Fill and Sign the How to Become the Legal Guardian of a Person Receiving Form

H OW TO U SE THIS O NLINE FORM This form can be filled out on screen, saved to your local drive, and printed out on your local printer or it can be printed out on your local printer for completion by hand or typewriter. The information you enter is NOT submitted electronically. Guardianship (DDD 2/1/02) How to Become the Legal Guardian of a Person Receiving Services From the Division of Developmental Disabilities (Superior Court of New Jersey, Chancery Division, Probate Part) DESCRIPTION OF GUARDIANSHIP ACTION : Guardianship over an incapacitated person over the age of 18 who is receiving servic\ es from the Division of Developmental Disabilities (DDD) can be obtained in one of two ways. The first way is that the Commissioner of the Department of Human Services can in\ itiate proceedings when it is determined that an individual is in need of a guardian. The\ second method is that a private citizen can petition the court to have a guardian nam\ ed. This packet contains instructions for a private citizen to follow to obtain the appointment \ of a legal guardian over an incapacitated person receiving Division of Developmental Disabil\ ities services. NOTE: These materials have been prepared by the New Jersey Administrative Of\ fice of the Courts for use by self-represented litigants. The guides, instructions,\ and forms will be periodically updated as necessary to reflect current New Jersey statutes and court r\ ules. The most recent version of the forms will be available at the county courthouse \ or on the Judiciary’s Internet site (www.judiciary.state.nj.us). However, you are ultimately respon\ sible for the content of your court papers. Click Here for a List of Where to Send your Completed Forms: 2 T HINGS TO THINK ABOUT BEFORE YOU REPRESENT YOURSELF IN COURT TRY TO GET A LAWYER The court system can be confusing and it is a good idea to get a lawyer if you can. If you cannot afford a lawyer, you may contact the legal services program in your county to see if you qualify for free legal services. Their telephone number can be found in your local yellow pages under “Legal Aid” or “Legal Services.” If you do not qualify for free legal services and need help in locating an attorney, you can contact the bar association in your county. Their telephone number can also be found in your local yellow pages. Most county bar associations have a Lawyer R eferral Service. The county bar Lawyer Referral Service can supply you with the names of attorneys in your area willing to handle your particular type of case and sometimes consult with you at a reduced fee. There are also a variety of organizations of minority lawyers throughout New Jersey, and also organizations of lawyers who handle specialized types of cases. Ask your county court staff for a list of lawyer referral services that include these organizations. WHAT YOU SHOULD EXPECT IF YOU REPRESENT YOURSELF While you have the right to represent yourself in court, you should not expect any special treatment, help, or attention from the court. You must still comply with the court rules, even if you are not familiar with them. The following is a list of some things the court staff can and cannot do for you. Please read it carefully before asking the court staff for help. -We can explain and answer questions about how the court works. -We can tell you what the requirements are to have your case considered by the court. -We can give you some information from your case file. -We can provide you with samples of court forms that are available. -We can provide you with guidance on how to fill out forms. -We can usually answer questions about court deadlines. -We cannot give you legal advice. Only your lawyer can give you legal advice. -We cannot tell you whether or not you should bring your case to court. -We cannot give you an opinion about what will happen if you bring your case to court. -We cannot recommend a lawyer, but we can provide you with the telephone number of a local lawyer referral service. -We cannot talk to the judge for you about what will happen in your case. -We cannot let you talk to the judge outside of court. -We cannot change an order issued by a judge. KEEP COPIES OF ALL PAPERS Make and keep for yourself copies of all completed forms and any canceled checks, money orders, sales receipts, bills, contract estimates, letters, leases, photographs, and other important documents that relate to your case. 3DEFINITIONS OF WORDS THAT MAY BE USED IN THIS PACKET Alleged Incapacitated Person: The individual over whom the plaintiff is seeking a guardian. Affidavit: An affidavit is a written statement of facts confirmed by an oath taken before a notary public or other official authorized to administer oaths. See certification. Certification : A certification is a written statement of facts confirmed by a certification that under\ penalty of law all information contained is true to the best