Guardianship - Petition - 17a Intellectual 2016 - GMD-1.pdf
Guardianship - Petition - 17a Intellectual 2016 - GMD-1A.pdf
Guardianship - Petition - 17a Intellectual 2016 - GMD-2A.pdf
Guardianship - Petition - 17a Intellectual 2016 - GMD-2b.pdf
Guardianship - Petition - 17a Intellectual 2016 - GMD-3.pdf
Guardianship - Petition - 17a Intellectual 2016 - GMD-4.pdf
Guardianship - Petition - 17a Intellectual 2016 - GMD-8.pdf
Guardianship - Petition - 17a Intellectual 2016 - GMD-7.pdf
SURROGATE’S COURT OF THE STATE OF NEW YORK
COUNTY OF
--------------------------------------------------------------------X
Proceeding for the Appointm ent of a
Guardian for
Pursuant to SCPA Article 17-A
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Filing Fee Paid $
Certs $
Certs $
$ Bond, Fee $
Receipt No: No:
PETITION FOR
APPOINTMENT OF GUARDIAN OF
[ ] PERSON
[ ] PROPERTY
[ ] PERSON AND PROPERTY
[ ] LIMITED GUARDIAN OF THE PROPERTY
File No.
TO THE SURROGATE’S COURT OF THE COUNTY OF _______________________
It is respectfully alleged:
1. T he n a m e , p e rm anent address, date of birth and telephone num ber of the Petitioner(s), and the Petitioner’s(s’) relationship to the [ ] intellectually disabled person [ ] developmentally disabled person (hereafter known as
Respondent) is as follows:
Nam e: __________________________________________________________________ Telephone Num ber: ________________________________________
Perm anent Address or Corporate Office: ________________________________________________________________ (Street and Number)
_________________________________________________________________________________________________ (City, Village, Town) (State)(Zip Code)
Mailing Address: _______________________________________________________________________________ (If different from permanent address)
Date of Birth: _________________________________ Interest/Relationship to Respondent: ______________________
Nam e: ______________________________________________ Telephone Num ber: ___________________________
Perm anent Address or Corporate Office: ________________________________________________________________ (Street and Number)
_________________________________________________________________________________________________ (City, Village, Town) (State)(Zip Code)
Mailing Address: _______________________________________________________________________________ (If different from permanent address)
Date of Birth: _________________________________ Interest/Relationship to Respondent: _______________________
2(a). The nam e, perm anent address, date of birth and marital status of the Respondent of this proceeding is as follows:
Nam e: ___________________________________________________________________________________________
Perm anent Address: ________________________________________________________________________________ (Street and Number)
_________________________________________________________________________________________________ (City, Village, Town) (State)(Zip Code)
Mailing Address: _______________________________________________________________________________ (If different from permanent address)
Date of Birth: _____________________________ Marital Status: _______________________________________
[Attach certified copy of birth certificate.]
G M D -1 (7 /2 0 1 6 ) -1-
2(b). [ ] The Respondent is not adm itted to a group home or facility as defined in Section 1.03 and/or Article 15 of the Mental
Hygiene Law.
[ ] The Respondent has been admitted to a group home or facility as defined in Section 1.03 and/or Article 15 of the
Mental Hygiene Law.
_______________________________________________, Nam e of group hom e or facility
_______________________________________________, Address of group hom e or facility
_______________________________________________, N am e of D irector of group hom e or facility
_______________________________________________, Address of Director of group hom e or facility
_______________________________________________, Nam e of the Director of the Mental Hygiene Legal Service
_______________________________________________, Address of the Director of the Mental Hygiene Legal Service
3. The names and perm anent addresses of the parents of the Respondent and, if the Respondent is m arried, the
Respondent’s spouse are: [If deceased give date of death and complete Number 6]
Nam e of Parent: ______________________________ Date of Birth: _______________ Date of Death: _____________
Perm anent Address:_________________________________________________________________________________ (Street and Number)
_________________________________________________________________________________________________ (City, Village, Town) (State)(Zip Code)
Mailing Address: _______________________________________________________________________________ (If different from permanent address)
Nam e of Parent:______________________________ Date of Birth: _______________ Date of Death:_____________
Perm anent Address:________________________________________________________________________________ (Street and Number)
_________________________________________________________________________________________________ (City, Village, Town) (State)(Zip Code)
Mailing Address:_______________________________________________________________________________ (If different from permanent address)
Nam e of Spouse: _____________________________ Date of Birth: _______________ Date of Death:_____________
Perm anent Address: ________________________________________________________________________________ (Street and Number)
_________________________________________________________________________________________________ (City, Village, Town) (State)(Zip Code)
Mailing Address: _______________________________________________________________________________ (If different from permanent address)
4. The names of the adult children and adult siblings, eighteen (18) years of age or older, of the Respondent are as follows: [Add rider if necessary.]
