth Judicial District Court
12/7/2017 3:08 PM
Polk County, MN
(Describe present general mental condition suppofiing this allegation): See attached letter of
Katie Midgarden;
B. and has demonstrated behavioral deficits evidencing an inability to meet Respondent's needs for
medical care, nutrition, clothing, shelter, and/or safety (Describe behavior supporting this
allegation): See attached letterof Katie Midgarden; and no alternative less restrictive of civil
rights and liberties exists, including the use of appropriate technological assistance.
The following powers are needed for a and supervise the person of the Respondent
Guardian to protect
With all of the rights and powers on behalf of the Respondent under M.S. § 5245—313 subd.(c)
paragraphs 1, 2, 3, 4, 5, 6 and 7. A limited guardianship is not appropriate because Respondent needs
assistance in all areas.
The probable value and the general character of the assets of the Respondent are monthly Social
Security of $1244.00.
The probable amount of the debts of the Respondent is unknown
The Respondent is not a patient at a State Hospital for the mentally ill; is not a mentally retarded or
dependent or neglected ward of the Commissioner of Human Services; and is not under the temporary
custody of the Commissioner of Human Services.
The name, age, address, and phone number of the proposed Guardian is:
Name, age Debra R. Camperud, Age 57
Address: 161 5 10th Ave. N.
Grand Forks, ND 58203-0723
Telephone number: (701) 740-6506
and the proposed Guardian has been nominated by some other person
10. The proposed Guardian has never been removed for cause from serving as a guardian.
11. The proposed Guardian is the most and best qualified among those available and willing
suitable to
discharge the trust and is not excluded from appointment pursuant to M.S. § 524.5—3 09(0).
12. Pursuant to M.S. 5245-502, petitioner requests that the court order that the guardian be compensated in
the following amount: 5% of the Respondent's monthly income, but not more than $100.00 per month,
and in no event shall such compensation be allowed if it would negatively affect the current living
ability or personal needs allowance of the Respondent.
WHEREFORE, your Petitioner respectfully requests the Court schedule a time and place for hearing this
petition and, after the hearing, an order appointing Debra R. Camperud Guardian of the person of Gordon L.
Johnson With the powers and duties described in allegations numbered 5 above.
FURTHER, under penalties for perjury for deliberate falsification therein, I declare or affirm that I have read
the foregoing petition and, to the best of my knowledge or information, its representations are true, correct and
complete.
60-PR-17-2571
Filed in Ninth Judicial District Court
12/7/2017 3:08 PM
Polk County, MN
I declare under penalty of perjury that everything I have stated in this document is true and correct. Minn. Stat.
358.1 16.
Signed in Polk County, State of Minnesota this Z day of December, 2017.
Kent dfihnson, Petitioner
Petitioner's Attorney:
Larry D. Orvik
POLK COUNTY ATTORNEY’S OFFICE
816 Marin Ave., Suite 254
Crookston, MN56716~2 148
(218) 281-4344
Imy.orvik@co.polk.mn.us
I
No. 188153
Atty. Reg.
60-PR-17-2571
Filed in Ninth Judicial District Court
12/7/2017 3:08 PM
Polk County, MN
POLK COUNTY SOCIAL SERVICES
612 North Broadway, Room 302,
*
56716-1452
Crookston,
Phone (218) 28 1-3 127 Fax (218) 281—3926
W
T011 Free (877) 28 1 —3 127
www.co.polk.mn.us
November 27, 2017
Larry Orvik
Polk County Attorney
816 Marin Avenue, Suite 125
Crookston, MN
56716
Re: General Guardianship Request
Dear Larry Orvik,
I am requesting the court to grant general “Guardianship of the Person” to Debra Camperud for
Mr. Gordon Johnson, DOB 4/23/1932. Mr. Johnson is diagnosed With dementia.