of your knowledge and belief. See affidavit. County of Settlement :The county of settlement is the county responsible for a share of the charg\ e incurred for services provided to persons unable to pay. Typically, this is the alleged inca\ pacitated person’s county of residence at the time of application for eligible DDD services. However, it is possible for the county of residence and the county of settlement may b\ e different. It depends on the residential history of the alleged incapacitated person. \ File: To file means to give the appropriate forms and fee to the court to begin the court’\ s consideration of your request. Judgment: A judgment is the official decision of a court in a case. Order: An order is a signed paper from the judge telling someone they must do something\ . Interested Party: An interested party is a person or government agency that has an involvement with the incapacitated person that is the subject of the court action. It includes the alleg\ ed incapacitated person’s next-of-kin who are his closest relatives, the county of settlement (the county adjuster) and the administrator of the Division of Developmental Disab\ ilities program providing services to the alleged incapacitated person. Plaintiff: The plaintiff is the party who starts the lawsuit. Proof of Service: A proof of service is a sworn statement that tells the court who was given notice of the complaint and supporting pleadings in your case. It also tells the court how tho\ se persons received these documents. Return Date: Return date is the date the plaintiff and defendant are told to appear in court. Service: Copies of your papers are personally delivered to the alleged incapacitated pe\ rson and mailed to the parties in interest and the attorney appointed to represent the all\ eged incapacitated person. Verified Complaint: A verified complaint is a document in which you briefly tell the court the facts in your cas\ e and the relief you want the court to grant. This is filed by the plaintiff.\ 4 IMPORTANT INFORMATION ON GUARDIANSHIP ACTIONS EXAMINATION The forms provided in this packet are for guardianships being obtained for persons receiving services from the Division of Developmental Disabilities and is often called a Title 30 guardianship. TITLE 30 GUARDIANSHIPS Titl e 30 requires that one medical physician or psychologist examine or evaluate the individual and submit a written report under oath. A second report under oa th is submitted by the chief executive officer, medical director or other Division of Developmental Disabilities official having administrative control over the functional program or services. Typically the regional DDD administrator supplies the report. From now on this package calls the report provider the “DDD official.” The DDD official must agree that the individual is in need of guardian based on the agency’s knowledge of his/her functional level. PLENARY AND LIMITED GUARDIANSHIPS It is important to recognize that DDD regulation s require that a guardianship recommendation must be founded upon a sound clinic basis and every effort must be made to seek a solution that is the least restrictive and intrusive to the person’s life and, thereby, preserve the person’s autonomy to the maximum extent possible. Therefore, limited guardianships may be recommended by the DDD official where the alleged incapacitated person can express some, but not all, decisions. A plenary (full) guardianship is appropriate for those persons incapable of making or expressing any decisions. PROCEDURE Once the verified complaint, physician or psycholo gist and the Division of D evelopmental Disabilities official’s affidavits or certifications are filed with the Surro gate, a hearing date is set to dete rmine the need for a legal guardian. The court orders that the next of kin be notified by certified and regular mail of the hearing date and also appoints an attorney for the alleged incapacitated person. The court appointed attorney will conduct an investigation including a meeting with the alleged incapacitated person and the proposed guardian. Based on his/her findings, the court appointed attorney will make a recommendation to the court. Payment for the attorney’s services may be paid out of the incapacitated person’s Social Security. Personal notice is also given to the alleged incapacitated person stating that the alleged incapacitated person and the court appointed attorney may oppose the request for guardianship. If the court appointed attorney does not dispute the need for a guardianship or the fitness of the proposed guardian, the appointed attorney may recommend to the court that a hearing is not necessary. If a hearing is required, the court appointed attorney and the proposed guardian must attend. The alleged incapacitated person does not need to attend if the court appointed attorney or the evaluating physician or psychologist recommend that it is not in the best interest of the alleged incapacitated person to attend. 