Nam e: _____________________________________________________ Relationship to Respondent: _______________
Perm anent Address: ________________________________________________________________________________ (Street and Number)
_________________________________________________________________________________________________ (City, Village, Town) (State)(Zip Code)
Mailing Address: _______________________________________________________________________________ (If different from permanent address)
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Nam e: _____________________________________________________ Relationship to Respondent: _______________
Perm anent Address: ________________________________________________________________________________
(Street and Number)
_________________________________________________________________________________________________ (City, Village, Town) (State)(Zip Code)
Mailing Address: _______________________________________________________________________________ (If different from permanent address)
Nam e: _____________________________________________________ Relationship to Respondent: _______________
Perm anent Address: ________________________________________________________________________________ (Street and Number)
_________________________________________________________________________________________________ (City, Village, Town) (State)(Zip Code)
Mailing Address: _______________________________________________________________________________ (If different from permanent address)
Nam e: _____________________________________________________ Relationship to Respondent: _______________
Perm anent Address: ________________________________________________________________________________ (Street and Number)
_________________________________________________________________________________________________ (City, Village, Town) (State)(Zip Code)
Mailing Address: _______________________________________________________________________________ (If different from permanent address)
5. The nam e and address of the prim ary care physician if other than a physician having subm itted a certification with the petition:
Nam e of prim ary care physician: ______________________________________________________________________
Post Office Address: _______________________________________________________________________________ (Street and Number)
________________________________________________________________________________________________ (City, Village, Town) (State)(Zip Code)
6. If the Respondent’s parents are both deceased, list the nam es and addresses of the nearest distributees of full age who live within the State of New York. [If not applicable, so state.]
N am e Perm anent A ddress R elationship
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
7. The nam e and address of the person(s) with whom the Respondent resides and/or the person(s) charged with his/her
care and custody, if other than the parents or spouse: N am e Perm anent A ddress R elationship
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
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8. If Respondent’s parents, spouse, adult children or adult siblings are living but not proposed to be appointed guardian,
standby guardian or alternate standby guardian, explain why below.
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
9. The persons proposed to be appointed guardian(s), standby guardian or alternate standby guardian are of sound
m ind, adult and com petent.
10. [Please check (a) and (b) for guardian of the Respondent’s person and property; check (a) for guardianship of
the Respondent’s person only; or (b) for the guardianship of the Respondent’s property only.]
(a) [ ] Petitioner(s) (is/are) requesting appointm ent of a guardian(s) of the Respondent’s person and allege(s) the
Petitioner(s) (is/are) m otivated solely by the best interest of the Respondent for the reasons set forth
below:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
(b) [ ] Petitioner(s) (is/are) requesting appointm ent of a guardian(s) of the Respondent’s property and allege(s) that the estim ated value of all REAL and PERSONAL property to which the Respondent is entitled is:
$________________________
[Answ er question 11 only if requesting guardianship of the property.]
11. (a) PERSONAL PROPERTY [State exact title of all bank accounts with account number and balance; any
insurance policies by com pany, policy num ber, am ount insured, nam e of insured and relationship to
Respondent; the nam e, num ber of shares and value of all stocks, bonds, and any other personal property
including all causes of action the Respondent may have.]
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
(b) REAL PROPERTY [State w hether real property is m ortgaged or under a lien and the am ount thereof. Indicate
whether property is to be occupied as a residence by the Respondent. If not, indicate rental income or whether
a sale of the property is contem plated.]
Location of Property_____________________________________ Gross Value $___________________________
Respondent’s Interest____________________________________ Annual Income $_________________________
[ ] Mortgaged or [ ] Under a Lien $_______________________ Rental Income $_________________________
Residence to be occupied by Respondent [ ] yes [ ] no Sale of property contem plated [ ] yes [ ] no
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(c) ANNUAL INCOME OF RESPONDENT FROM ALL SOURCES:
(1) W ages to be received from : _____________________________________ $ _________________
(2) Pension to be received from : ____________________________________ $ _________________
(3) Income from trust: ____________________________________________ $ _________________
(4) Governm ental entitlem ents from : _________________________________ $ _________________
(5) Other Income: ________________________________________________ $ _________________
(d) STATE SO URCE O F ALL PRO PERTY listed above. [If any property is derived from an estate or as a result of
the death of any person, name the decedent; his or her date of death and relationship to the Respondent; whether
a fiduciary has been appointed; court name; file number; and type of letters. Provide a copy of any will or decree
directing payment. List names and addresses of all banks, insurance companies and persons from whom payment
is expected.]
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
12. Respondent has been duly certified as a person incapable of managing himself/herself and/or his/ her affairs by reason
of [ ] intellectual disability [ ] developmental disability, and such condition is perm anent in nature or likely to continue
indefinitely, as shown by the certification of:
_________________________________Physician dated: ___________________________and
_________________________________Physician/Licensed Psychologist dated: ___________________________
Said certifications shall be attached hereto and m ade part of the petition. [ Where certifications of two licensed physicians
are used, at least one certification must evidence special qualifications to make the certification as set forth in SCPA
Section 1750 or Section 1750-a. At least one certification must evidence that the physician is familiar with or has
professional know ledge in the care and treatm ent of persons w ith an intellectual disability or developm ental disability,
as appropriate.]
13. [If application for a lim ited guardian of the property] Respondent is over the age of 18 years and is employed by
_________________________________________ , located at __________________________________________
_____________________________________________________________________________________________ (Street/Number) (City, Village/Town) (State)(Zip Code)
and is wholly or substantially self supporting by m eans of his/her wages or earnings from em ploym ent.
