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FORM 42 10/2017 P AGE 1 OF 2 SEND TO : EXECSEC @ IC.NC .GOV O FFICE OF THE EXECUTIVE SECRETARY 1236 MAIL SERVICE CENTER R ALEIGH , NC 27699-1236 MAIN TELEPHONE : (919) 807-2500 H ELPLINE : (800) 688-8349 W EBSITE : HTTP ://WWW .IC.NC .GOV F ORM 42 North Carolina Industrial Commission IC File # A PPLICATION FOR A PPOINTMENT OF G UARDIAN Emp. Code # A D L ITEM Carrier Code # The Use of This Form Is Required Under the Provisions of the Workers' Compensation Act Employer FEIN v. Plaintiff (s) Defendant (s) TO THE NORTH CAROLINA INDUSTRIAL COMMISSION: The undersigned respectfully shows unto the North Carolina Industrial Commission that Is an infant or incompetent without general or testamentary guardian in this State, and that by reason thereof can bring an action only by a guardian ad litem; that the person has a cause of action a gainst the defendants on account of the followin g matter and thin gs: The undersi gned is a reputable person closel y connected with the infant or incompetent havin g the relationship with the infant o r incompetent as follows: WHEREFORE, the undersi gned pra ys the Commission that a fit and proper person be appointed Guardian Ad Litem for the infant or incompetent for the purpose of bringing in his behalf an action as above set out. Signature of Applicant Date (Please complete page 2 of form) ORDER APPOINTING GUARDIAN AD LITEM It appearing to the North Carolina Industrial Commission from the above application that is an □ infant or □ incompetent having no general or testamentary guardian within this State and that said infant (or incompetent) appears to have a good cause of action against the defendant(s) ; and it further appearing to the Commission after due inquiry that is a fit and proper person to be appointed guardian ad litem for the infant or incompetent for the pu rpose of brin ging this action in his or her behalf; IT IS THEREFORE ORDERED that be and is hereby appointed guardian ad litem of to bring this action in his or her behalf. This day of . Commissioner or Deputy Commissioner FORM 42 10/2017 P AGE 2 OF 2 SEND TO : EXECSEC @ IC.NC .GOV O FFICE OF THE EXECUTIVE SECRETARY 1236 MAIL SERVICE CENTER R ALEIGH , NC 27699-1236 MAIN TELEPHONE : (919) 807-2500 H ELPLINE : (800) 688-8349 W EBSITE : HTTP ://WWW .IC.NC .GOV F ORM 42 PLEASE TYPE OR PRINT: Full name and address of minor or incompetent: Birth date of minor: Full name and address of proposed guardian ad litem: DUTIES OF GUARDIAN AD LITEM In civil actions in North Carolina when any of the parties is an infant or incompetent person, he or she must appear by general o r testamentary guardian, if he or she has any within this State, or by guardian ad litem. The guardian ad litem may take such steps as he or she deems appropriate to prosecute the action in behalf of the ward, and may take settlement of the ward's claim, subject to the approval of the Commission. THE GUARDIAN AD LITEM HAS NO AUTHORITY TO RECEIVE OR ACCEPT ANY FUNDS IN BEHALF OF HIS WARD. Only the Clerk of Superior Court or a general guardian appointed under the Clerk’s jurisdiction has the authority to receive funds and disburse them for an incompetent or infant.