5 JUDGMENT AND LETTERS OF GUARDIANSHIP Once the court enters the judgment, the guardian(s) will be requested to appear in the Surrogate’s Court to qualify and sign the necessary papers. Letters of Guardianship will be issued by the Surrogate and mailed to the guardian(s). ++++++ 6 H OW TO FILE A GUARDIANSHIP ACTION WITH THE COUNTY SURROGATE The numbered steps listed below tell you what forms you will need to fill out, and what to do with them. Each form should be typed or clearly printed on 8 ½” x 11" white paper only. Forms may not be filed on a different size or color paper. The text must be double spaced. STEPS FOR FILING YOUR COMPLAINT FOR GUARDIANSHIP. STEP 1: Fill out the VERIFIED COMPLAINT TO APPOINT GUARDIAN. (FORM A) This complaint must be verified either by an affidavit (oath before a notary public) or certification (shown in Form A). STEP 2: Have a physician or psychologist complete a certification form. (FORM B or C) If you choose to have a physician complete the certification form use FORM B. If you want a psychologist to complete a certification use FORM C. The physician or psychologist who completes these forms must be the person who examined the alleged incapacitated person. Note: The examination of the alleged incapacitated person cannot be more than 30 days prior to the filing of the Complaint. STEP 3: Obtain a Cert ification from the New Jersey DDD Official The DDD official will complete a form verifying that the individual is a current client of the Division of Developmental Disabilities (DDD) and is receiving services. This form is not included in this packet . Contact your county Surrogate for information on how to contact the regional DDD office. STEP 4: Fill out the ORDER FOR HEARING (FORM D) This form will allow the court to insert the date and time of hearing and assign an attorney for the alleged incapacitated person. A copy of this order is served on the alleged incapacitated person, the attorney appointed to represent the alleged incapacitated person and the parties-in-interest (next of kin, county adjuster and regional DDD official). STEP 5: Complete the top portion of the Judgment Appointing Guardian. (FORM E) If the judge grants your request, this is the document that he or she will sign naming you as guardian. STEP 6: Check your completed forms and Make Copies. Check your forms to make sure they are complete. Remove all instruction sheets. Make sure you have signed all the forms whenever necessary. Make at least three copies. One set will be your records. STEP 7: Pay the Filing Fee . The filing fee to file these forms is $200, payable by check or money order. Make the check payable to the Surrogate of the county in which you are filing. STEP 8: Deliver or Mail your completed forms (FORMS A, [B or C] and D), along with the Certification of the DDD Official, to the County Surrogate. DO NOT send in Forms F or G at this time. You must wait until you get copies of the SIGNED Order for Hearing (FORM D) from the court before you complete these forms. You can deliver your completed forms in person or you can mail them. If you mail them, we recommend you mail them certified, return receipt requested. This will provide you with proof that you mailed your forms. Your post office can tell you how to send out mail certified, return receipt requested. The county you mail your papers to is the county where the alleged incapacitated person lives. When you deliver or mail your completed forms to the Surrogate, you must supply the court with a self-addressed stamped envelope so that the court can send you certified copies of the order. STEP 9: Review copies of the Order for Hearing returned from the court for instructions on how to proceed. The court will return copies of the Order for Hearing to you. Once you receive these copies, you must follow the court’s instructions in the Order for Hearing to complete your paperwork properly. 7 S TEP 10: Fill out the NOTICE OF PENDING HEARING . (FORM F) Once you get the signed Order for Hearing from the court, complete the Notice of Pending Hearing . This will inform the alleged incapacitated person of the time, date and place of the hearing to det ermine whether they are incapacitated. This form MUST be personally delivered to the alleged incapacitated person at least 20 days prior to the date of the hearing. STEP 11: Arrange to serve the Complaint (FORM A), Physician’s or Psychologist’s Certification (FORM B or C), DDD Official’s affidavit or certification and the signed Order for Hearing (FORM D) on the alleged incapacitated person and on the other interested parties. Once you get back the Order for Hearing signed by the judge, you must personally deliver a copy of the complaint (Form A), physician’s or psychologist’s ce rtification (FORM B or C), regional director’s affidavit or certification and the signed order (Form D) to the alleged incapacitated person. You must deliver copies of the same forms to all other parties by certified