14. The nam es, perm anent addresses, dates of birth and relationship of the guardian(s) is/are:
(a) Nam e of Guardian, if other than Petitioner: _____________________________________________________
Perm anent Address: ____________________________________________________________________________ (Street and Number)
_____________________________________________________________________________________________ (City, Village, Town) (State)(Zip Code)
Date of Birth:_________________________ Interest/Relationship to Respondent: __________________________
Education: _____________________________________ Qualifications: ________________________________
to be appointed Guardian of the [ ] person [ ] property
[ ] person and property
[ ] lim ited guardian of the property
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Nam e of Guardian, if other than Petitioner: _____________________________________________________
Perm anent Address: ____________________________________________________________________________ (Street and Number)
_____________________________________________________________________________________________ (City, Village, Town) (State)(Zip Code)
Date of Birth:_________________________ Interest/Relationship to Respondent: __________________________
Education: _____________________________________ Qualifications: ________________________________
to be appointed Guardian of the [ ] person [ ] property
[ ] person and property
[ ] lim ited guardian of the property
(b) Nam e of the Standby Guardian: _____________________________________________________________
Perm anent Address: ____________________________________________________________________________ (Street and Number)
_____________________________________________________________________________________________ (City, Village, Town) (State)(Zip Code)
Date of Birth:_________________________ Interest/Relationship to Respondent: __________________________
Education: _____________________________________ Qualifications: ________________________________
to be appointed Standby Guardian of the [ ] person [ ] property
[ ] person and property
[ ] lim ited guardian of the property
(c) Nam e of the First Alternate Standby Guardian:
Perm anent Address:_____________________________________________________________________________ (Street and Number)
_____________________________________________________________________________________________
(City, Village, Town) (State) (Zip Code)
Date of Birth: _________________________ Interest/Relationship to Respondent: __________________________
Education: _____________________________________ Qualifications: _________________________________
to be appointed First Alternate Standby Guardian of the [ ] person [ ] property
[ ] person and property
[ ] lim ited guardian of the property
(d) Nam e of the Second Alternate Standby Guardian:
Perm anent Address:_____________________________________________________________________________ (Street and Number)
_____________________________________________________________________________________________ (City, Village, Town) (State)(Zip Code)
Date of Birth: _________________________ Interest/Relationship to Respondent: __________________________
Education: _____________________________________ Qualifications: _________________________________
to be appointed Second Alternate Standby Guardian of the [ ] person [ ] property
[ ] person and property
[ ] lim ited guardian of the property
-6-
15.
[Check appropriate box]:
[ ] (a) Respondent is able to attend the hearing to be scheduled by the court.
[ ] (b) R espondent’s presence at the hearing should be dispensed with because R espondent is m edically
incapable of being present to the extent that attendance is likely to result in physical harm to Respondent.
[Certification of certifying physician must so attest]
[ ] (c) Respondent’s presence at the hearing should be dispensed with because [Specify other circumstances
enabling the court to determine that Respondent’s presence at the hearing would not be in his/her
best interest, attach rider if necessary.] _____________________________________________________
_____________________________________________________________________________________
[ ] (d) Respondent is less than 18 years of age, and Petitioner(s) request(s) that a hearing be dispensed with.
16. Respondent never has had a guardian appointed by will or deed or an acting guardian in socage, or a guardian of the person appointed pursuant to Section 384 or 384-b of the Social Services Law.
17. Petitioner(s) [ ] has/have [ ] does/do not have knowledge that a person nom inated to be a guardian, or any individual eighteen years of age or over who resides in the hom e of the proposed guardian:
a. Is the subject of a report filed with the Statewide Central Register of Child Abuse and Maltreatm ent pursuant to the rules of Child Protective Services, following an investigation which determ ines that som e credible evidence
of alleged abuse or maltreatm ent exists, and/or
b. Has been the subject of or the Respondent in a Child Protective Proceeding com m enced pursuant to law, which proceeding resulted in an order finding that the R espondent is an abused or neglected individual.
[If Petitioner has such know ledge, attach an affidavit explaining in detail.]
18. Petitioner(s) has/have completed and submitted to the court the Request For Information Guardianship Form (OCFS 3909) required to be subm itted to the New York State Central Register of Child Abuse and Maltreatm ent.
19. [If the Respondent is under the age of 18 years com plete the follow ing]:
The Respondent [ ] is [ ] is not a Native American child under the Indian Child W elfare Act of 1978 (25 U.S.C.
Sections 1901 - 1963).
20. There are no other persons interested in this proceeding upon whom process is required to be served other than those listed above.
21. No prior application has been m ade to any court for the relief requested herein, except: [Enter “NONE” or specify]
-7-
W HEREFO RE, your Petitioner(s) respectfully request(s) that:
[Check and complete all relief requested]
(a) Letters of Guardianship of the [ ] person
[ ] property
[ ] person and property
[ ] lim ited guardianship of the property
of the Respondent be granted to ____________________________________________________________________
(b) Appointm ent of _______________________________________________ as Standby Guardian of the [ ] person
[ ] property
[ ] person and property
[ ] lim ited guardianship of the property
of the Respondent
(c) Appointm ent of ____________________________________________ as First Alternate Standby Guardian of the [ ] person
[ ] property
[ ] person and property
[ ] lim ited guardianship of the property
of the Respondent
(d) Appointm ent of ____________________________________________ as Second Alternate Standby Guardian of the [ ] person
[ ] property
[ ] person and property
[ ] lim ited guardianship of the property
of the Respondent
be granted, or to such other person or corporation as may be entitled thereto and that process issue to all interested
persons who have not waived the issuance of sam e requiring them to show cause why such relief should not be granted. (e)
The appearance of the Respondent [ ] should be [ ] should not be required at any hearing.
(f) The guardian(s)
of the person be authorized and empowered to make all decisions with respect to the medical and dental
needs of
the Respondent and to render consent to any medical procedures which are necessary to the health and
welfare o
f the Respondent unless the court directs otherwise. A health care decision may include a decision to withhold or
withdraw l
ife-su staining
treatment treatment as defined in
Section 1750-b(1) of the Surrogate’s Court Procedure Act.