Mr. Gordon Johnson a resident of Edgewood Vista in East Grand Forks, MN. He is unable to
is
make decisions for himself due to the state of his dementia. His family has stated they d0 not
wish t0 have anything t0 do with his finances or personal decision—making. Mr. Johnson does not
have anyone who can make safe, appropriate decisions on his behalf. A Vulnerable Adult report
was filed recently and it was determined there was enough evidence and concern to open up an
investigation. I have also included a Neuropsychological Evaluation completed with Dr. Susan
Thompson on 1/30/17.
Polk County Social Services is concerned about Mr. Gordon Johnson’s vulnerability and his
make responsible, personal decisions and is requesting the court to grant
inability to
“Guardianship” to Debra Campemd. Iwould like to request the court to order Mr. Johnson to
pay Guardianship fees to Debra Camperud for her services. The fees should not to exceed 5% of
his income.
If you have any questions 01‘ concerns, you may contact me at the number below.
Sincerely, M
WEB MMMMLN
Katie Midgatden
Case Manager
218—399-8559
”
"An Equal Opportunity/Aflirmative Action Employer
Preview
60-PR-17-2571 Filed in Ninth Judicial District Court 12/7/2017 3:08 PM Polk County, MN STATE OF MINNESOTA DISTRICT COURT COUNTY OF POLK PROBATE I - NINTH JUDICIAL DISTRICT Court File No. Cty. Atty. File No. G-17-016 IN RE: GUARDIANSHIP OF: Gordon L. Johnson Respondent. PETITION FOR APPOINTMENT OF GUARDIAN OF THE PERSON TO THE HONORABLE JUDGE OF THE DISTRICT COURT: 1. Petitioner's: Name: Kent Johnson Address: 612 N. Broadway, Room 302 Crookston, MN 567 l 6 Telephone number: (21 8) 28 1—3 127 Interest in this matter: Director ofPolk County Social Services 2. Respondent's: Name: Gordon L. Johnson Address: 608 5th Ave. NW East Grand Forks, MN 56721 Telephone number: (21 8) 773-6648 Age/Date ofbirth: 4/23/1 932 / 85 The names and addresses of the Respondent's spouse and kindred are: Relationshin Name Address a) Spouse (include an adult with whom Respondent has resided for six months or more): None. b) Kindred: (adult children, parents and adult brothers and sisters; ifnone ofthese, then list the nearest adult kin; See M.S. § 524.5-102 subd. 7) Sister Bev Dewey 1802 S. 20"“ St., Apt. #8, Grand Forks, ND 58201 C) Administrator (if Respondent is in a hospital, VA, unit, nursing home, home care agency or other institution): Edgewood Vista 608 5‘“ Ave. NW, East Grand Forks, MN 56721 d) Legal Representative (guardian/conservator, representative payee, trustee or custodian of property): None. e) Persons nominated, proposed, or confirmed by prior order, as guardian or conservator (file applicable document with petition Including a prior order, health care directive or related document): None. A Guardian for the person of Respondent should be appointed because: A. The Respondent is an incapacitated person in that Respondent lacks sufficient understanding or capacity to make or communicate responsible decisions concerning Respondent's person 60-PR-17-2571 Filed in Ninth Judicial District Court 12/7/2017 3:08 PM Polk County, MN (Describe present general mental condition suppofiing this allegation): See attached letter of Katie Midgarden; B. and has demonstrated behavioral deficits evidencing an inability to meet Respondent's needs for medical care, nutrition, clothing, shelter, and/or safety (Describe behavior supporting this allegation): See attached letterof Katie Midgarden; and no alternative less restrictive of civil rights and liberties exists, including the use of appropriate technological assistance. The following powers are needed for a and supervise the person of the Respondent Guardian to protect With all of the rights and powers on behalf of the Respondent under M.S. § 5245—313 subd.