mail, return receipt requested, and by regular mail. You must also forward copies of the complaint and order to the court appointed attorney. STEP 12: Complete the PROOF OF SERVICE Form (FORM G) and the Judgment (FORM E). After service on the parties-in-interest is accomplished, complete the Proof of Service form and the Judgment and mail or deliver both forms to the Surrogate to show that the papers have been properly served. This must be filed at least 5 days prior to the hearing. This document lists all the papers that were served personally on the alleged incapacitated person and all papers that were mailed (certified and regular mail) to the next of kin and to the alleged incapacitated person’s attorney. Attach photocopies of the return receipt cards returned by the post office. STEP 13: Call the Surrogate a few days prior to the date set for the hearing to confirm the hearing will be held. If there has been no opposition to the guardianship application, the judge may not require a hearing. However, if a hearing is scheduled, you must attend the hearing. Call to confirm whether a hearing will be held. STEP 14: Qualification. If the court declares the alleged incapacitated person to be incapacitated and appoints a guardian, then the appointed person must appear in the Surrogate to qualify. This involves signing acceptance documents and filing a surety bond, if the court requires the same. STEP 15: Legal Fee Payment. If the court awards the attorney appointed to represent the incapacitated person a fee, arrange to pay the same from the incapacitated person’s assets or income. DEADLINES YOU NEED TO MEET Examinations by the physician or psychologist of the alleged incapacitated person must be made no more than 30 days prior to the filing of the complaint. The alleged incapacitated person and all interested parties listed in the complaint must have at least 20 days notice of the hearing date . The Proof of Service (FORM F) must be filed with the court at least 5 days prior to the date scheduled for the hearing . INTERPRETER OR ACCOMMODATION If you need an interpreter or an accommodation for a disability for the hearing, please contact the court before the hearing date. ++++++ 8INSTRUCTIONS FOR COMPLETING THE ATTACHED FORMS INSTRUCTIONS FOR FORM A - VERIFIED COMPLAINT TO APPOINT GUARDIAN A. In paragraph #1 type or print the information about the person over whom y\ ou are seeking to be appointed guardian. B. In paragraph #2 type or print the name of the person over whom guardianshi\ p is sought and the disability that he or she has been diagnosed with. Type or print the name of the \ physician or psychologist who completed either a physician’s or psychologist’s certificatio\ n (FORM B or C) (See step #2 for more information on this.) C. In paragraph # 3 type or print the name of the person over whom guardiansh\ ip is sought and indicate where he/she is receiving services from the New Jersey Division of Devel\ opmental Disabilities. D. In paragraph # 4 type or print the names of the next of kin of the person \ over whom a guardian is sought. Insert the name and address of the appropriate county adjuster for the county of settlement\ and the name and address of the DDD service provider administrator. E. In paragraph # 5 insert your personal information F. In paragraph #6 indicate whether the person over whom guardianship is soug\ ht owns any real or personal property and his or her monthly income, if any. Type or print any empl\ oyer’s name and the salary of any employment by the alleged incapacitated person. G. In paragraph #7 type or print any courses of instructions or other train\ ing the alleged incapacitated person attends. H. In paragraph #9 type or print the name of the person over whom guardianshi\ p is sought. Use the first paragraph #9A if a plenary (full) guardianship is requested; use the second par\ agraph #9B if a limited guardianship is requested. I. In the relief demanded use the first letter (A1,B1 and C1) paragraphs, if a plenary\ (full) guardianship is requested. Use the second letter (A2,B2 and C2) paragraphs, if a limi\ ted guardianship is requested. J. Sign and date the form where it asks you to do so. 9INSTRUCTIONS FOR FORM B -- PHYSICIAN CERTIFICATION You must have a New Jersey licensed medical physician or psychologist complete a certification att\ esting to the fact that the alleged incapacitated person is in fact incapacitated\ . The medical physician or psychologist who completes this form must be the one to examine the alle\ ged incapacitated person. This form is for medical physicians only . If a medical physician is the one who has conducted the evaluation of the alleged incapacitated person, then this form should be used. Inform him/her that you are seeking to be appointed guardian over the alleged incapacitated person and that you need him/her to complete this form. INSTRUCTIONS FOR FORM C -- PSYCHOLOGIST CERTIFICATION You must have a New Jersey licensed medical physician or