(g) The guardian(s)
of the property be directed to collect and receive all moneys and other property of the Respondent jointly with a
clerk of
the Surrogate’s Court, or depository subject to the provisions of SCPA 1708, and shall deposit same in the name
of
the guardian(s), subject to order of the court with either:
1. _______________________________________________________________________\
_____________________ 2. ____________________________________________________________________________________________
[List tw o Banks/Depositories in _______________________ County.]
(h) The bond of the guardian(s) be dispensed with.
-8-
Name of Bank/Depository
Branch Address
Name of Bank/Depository Branch Address
(I) Additional relief requested _________________________________________________________________________
______________________________________________________________________________________________
Dated: ______________________
1. ______________________________________ 2. __________________________________________
(Signature of Petitioner) (Signature of Petitioner)
______________________________________ __________________________________________
(Print Nam e) (Print Nam e)
3. ______________________________________ (Nam e of Corporate Petitioner)
_______________________________________ (Signature of Officer)
_______________________________________ (Print Nam e and Title of Officer)
STATE OF NEW YORK )
CO UNTY O F _________________) ss.:
____________________________________________________, being duly sworn deposes and says that I am/we are the
Petitioner(s) above nam ed. I/we have read the foregoing petition and the sam e is true of m y own knowledge except as to
m atters therein stated to be alleged upon inform ation and belief and as to those m atters I/we believe them to be true.
__________________________________________ __________________________________________
(Signature of Petitioner) (Signature of Petitioner)
__________________________________________ ________________________________________
(Print Nam e) (Print Nam e)
__________________________________________ (Nam e of Corporate Petitioner)
__________________________________________ (Signature of Officer)
__________________________________________ (Print Nam e and Title of Officer)
Sworn to before m e this
________ day of ___________________, ________
__________________________________________
N otary Public
Com m ission Expires:
(Affix N otary Stam p or Seal) Signature of Attorney: ____________________________________________________________________________
Print Nam e: ____________________________________________________________________________________
Firm Nam e: _____________________________________________ Telephone Num ber: ___________________
Address of Attorney: _____________________________________________________________________________
-9-
COMBINED OATH & DESIGNATION
[F or use when Petitioner is an individual]
STATE OF NEW YORK )
CO UNTY O F _______________) ss.:
_________________________________________________ being duly sworn, deposes and says: 1. O AT H O F G U AR D IA N : I am over eighteen (18) years of age and a citizen of the U nite d States; that I will well, faithfully and ho nestly discharge the duties of such guardian: T hat I am acquainted with the estate of said
(intellectually disabled) (developmentally disabled) person and have read the statem ent contained in the foregoing
petition as to the estim ated value of sam e, and believe sam e to be correct, and that I am not ineligible to receive
letters.
2. DESIGNATION OF CLERK FOR SERVICE O F PROCESS: I hereby designate the Clerk of the Surrogate’s Court of ______________________ County, and his/her successor in office, as a person on whom service of any
process issuing from such Surrogate’s Court may be m ade in like m anner and with like effect as if it were served
personally upon me, whenever I cannot be found within the state of New York after due diligence used.
My perm anent address is: ____________________________________________________________________________ (Street Address) (City, Town, Village) (State) (Zip Code)
My perm anent address is: ____________________________________________________________________________ (Street Address) (City, Town, Village) (State) (Zip Code)
_________________________________________ _____________________________________________
(Signature of Proposed Guardian) (Signature of Proposed Guardian)
_________________________________________ _____________________________________________
(Print Nam e) (Print Nam e)
On ___________________________________________________________, _______ , before me personally came
_________________________________________________________________________________________________
to m e known to be the person(s) described in and who executed the foregoing instrum ent. Such person(s) duly swore to
such instrum ent before me and duly acknowledged that he/she/they executed the sam e.
________________________________________
N otary Public
Com m ission Expires:
(Affix N otary Stam p or Seal)
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COMBINED CORPORATE CONSENT & DESIGNATION
[For use when a Petitioner to be appointed is a corporation]
STATE OF NEW YORK )
CO UNTY O F _______________) ss.:
I, the undersigned, a ______________________________________________________________________________ of (Title)
_________________________________________________________________________________________________ (Nam e of Corporation)
a corporation duly qualified to act in a fiduciary capacity without further security, being duly sworn, say:
1. VERIFICATION: I have read the foregoing petition subscribed by me and know the contents thereof, and the sam e is true of my own knowledge, except as to the matters therein stated to be alleged upon inform ation and
belief, and as to those m atters I believe it to be true.
2. CO NSENT: I consent to accept the appointm ent as [ ] Guardian [ ] Standby G uardian [ ] First Alternate Standby Guardian [ ] Second Alternate Standby Guardian of the [ ] person [ ] property [ ] person and
property [ ] lim ited guardianship of the property of the Respondent described in the foregoing petition and
consent to act as such fiduciary.
3. DESIGNATION OF CLERK FOR SERVICE OF PROCESS: I hereby designate the Clerk of the Surrogate’s Court of ______________________ County, and his/her successor in office, as a person on whom service of any
process issuing from such Surrogate’s Court may be m ade in like m anner and with like effect as if it were served
personally upon me, whenever I cannot be found within the state of New York after due diligence used.
__________________________________________ (Proposed Corporate Guardian)
__________________________________________ (Signature of Officer)
__________________________________________ (Print Nam e and Title of Officer)
On ______________________________, _______, before me personally came _____________________________,
to me known, who duly swore to the foregoing instrum ent and which did say that he/she resides at ___________________
______________________ and that he/she is a _________________________________________________________ of
_________________________________________ the corporation described in and which executed such instrum ent, and
that he/she signed his/her name thereto by order of the Board of Directors of the corporation.