(c) paragraphs 1, 2, 3, 4, 5, 6 and 7. A limited guardianship is not appropriate because Respondent needs assistance in all areas. The probable value and the general character of the assets of the Respondent are monthly Social Security of $1244.00. The probable amount of the debts of the Respondent is unknown The Respondent is not a patient at a State Hospital for the mentally ill; is not a mentally retarded or dependent or neglected ward of the Commissioner of Human Services; and is not under the temporary custody of the Commissioner of Human Services. The name, age, address, and phone number of the proposed Guardian is: Name, age Debra R. Camperud, Age 57 Address: 161 5 10th Ave. N. Grand Forks, ND 58203-0723 Telephone number: (701) 740-6506 and the proposed Guardian has been nominated by some other person 10. The proposed Guardian has never been removed for cause from serving as a guardian. 11. The proposed Guardian is the most and best qualified among those available and willing suitable to discharge the trust and is not excluded from appointment pursuant to M.S. § 524.5—3 09(0). 12. Pursuant to M.S. 5245-502, petitioner requests that the court order that the guardian be compensated in the following amount: 5% of the Respondent's monthly income, but not more than $100.00 per month, and in no event shall such compensation be allowed if it would negatively affect the current living ability or personal needs allowance of the Respondent. WHEREFORE, your Petitioner respectfully requests the Court schedule a time and place for hearing this petition and, after the hearing, an order appointing Debra R. Camperud Guardian of the person of Gordon L. Johnson With the powers and duties described in allegations numbered 5 above. FURTHER, under penalties for perjury for deliberate falsification therein, I declare or affirm that I have read the foregoing petition and, to the best of my knowledge or information, its representations are true, correct and complete. 60-PR-17-2571 Filed in Ninth Judicial District Court 12/7/2017 3:08 PM Polk County, MN I declare under penalty of perjury that everything I have stated in this document is true and correct. Minn. Stat. 358.1 16. Signed in Polk County, State of Minnesota this Z day of December, 2017. Kent dfihnson, Petitioner Petitioner's Attorney: Larry D. Orvik POLK COUNTY ATTORNEY’S OFFICE 816 Marin Ave., Suite 254 Crookston, MN56716~2 148 (218) 281-4344 Imy.orvik@co.polk.mn.us I No. 188153 Atty. Reg. 60-PR-17-2571 Filed in Ninth Judicial District Court 12/7/2017 3:08 PM Polk County, MN POLK COUNTY SOCIAL SERVICES 612 North Broadway, Room 302, * 56716-1452 Crookston, Phone (218) 28 1-3 127 Fax (218) 281—3926 W T011 Free (877) 28 1 —3 127 www.co.polk.mn.us November 27, 2017 Larry Orvik Polk County Attorney 816 Marin Avenue, Suite 125 Crookston, MN 56716 Re: General Guardianship Request Dear Larry Orvik, I am requesting the court to grant general “Guardianship of the Person” to Debra Camperud for Mr. Gordon Johnson, DOB 4/23/1932. Mr. Johnson is diagnosed With dementia. Mr. Gordon Johnson a resident of Edgewood Vista in East Grand Forks, MN. He is unable to is make decisions for himself due to the state of his dementia. His family has stated they d0 not wish t0 have anything t0 do with his finances or personal decision—making. Mr. Johnson does not have anyone who can make safe, appropriate decisions on his behalf. A Vulnerable Adult report was filed recently and it was determined there was enough evidence and concern to open up an investigation. I have also included a Neuropsychological Evaluation completed with Dr. Susan Thompson on 1/30/17. Polk County Social Services is concerned about Mr. Gordon Johnson’s vulnerability and his make responsible, personal decisions and is requesting the court to grant inability to “Guardianship” to Debra Campemd. Iwould like to request the court to order Mr. Johnson to pay Guardianship fees to Debra Camperud for her services. The fees should not to exceed 5% of his income. If you have any questions 01‘ concerns, you may contact me at the number below. Sincerely, M WEB MMMMLN Katie Midgatden Case Manager 218—399-8559 ” "An Equal Opportunity/Aflirmative Action Employer