psychologist complete a certif\ ication attesting to the fact that the alleged incapacitated person is in fact incapacitated\ . The medical physician or psychologist who completes this form must be the one to examine the alleged incapacitated person. The examination must take place no more than 30 days before you file this gu\ ardianship action. This form is for psychologists only . If a psychologist is the one who has conducted the evaluation of the alleged incapacitated person, then this form should be used. Inform him/her th\ at you are seeking to be appointed guardian over the alleged incapacitated person and that you need him/he\ r to complete this form. INSTRUCTION FOR FORM D - ORDER FOR HEARING (This form is self explanatory. Fill in only the top portion.) Note: The Public Defender, if available, may be appointed if only guardi\ anship of the person is sought. If you seek guardianship of the person and the estate or the public defende\ r is not available, then the court will appoint a private attorney. INSTRUCTIONS FOR FORM E - JUDGMENT APPOINTING GUARDIAN Where indicated, type or print your name, the name of the attorney appointed \ for the alleged incapacitated person, the name of the physician or psychologist and the name of the Division \ of Developmental Disabilities official who has completed the certification. 10INSTRUCTIONS FOR FORM F - NOTICE OF PENDING HEARING (Portions that are not self explanatory) A. Where shown, enter the docket number in this case. You will get this number when the court returns the signed order to you. (FORM D) B. Where it says “TO” type or print the name of the alleged incapacit\ ated person. C. Fill out the date, time, and place of the hearing. You will get this information when the court sends back the signed order for hearing with all of this information on it. D. Type or print the name of the proposed guardian in the last paragraph. INSTRUCTIONS FOR FORM G - PROOF OF SERVICE(Portions that are not self explanatory.) A. In paragraph #1 type or print the name of the person who handled service\ of the pleadings. B. In paragraph #2 type or print the date you personally mailed or delivered copies of FORMS A, [B or C] & D to the alleged incapacitated person. C. In paragraph # 4 type or print the date you mailed a copy of FORMS A, [B o\ r C] & D to the next of kin of the alleged incapacitated person and other interested parties. D. Sign and date the form where it asks you to do so. 11FORM A -- VERIFIED COMPLAINT TO APPOINT GUARDIAN Plaintiff(s) Type your name(s) Address: Telephone Number : SUPERIOR COURT OF NEW JERSEYCHANCERY DIVISION COUNTY PROBATE PART In The Matter of TYPE INCAPACITATED PERSON’S NAME an Alleged Incapacitated Person Docket No. CIVIL ACTION VERIFIED COMPLAINT TO APPOINT GUARDIAN FOR PERSON RECEIVING DIVISION OF DEVELOPMENTAL DISABILITIES SERVICES I/ We, the Plaintiff(s), \ and \ , residin\ g at \ , City /Township /Borough of , County of \ and State of New Jersey, by way of verified complaint says: 1.The name, age, present resident address, length of time at residence, permanent residence (domicile) and marital status of the alleged incap\ acitated person are: A.Name: B. Age: C: Present residence: \ since . D. Permanent residence: \ since . E. Marital status: (Check one) __Married __Never Married__Divorced F. Children: (Check one) __No Children __Children as listed in Paragraph 4 12 2. has been diagnosed as suffering from as shown \ by the attached affidavit or certification of (Medical Physician or Psycho\ logist). Because of this condition, lacks sufficient capacity to govern himself/herself and manage his/her affairs. 3. has been receiving services fro\ m the New Jersey Division of Developmental Disabilities at \ since \ . He/She continues to need such services, as shown by the attached affidavit or certification of , Division of Developmental Disa\ bilities official. 4. The names, residence addresses, and relationships of the spouse, next-of-kin most closely related to the alleged incapacitated person (parents, siblings\ et cetera ) and other persons interested in the status of the alleged incapacitated person (custodia\ n, county adjuster, DDD program administrator) are as follows: Name Address Relationship Age 13 5. The name, address, age, telephone number and relationship to the alleged incapacitated person of the proposed guardian(s) are as follows: Name: Address: Age: Telephone number Relationship 6. The character and approximate value of the real and personal property and \ income of the alleged incapacitated person are as follows: A.Personal property: (i) bank accounts $ (ii) stocks, bonds and mutual funds $ (iii) other personal property (specify) $ _________________ Total personal property value $ B. Real property (describe) $ $ C. Periodic compensation and income from: i.real property $ / month ii personal property $ / month iii pensions $ / month iv public assistance benefits $ / month v social security benefits $ / month vi trust distributions: $ / month vii other income sources (specify) $ / month viii wages (employer:) $ _________________/ month Total monthly income $ / month 14 7. (If applicable) , the alleged incapacitated\ person, attends classes at \ . 