_______________________________________
N otary Public
Com m ission Expires:
(Affix N otary Stam p or Seal)
-11-
SURROGATE’S COURT OF THE STATE OF NEW YORK
COUNTY OF _____________________________
----------------------------------------------------------------------------X
Proceeding for the Appointm ent of a
Guardian for
AFFIDAVIT OF PROPOSED
GUARDIAN OF THE
[ ] PERSON
[ ] PROPERTY
[ ] PERSON AND PROPERTY
[ ] LIMITED GUARDIAN OF THE PROPERTY
Pursuant to SCPA Article 17-A
----------------------------------------------------------------------------X File No. ________________________________
STATE OF NEW YORK )
CO UNTY O F ) ss.:
To the Surrogate’s Court, County of _______________________
The undersigned ____________________________________________, being duly sworn, deposes and says:
1. I am a com petent person over the age of eighteen (18) years, and I subm it this affidavit in support of m y petition to
be appointed guardian of [ ] an intellectually disabled person [ ] a developmentally disabled person.
2. I have known the subject Respondent since _____________________________________________ by reason of the
following: [State relationship if any.]
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
3. I reside at ______________________________________________________________________________, and the
other resident m em bers of the household are: [Include all persons residing there and their dates of birth.]
__________________________________________ _____________________________________________
__________________________________________ _____________________________________________
__________________________________________ _____________________________________________
4. My educational background is as follows:
_________________________________________________________________________________________________
5. Not including m inor traffic offenses and adjudications as a youthful offender or juvenile delinquent, (a) I have never been convicted of an offense against the law, except _____________________________________
_____________________________________________________________________________________________
(b) I have never forfeited bail or other collateral, except ________________________________________________
_____________________________________________________________________________________________
GMD-1A (7/2016) -1-
(c) I do not have any crim inal charges pending against me, except _______________________________________
_____________________________________________________________________________________________
6. I have no physical or mental im pairm ent, or medical condition, which would interfere with m y ability to perform the
duties of guardian of the [ ] intellectually disabled person [ ] developmentally disabled person, except
_________________________________________________________________________________________________
_________________________________________________________________________________________________
7. I am not addicted to narcotics or to alcohol.
8. I am willing and able to undertake care, custody and control of the Respondent until the court determ ines otherwise.
9. I believe that my appointm ent as guardian would be in the best interests of the Respondent for the following reasons:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_______________________________________(Signature of Proposed Guardian)
_______________________________________ (Print Name)
Sworn to before m e this
_______ day of ______________, _______
___________________________________
N otary Public
Com m ission Expires:
(Affix N otary Stam p or Seal)
-2-
SURROGATE’S COURT OF THE STATE OF NEW YORK
COUNTY OF _________________________
--------------------------------------------------------------------X
Proceeding for the Appointm ent of a
Guardian for
AFFIDAVIT (CERTIFICATION) OF EXAMINING
PHYSICIAN OR LICENSED PSYCHOLOGIST
File No. _______________________________
Pursuant to SCPA Article 17-A
--------------------------------------------------------------------X
STATE OF NEW YORK )
CO UNTY O F ) ss.:
I, ________________________________________________________, [ ] Physician [ ] Licensed Psychologist,
being duly sworn, deposes and says:
[PLEASE ANSWER ALL QUESTIONS]
1. My license num ber is : ________________________________________________________________________
2. My offices are located at: ______________________________________________________________________
_____________________________________________________________________________________________
3. My professional knowledge and/or background in the care and treatm ent of persons with [ ] intellectual disabilities [ ] developmental disabilities is as follows:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
4(a). I have exam ined the Respondent on: [Set forth date(s).]
_____________________________________________________________________________________________
(b). [Check appropriate box(es) and explain w here requested]:
[ ] I have perform ed the following tests or evaluations of the Respondent. [Set forth in detail the names
of tests and/or evaluations, dates perform ed and results.]
____________________________________________________________________________________
____________________________________________________________________________________
[ ] I have reviewed the following tests or evaluations perform ed on Respondent. [Set forth in detail the
names of tests and/or evaluations, dates performed, results and names of doctors who performed the
tests and/or evaluations.]
____________________________________________________________________________________
____________________________________________________________________________________
GMD-2A (7/2016) -1-
5. The m ental and physical condition of the Respondent is as follows:
[D escribe in detail.]
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
6. [Check appropriate box(es)]:
INTELLECTUALLY DISABLED [ ] Based upon the foregoing, it is m y conclusion the Respondent is an intellectually disabled person andin my opinion incapable of m anaging himself/herself and/or his/her affairs by reason of an intellectual
disability. The nature and degree of the intellectual disability is as follows:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
DEVELOPMENTALLY DISABLED [ ] Based upon the foregoing, it is m y conclusion that the Respondent is developmentally disabled andin my opinion he/she has an im paired ability to understand and appreciate the nature and
consequences of decisions, which results in Respondent being incapable of m anaging him self/herself
and/or his/her affairs by reason of developmental disability, and whose disability is attributable to:
[ ] (a) Cerebral palsy, which originated before the Respondent attained the age of twenty-two.
[D escribe, in detail, the nature, degree and origin of the disability.]
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
[ ] (b) Epilepsy, which originated before the Respondent attained the age of twenty-two.
[D escribe, in detail, the nature, degree and origin of the disability.]
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
[ ] (c) Neurological im pairm ent, which originated before the Respondent attained the age oftwenty-two.
[D escribe, in detail, the nature, degree and origin of the disability.]
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
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[ ] (d) Autism , which originated before the Respondent attained the age of twenty-two.
