4-999.1. Grievance about guardian or conservator.
Name of protected person: ________________________________________________
Case number: __________________________________________________________
County where case is filed: ________________________________________________
Judge assigned to case: __________________________________________________
(Note: You can search for the case online at https://caselookup.nmcourts.gov/caselookup/)
GRIEVANCE ABOUT GUARDIAN, CONSERVATOR, OR REPRESENTATIVE PAYEE
This form is optional. If you choose to use it, please answer each question. Write “Unknown” or “N/A” if you do not know the answer or the question does not apply to your grievance. It will help the court to review your grievance if you provide as much information as possible. You may attach additional pages if needed for explanation of your grievance.
1. Information about you and/or protected person
Your name: ____________________________________________________________
Your contact information:
Address: _________________________________________________________
Phone number: ( )______________ Email: ____________________________
Are you the protected person? ☐ Yes ☐ No
If no, what is your interest in the welfare of the protected person or to the case?
______________________________________________________________________
______________________________________________________________________
2. Information about your grievance
Type of Case:
☐ Guardianship ☐ Conservatorship ☐ Other (e.g., trustee, representative payee, VA fiduciary)
Name of person grievance is against: _______________________________________
Their contact information:
Address: _________________________________________________________
Phone number: ( )______________ Email: ____________________________
Briefly describe below how the person has failed to comply with their duties and responsibilities. Describe what the person did or did not do, what they said, or any other actions of the person you are concerned about. Be as specific as possible, and please attach copies of relevant documents, such as court orders, petitions, letters to the protected person, etc.
Date: _____________________________________
Time: _____________________________________
Location: __________________________________
Description of what happened: _____________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
What would you like the court to do? ________________________________________
______________________________________________________________________
______________________________________________________________________
Have you brought this to the court’s attention within the past six months?
☐ Yes ☐ No
Do you have concerns for yourself or the protected person about raising this grievance?
☐ Yes ☐ No If yes, what are your concerns? _______________________
______________________________________________________________________
If you are not the protected person, is the protected person aware of your grievance?
☐ Yes ☐ No
If yes, what was the protected person’s response? _____________________________
______________________________________________________________________
If no, why not? _________________________________________________________
______________________________________________________________________
Have you discussed your grievance with the person you have the grievance against?
☐ Yes ☐ No
If yes, what was the response? ____________________________________________
_____________________________________________________________________
If no, why not? _________________________________________________________
______________________________________________________________________
Have you contacted other authorities about this incident, such as Adult Protective Services, nursing home staff, ombudsman, law enforcement, Attorney General’s Office, District Attorney’s Office, Center for Guardianship Certification, Social Security Administration, Veteran’s Administration, Office of State Auditor, or Office of Guardianship?
☐ Yes ☐ No If yes, please identify any authorities you have notified, the date, and the result. Attach a copy of any materials submitted or received.
Authority: _____________________ Date: _____________ Result: ________________
Authority: _____________________ Date: _____________ Result: ________________
Authority: _____________________ Date: _____________ Result: ________________
3. Affirmation and signature.
• The information in this grievance is true and accurate to the best of my knowledge.
• I understand that my grievance will be filed in the court file and available to the person who my grievance is against and anyone else who is entitled to access court records in the case.
____________________ _____________________________________
Date Name