8.The alleged incapacitated person does not have an attorney. It is requeste\ d that the court appoint an attorney to serve as legal counsel for the alleged inca\ pacitated person. 9A. Because of ’s condition, he/she is without the necessary cognitive capacity to understand personal, financial, hea\ lth and medical matters that affect his/her well-being and, therefore, he/she lacks the capacit\ y to govern himself /herself in all of his/her financial and personal affairs. OR 9B. Because of ’s condition, he/she is without the necessary cognitive capacity to understand some of the personal, financial, health and medical matters that affect his/her well-being and, therefore, he/she lacks the capacity to govern himself/herself in the following financial and personal affair ar\ eas: \ \ . In all other respects, he/she is fully able at this time to govern himself/\ herself and govern and manage his/her affairs. WHEREFORE, the plaintiff(s) demand(s) judgment pursuant to N.J.S.A. 30:4-165.7: A1. declaring to be suffering from a c\ hronic functional impairment and as a result is incapable and unable to govern himself/he\ rself and manage his/her affairs; OR A2.declaring to be suffering from a chronic functional impairment and as a result is incapable and unable to govern himself/h\ erself and manage his/her affairs with respect to : \ \ ; 15 B1. Appointing the plaintiff(s) the guardian of his/her PERSON and issuing Letters of Guardianship upon qualifying according to law; OR B2. Appointing the plaintiff(s) the limited guardian of his /her PERSON and issuing\ Letters of Limited Guardianship upon qualifying according to law; C1. Appointing the plaintiff(s) the guardian of his/ her ESTATE and issuing Letters\ of Guardianship upon qualifying according to law. OR C2. Appointing the plaintiff(s) the limited guardian of his/her ESTATE and issuing Letters of Limited Guardianship upon qualifying according to law. Date: \ \ ___________________________________ SIGNATURE OF PLAINTIFF \ TYPE NAME Date: \ \ ___________________________________ SIGNATURE OF PLAINTIFF \ TYPE NAME VERIFICATION I/We, and \ , hereby certify and say: 1. I/ We are the plaintiff(s). 2. The contents of the complaint are true to my (our) personal knowledge \ and belief. I (We) hereby certify that the statements made by me are true. I am awa\ re that if any are wilfully false, I am (We are) subject to punishment. Date: Date: ______________________________________________________ ________________________________________________ Signature of Plaintiff Signature of Plaintiff Type Name Type Name 16FORM B -- PHYSICIAN’S CERTIFICATION Plaintiff(s) TYPE YOUR NAME(s) Address: Telephone Number: SUPERIOR COURT OF NEW JERSEYCHANCERY DIVISION COUNTY PROBATE PART IN THE MATTER OF TYPE INCAPACITATED PERSON’S NAME AN ALLEGED INCAPACITATED PERSON Docket No. CIVIL ACTION CERTIFICATION OF MEDICAL PHYSICIAN TYPE PHYSICIAN’S NAME I, \ , M.D., with offices at \ \ , being of full age, do hereby certify and say as follows: 1.I am a permanent resident of the State of New Jersey and a physician lic\ ensed to practice medicine in the State of New Jersey. 2.I am not a relative, either through blood or marriage, to \ or of \ the proprietor, director or chief executive of any private institution for the care and treatment o\ f the mentally ill at which he/she is living or at which it is proposed to place him/her, nor am I profess\ ionally employed by the management thereof as a resident physician, nor do I have any finan\ cial interest therein. 3. I have reviewed the clinical data and history regarding \ \ and personally examined him/her on , 20 \ . 1 Note. Complete this paragraph if it is your opinion that the alleged incapacitated person has sufficient capacity in certain areas that he or\ she should retain decision making rights. This paragraph will set out the basis for the s\ ame for the court’s consideration. Otherwise cross this paragraph out before signing. 17 4. My opinion as to \ ’s capacity to govern himself/herself and manage his/her affairs is based upon the following: \ 5. Based upon my personal examination and the aforementioned clinical data and history, it is my conclusion that \ suffers from a significant chronic functional impairment and lacks the cognitive capacity to make d\ ecisions for himself/herself or to communicate, in any way, decisions to others. His\ /Her significant chronic functional impairment includes, but is not limited to, a lack o\ f comprehension of concepts related to personal care, health care or medical treatment and is, therefore, incapable of governing himself/herself or managing his/he\ r personal or financial affairs. 