[D escribe, in detail, the nature, degree and origin of the disability.]
_______________________________________________________________________________
_______________________________________________________________________________
[ ] (e) T raum atic head injury.
[D escribe, in detail, the nature, degree and origin of the disability.]
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
[ ] (f) A condition, which originated before the Respondent attained the age of twenty-two, found
to be closely related to an intellectual disability, because such condition results in sim ilar im pairm ent
of general intellectual functioning or adaptive behavior to that of intellectually disabled persons.
[D escribe in detail the condition, and the nature, degree and origin of the disability.]
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
[ ] (g) Dyslexia resulting from a disability described in subdivision (a) through (f) or an intellectual
disability which condition originated before the Respondent attained the age of twenty-two.
[Describe
in detail the nature, degree and origin of the developm ental disability or intellectual disability.]
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
7. [Check appropriate box]:
[ ] T he condition of the R espondent is perm anent in nature or likely to continue indefinitely.
[ ] T he condition of the R espondent is not perm anent in nature nor likely to continue indefinitely.
8. [Check appropriate box]:
[ ] There are no circum stances warranting Respondent’s nonappearance at the hearing required by thecourt.
[ ] R espondent’s presence at the hearing should be dispensed with because he/she is m edically incapable of being present to the extent that attendance is likely to result in physical harm to the Respondent.
[Explain in detail.]
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
-3-
[ ] Respondent’s presence at the hearing should be dispensed with for the following reasons:
[Set forth
facts and circumstances which would result in the court finding that the Respondent’s presence
at the hearing w ould not be in his/her best interest.]
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
9. [Check appropriate box for an intellectually disabled person]:
[ ] Based upon the foregoing, it is m y conclusion that the Respondent is not capable of understanding and
appreciating the nature and consequences of health care decisions, including the benefits and risks of and
alternatives to any proposed health care, and of reaching an inform ed decision in order to prom ote his/her
own well being. A health care decision may include a decision to withhold or withdraw life-sustaining
treatm ent as defined in Section 1750-b.1 of the Surrogate’s Court Procedure Act.
[ ] Based upon the foregoing, it is m y conclusion that the Respondent is capable of understanding and
appreciating the nature and consequences of health care decisions, including the benefits and risks of and
alternatives to any proposed health care, and of reaching an inform ed decision in order to prom ote his/her
own well being. A health care decision may include a decision to withhold or withdraw life-sustaining
treatm ent as defined in Section 1750-b.1 of the Surrogate’s Court Procedure Act.
10. [Check appropriate box for a developm entally disabled person]:
[ ] Based upon the foregoing, it is my conclusion that the Respondent has a developm ental disability, as defined in Section 1750-b(1) of the Surrogate’s Court Procedure Act, which includes an intellectual
disability, or results
in a similar impairment of general intellectual functioning or adaptive behavior so that
such person is incapable of managing himself or herself, and/or his or her affairs by reason of such
developmental disability, and
that the Respondent is
not capable of understanding and appreciating the
nature and consequences of health care
decisions, including the benefits and risks of and alternatives
to any proposed
health care, and of reaching an
informed decision in order to promote his/her own
well being.
A health care decision may include
a decision to withhold or withdraw life-sustaining
treatment as defined in Section 1750-b.1 of the Surrogate’s Court Procedure Act.[ ] Based upon the foregoing, it is m y conclusion that the Respondent
is capable of understanding and
appreciating the nature and consequences of health care decisions, including the benefits and risks of and
alternatives to any proposed health care, and of reaching an inform ed decision in order to prom ote his/her
own well being. A health care decision may include a decision to withhold or withdraw life-sustaining
treatm ent as defined in Section 1750-b.1 of the Surrogate’s Court Procedure Act.
_______________________________________
Signature of Physician/Licensed Psychologist
_______________________________________Print Name
Sworn to before m e this
_____________ day of __________________. ______
____________________________________________
N otary Public
Com m ission Expires:
(Affix N otary Stam p or Seal) -4-
SURROGATE’S COURT OF THE STATE OF NEW YORK
COUNTY OF _________________________
--------------------------------------------------------------------X
Proceeding for the Appointm ent of a
Guardian for
AFFIRM ATION (CERTIFICATION)
OF EXAM INING PHYSICIAN
File No. _______________________________
Pursuant to SCPA Article 17-A
--------------------------------------------------------------------X
STATE OF NEW YORK )
CO UNTY O F ) ss.:
I, __________________________________________________________, a physician duly licensed to practice
m edicine in the State of New York, under penalty of perjury affirm s as follows:
[PLEASE ANSWER ALL QUESTIONS]
1. My license number is : ______________________________________________________________________
2. My offices are located at: ____________________________________________________________________
___________________________________________________________________________________________
3. My professional knowledge and/or background in the care and treatm ent of persons with [ ] intellectualdisabilities [ ] developmental disabilities is as follows:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
4(a). I have exam ined the Respondent on: [Set forth date(s).]
___________________________________________________________________________________________
(b). [Check appropriate box(es) and explain w here requested]:
[ ] I have perform ed the following tests or evaluations of the Respondent. [Set forth in detail the names of
tests and/or evaluations, dates perform ed and results.]
____________________________________________________________________________________
____________________________________________________________________________________
[ ] I have reviewed the following tests or evaluations perform ed on Respondent. [Set forth in detail the
names of tests and/or evaluations, dates performed, results and names of doctors who performed
the tests and/or evaluations.]
____________________________________________________________________________________
____________________________________________________________________________________
GMD-2B (7/2016) -1-
5. The m ental and physical condition of the Respondent is as follows:
[D escribe in detail.]