6.1 It is also my opinion that does have sufficient capacity to make limited decisions in the areas of : \ The reasons for my opinion that he/she has the ability to make the aforement\ ioned limited decisions are: 7.Based upon my personal examination and aforementioned clinic data and history, it is my conclusion that he/she is (check one) ___capable ___incapable of attending the hearing in this matter. If incapable, state reasons: I certify that the foregoing statements made by me are true. I am aware\ that if any of the foregoing statements made by me are willfully false, I am sub\ ject to punishment. Date: _______________________________ M.D. type name 18FORM C -- PSYCHOLOGIST’S CERTIFICATION Plaintiff(s) TYPE YOUR NAME(s) Address: Telephone Number: SUPERIOR COURT OF NEW JERSEYCHANCERY DIVISION COUNTYPROBATE PART In the Matter of TYPE INCAPACITATED PERSON’S NAME An Alleged Incapacitated Person Docket No. CIVIL ACTION CERTIFICATION OF PSYCHOLOGIST TYPE PSYCHOLOGIST’S NAME I, , with offices at \ \ , being of full age, do hereby certify and say as follows: 1.I am a permanent resident of the State of New Jersey and a psychologist licensed pursuant to N.J.S.A. 45:14B-1 et seq. to practice in the State of New Jersey. 2. I am not a relative, either through blood or marriage, to \ \ or of the proprietor, director or chief executive of any private institution for the care and treatment o\ f the mentally ill at which \ is living or at which it is proposed to place him/her, nor am I professionally employed by the management \ thereof as a resident physician, nor do I have any financial interest therein. 3.I have reviewed the clinical data and history regarding \ \ and personally examined him/her on the \ , 20 . 1 Note. Complete this paragraph if it is your opinion that the alleged incapacitated person has sufficient capacity in certain areas that he or\ she should retain decision making rights. This paragraph will set out the basis for the s\ ame for the court’s consideration. Otherwise cross this paragraph out before signing. 19 4. My opinion as to \ ’s capacity to govern himself/herself and manage his/her affairs is based upon the following: 5.Based upon my personal examination and the aforementioned clinic data and history, it is my conclusion that suffers from \ a significant chronic functional impairment and lacks the cognitive capacity to make d\ ecisions for himself/herself or to communicate, in any way, decisions to others. His/Her significant chronic functional impairment includes, but is not limited to, a lack of comprehension of concepts related to personal care, health care\ or medical treatment and is, therefore, incapable to governing himself/herself or managing his/her personal or financial affairs. 6.1 It is also my opinion that \ does have sufficient capacity to make limited decisions in the areas of : \ The reasons for my opinion that he/she has the ability to make the afore\ mentioned limited decisions are: 7.Based upon my personal examination and aforementioned facts and history, it is my conclusion that he/she is (check one) capable \ incapable of attending the hearing in this matter. If incapable, state reasons: I certify that the foregoing statements made by me are true. I am aware that if any of the foregoing statements made by me are willfully false, I am subject to\ punishment. Date: _______________________________ TYPE PSYCHOLOGIST’S NAME 20FORM D -- ORDER FOR HEARING Plaintiff(s) TYPE YOUR NAME(S) Address: Telephone Number: SUPERIOR COURT OF NEW JERSEYCHANCERY DIVISION COUNTY PROBATE PART In the Matter of PRINT INCAPACITATED PERSON’S NAME an Alleged Incapacitated Person Docket No. CIVIL ACTION ORDER FIXING HEARING DATE AND APPOINTING ATTORNEY FOR ALLEGED INCAPACITATED PERSON RECEIVING DIVISION OF DEVELOPMENTAL DISABILITIES SERVICES This matter having been opened to the court on complaint of the plaintiff(s\ ) for an order seeking the appointment of a guardian for under R.4:86-10 and for such other relief as the court may deem just, and the court having \ read and considered the verified complaint, the supporting affidavits or certifications and all\ other papers and pleadings presented with this application, and for good cause shown: (Do not write below this line - for court use only - except for the appropr\ iate spaces where the name of the person over whom guardianship is sought should be inserted.) IT IS on this day of , 20___, ORDERED that: 1. This matter be set down for hearing before this court at the County Court House, , New Jersey, before the Hon. on the day of , 20 , at o’clock in the a.m. p.m. or as soon thereafter as plaintiff(s) may be heard, to determine the iss\ ue of the legal incapacity of and for the determination of the app\ ointment of a guardian; and 2.A copy of the complaint and supporting affidavits along with this order, shall be\ served on , the alleged incapacitated person, by personal service at least 20 days prior to the date scheduled for the hearing. 