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
6. [Check appropriate box(es)]:
INTELLECTUALLY DISABLED [ ] Based upon the foregoing, it is m y conclusion the Respondent is an intellectually disabled person andin my opinion incapable of managing him self/herself and/or his/her affairs by reason of intellectual
disability. The nature and degree of the intellectual disability is as follows:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
DEVELOPMENTALLY DISABLED [ ] Based upon the foregoing, it is m y conclusion that the R espondent is developm entally disabled and inm y opinion he/she has an im paired ability to understand and appreciate the nature and consequences
of decisions, which results in Respondent being incapable of managing him self/herself and/or his/her
affairs by reason of developmental disability, and whose disability is attributable to:
[ ] (a) Cerebral palsy, which originated before the Respondent attained the age of twenty-two.
[D escribe, in detail, the nature, degree and origin of the disability.]
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
[ ] (b) Epilepsy, which originated before the Respondent attained the age of twenty-two.
[D escribe, in detail, the nature, degree and origin of the disability.]
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
[ ] (c) Neurological im pairm ent, which originated before the Respondent attained the age of
twenty-two.
[D escribe, in detail, the nature, degree and origin of the disability.]
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
-2-
[ ] (d) Autism , which originated before the Respondent attained the age of twenty-two.
[D escribe, in detail, the nature, degree and origin of the disability.]
______________________________________________________________________________
______________________________________________________________________________
[ ] (e) T raum atic head injury.
[D escribe, in detail, the nature, degree and origin of the disability.]
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
[ ] (f) A condition, which originated before the Respondent attained the age of twenty-two, found to
be closely related to an intellectual disability, because such condition results in sim ilar im pairm ent of
general intellectual functioning or adaptive behavior to that of intellectually disabled persons.
[D escribe in detail the condition, and the nature, degree and origin of the disability.]
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
[ ] (g) Dyslexia resulting from a disability described in subdivision (a) through (f) or an intellectual
disability which condition originated before the Respondent attained the age of twenty-two.
[Describe in detail the nature, degree and origin of the developmental disability or intellectual
disability.]
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
7. [Check appropriate box]:
[ ] T he condition of the R espondent is perm anent in nature or likely to continue indefinitely.
[ ] T he condition of the R espondent is not perm anent in nature nor likely to continue indefinitely.
8. [Check appropriate box]:
[ ] There are no circum stances warranting Respondent’s nonappearance at the hearing required by the court.
[ ] Respondent’s presence at the hearing should be dispensed with because he/she is medically incapable of being present to the extent that attendance is likely to result in physical harm to the Respondent.
[Explain in detail.]
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
-3-
[ ] Respondent’s presence at the hearing should be dispensed with for the following reasons:
[Set forth facts
and circumstances which would result in the court finding that the Respondent’s presence at the
hearing w ould not be in his/her best interest.]
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
9. [Check appropriate box for intellectually disabled person]:
[ ] Based upon the foregoing, it is m y conclusion that the Respondent is not capable of understanding and
appreciating the nature and consequences of health care decisions, including the benefits and risks of and
alternatives to any proposed health care, and of reaching an inform ed decision in order to prom ote his/her
own well being. A health care decision may include a decision to withhold or withdraw life-sustaining
treatm ent as defined in Section 1750-b.1 of the Surrogate’s Court Procedure Act.
[ ] Based upon the foregoing, it is m y conclusion that the Respondent is capable of understanding and
appreciating the nature and consequences of health care decisions, including the benefits and risks of and
alternatives to any proposed health care, and of reaching an inform ed decision in order to prom ote his/her
own well being. A health care decision may include a decision to withhold or withdraw life-sustaining
treatm ent as defined in Section 1750-b.1 of the Surrogate’s Court Procedure Act.
10. [Check appropriate box for a developm entally disabled person]:
[ ] Based upon the foregoing, it is my conclusion that the Respondent has a developmental disability, as defined
in Section 1750-b(1) of the Surrogate’s Court Procedure Act , which includes an intellectual
disability, or
results in a similar impairment of general intellectual functioning or adaptive behavior so that
such
person is incapable of
managing himself or herself, and/or his or her affairs by reason of such
developmental disability,
and that the Respondent is not capable of understanding and appreciating the
nature and
consequences of health care decisions, including the benefits and risks of and alternatives
to any
proposed health care, and of reaching
an informed decision in order to promote his/her own
well being. A health
care decision may include a decision to withhold or withdraw life-sustaining
treatment as defined in Section 1750-b.1 of the Surrogate’s Court Procedure Act. [ ] Based upon the foregoing, it is m y conclusion that the Respondent
is capable of understanding and appreciating the nature and consequenc
es of health care decisions, including the benefits and risks of and
alternatives to any
proposed health care, and of reaching an informed decision in order to promote his/
her own well
being. A health care decision may include
a decision to withhold or withdraw
l
ife-sustaining t reatment as defined in Section 1750-b.1 of the Surrogate’s Court Proc\
edure Act. _______________________________________
Signature of Physician
_______________________________________ Print Nam e
Dated: ____________________________
-4-
SURROGATE’S COURT OF THE STATE OF NEW YORK
COUNTY OF ______________________________
--------------------------------------------------------------------X
Proceeding for the Appointm ent of a
Guardian for
WAIVER OF PROCESS
RENUNCIATION AND CONSENT
TO APPOINTM ENT OF A GUARDIAN
File No. _______________________________
Pursuant to SCPA Article 17-A
--------------------------------------------------------------------X
T he undersigned _____________________________________________________, whose perm anent address is
_________________________________________________________________________________________________ (Street and Num ber) (City, Village, Town)
_________________________________________________________________________________________________ (State) (Zip Code)
and who is a com petent person over the age of eighteen (18) years and whose interest in the above-named proceeding is as
follows:
[Check appropriate interest]
[ ] Parent of the above-named alleged [ ] intellectually disabled person [ ] developmentally disabled person.
[ ] Spouse of the above-named alleged [ ] intellectually disabled person [ ] developmentally disabled person.
[ ] An adult child of the above-named alleged [ ] intellectually disabled person [ ] developmentally disabledperson.
[ ] An adult brother/sister of the above-named alleged [ ] intellectually disabled person [ ] developmentally disabled person
[ ] O ther [Specify] _____________________________________________________________________________
hereby personally appears in this proceeding and
1. renounces all right to apply as a guardian under Article 17-A of the SCPA
2. waives the issuance and service of process in this matter, and
3. consents that _________________________________________________________ be nam ed the Guardian(s) of the [ ] person
[ ] property
[ ] person and property
[ ] lim ited guardianship of the property
and that _____________________________________________________________________ be named the Standby
Guardian of the [ ] person
[ ] property
[ ] person and property
[ ] lim ited guardianship of the property
GMD-3 (7/2016) -1-
and that ___________________________________________________________________ be nam ed the First Alternate
Standby Guardian of the
[ ] person
[ ] property
[ ] person and property
[ ] lim ited guardianship of the property
and that ___________________________________________________________________ be nam ed the Second Alternate
Standby Guardian of the [ ] person
[ ] property
[ ] person and property
[ ] lim ited guardianship of the property
and that such letters m ay be granted to said person(s) or to any other person(s) entitled thereto without notice to the
undersigned. _______________________________________(Signature)
Date: ____________________________ _______________________________________(Print Name)
STATE O F ____________________) ss.:
COUNTY OF___________________) On __________________________________________________________, _________, before me personally came
_________________________________________________________________________________________________to
m e known to be the person described in and who executed the foregoing instrum ent. Such person duly swore to such
instrum ent before me and duly acknowledged that he/she executed the sam e.
_______________________________________
N otary Public
Com m ission Expires:
(Affix N otary Stam p or Seal)
SURROGATE’S COURT OF THE STATE OF NEW YORK
COUNTY OF ______________________________
--------------------------------------------------------------------X
Proceeding for the Appointm ent of a
Guardian for
CONSENT, OATH AND
DESIGNATION
File No. _______________________________
Pursuant to SCPA Article 17-A
--------------------------------------------------------------------X
STATE OF NEW YORK )
CO UNTY O F _______________) ss.:
___________________________________________________________________, being duly sworn, deposes and says:
I am an adult competent person and I do hereby consent to the relief requested in the petition and my appointm ent as
[ ] standby guardian [ ] first alternate standby guardian [ ] second alternate standby guardian
of the [ ] person [ ] property
[ ] person and property
[ ] lim ited guardianship of the property
of the above-named Respondent and I waive the issuance and service of process upon m e herein. I will make an application
for confirm ation in accordance with SCPA §1757 and will be subject to a form al hearing if the Respondent is eighteen years
of age or over. I agree that upon the death, incapacity, renunciation or rem oval of the last guardian who has been designated
to serve prior to me, I will im m ediately assume the duties of guardian
of the [ ] person [ ] property
[ ] person and property
[ ] lim ited guardianship of the property
and will seek to have this Court confirm my appointm ent within (180) days of my assumption of duties.
1. OATH OF [ ] STANDBY GUARDIAN [ ] FIRST ALTERNATE STANDBY GUARDIAN [ ] SECOND
ALT ER N AT E ST AN D BY G U AR D IA N : I am over eighteen (18) years of age and a citizen of the U nited States; that I will well,
faithfully and honestly discharge the duties of
[ ] standby guardian [ ] first alternate standby guardian [ ] second alternate standby guardian
of the [ ] person [ ] property
[ ] person and property
[ ] lim ited guardianship of the property
of the above nam ed Respondent, that I am acquainted with the estate of the Respondent; and that I am not ineligible to receive
letters.
2. DESIGNATION OF CLERK FOR SERVICE OF PROCESS: I do hereby designate the Clerk of the Surrogate’s Court
of ____________________ County, and his/her successor in office, as a person on whom service of any process issuing from
such Surrogate’s Court may be m ade, in like manner and with like effect as if it were served personally upon me whenever
I cannot be found and served within the State of New York after due diligence used.
GMD-4 (7/2016) -1-
My perm anent address is : ___________________________________________________________________________
(Street Address) (City/Town/Village) (State) (Zip)
_____________________________________________ (Signature of Proposed Guardian)
_____________________________________________ (Print Nam e)
On __________________________________________________________, ________, before me personally came
_________________________________________________________________________________________________
to me known to be the person described in and who executed the foregoing instrument. Such person duly swore to such
instrum ent before me and duly acknowledged that he/she executed the sam e.
__________________________________
N otary Public
Com m ission Expires:
(Affix N otary Stam p or Seal)
-2-
SURROGATE’S COURT OF THE STATE OF NEW YORK
COUNTY OF _____________________________
---------------------------------------------------------------------------X
Proceeding for the Appointm ent of a
Guardian for
NOTICE OF PETITION
SCPA §1753 (2)
File No. _______________________________
Pursuant to SCPA Article 17-A
---------------------------------------------------------------------------X
Notice is hereby given that:
1. On the __________ day of _____________________, 20___, _____________________________________________, (Nam e of Petitioner(