21 3. A separate notice advising the alleged incapacitated person of his her right to a jury trial and to personally, or through legal counsel, appear and oppose the application shall be personally served on the alleged incapacitated person at least 20 days prior to the date scheduled for the hearing. 4.A copy of the complaint and supporting documents, along with this order, shall be served on all the next of kin and other interested parties set out in the complaint by regular and certified mail, return receipt requested, at least 20 days prior to the date scheduled for the hearing. 5. , Esquire, whose address is ____________________________________and telephone is _____________________, be and hereby is appointed as counsel for the alleged incapacitated person. Said attorney shall be immediately served with copies of the complaint and supporting\ documents along with this order. Said attorney shall personally interview the client, examin\ e the medical records, make inquiries of persons having knowledge of the alleged incapacitated pers\ on’s circumstances, make reasonable inquiries to locate any will, powers of attorney or hea\ lth care directive previously executed by the alleged incapacitated person and prepare a w\ ritten report of findings and recommendations to be filed in court and with the plaintif\ f(s) pursuant to R.4:86-10 at least ____ days prior to the hearing. 6.This court may summarily appoint a guardian of the person and estate without\ a hearing if the attorney appointed for \ reports that he/she on behalf of the alleged incapacitated person does not dispute ei\ ther the need for the guardianship or the fitness of the proposed guardian and the allege\ d incapacitated person does not request a plenary hearing. ______________________________________ , J.S.C. 22FORM E -- JUDGMENT APPOINTING GUARDIAN Plaintiff(s) TYPE YOUR NAME(S) Address: Telephone Number: SUPERIOR COURT OF NEW JERSEYCHANCERY DIVISION COUNTY PROBATE PART In the Matter of TYPE INCAPACITATED PERSON’S NAME An Incapacitated Person Docket No. CIVIL ACTION JUDGMENT OF LEGAL INCAPACITY AND APPOINTING A GUARDIAN OF THE PERSON AND ESTATE FOR PERSON RECEIVING DIVISION OF DEVELOPMENTAL DISABILITIES SERVICES This matter having been opened to the court on the complaint of the plaintiff(s) \ , and the court having appointed \ as attorney for and the court having reviewed the pleadings and the affidavits or certif\ ications of , M.D., (or \ licensed psychologist) and , Division of Deve\ lopmental Disabilities official, and the report of , Esq., and it appearing that s\ uffers from a chronic functional impairment and that he/she lacks cognitive capacity and as a result is incapable of governin\ g himself/herself and managing his/her affairs. It is on this day of , 20__ ORDERED and ADJUDGED that: 1. is an incapacitated person\ and is unfit and unable to govern himself/herself and manage his /her affairs because of a significant chronic functional impairment, except, but subject to the right of the guardian(s) herein appointed to seek to have this portion of the judgment vacated or modifi\ ed for good cause, is able at this time to gov\ ern himself /herself and manage his/her own affairs with respect to the following areas: _______________________________________________________ ________________ __________________ ____________________________________________________ _____________________________________ ________________________________. 23 2: be and hereby is/are appointed [Limited] Guardian(s) of the Person and Estate of and that Letters of [Limited] Guardianship of the Person and Estate shall be issued upon him/her /them (a) qualifying according to law, (b) acknowledging to \ the Surrogate of ________________ County, upon receipt of a copy of the guardian’s manual, the receipt of the same and (c) entering into a surety bond unto the Superior Cour\ t of New Jersey in the amount of $ , which bond shall contain the conditions set forth in N.J.S.A.3B:15-7 and R. 1:13-3. The court shall approve the bond as to form and sufficiency. 3. The guardian(s) shall have authority to make any and all medical decision\ s regarding including, but not limited to, the authority to consent or withhold consent to surgical procedures and such other procedures reasonably attendant t\ hereto, and all decisions concerning withdrawal or denial of life support shall be exer\ cised in full compliance with existing statutory and case law. 4.Upon qualifying, the Surrogate of ________________ County shall issue Letters of Guardianship of the Person and Estate to \ thereupon he/she/they shall then be authorized to perform all the functions and du\ ties of a guardian as allowed by law, except as limited herein or in areas here\ in above set forth where retains decision making rights. 5.The Guardian(s) of the Estate may not alienate, mortgage, transfer or oth\ erwise encumber or dispose of real property without court approval. Said limitation shall be stated in the Letters of Guardianship. 6. The court having reviewed the affidavit or certification of services o\ f \ , Esq., previously filed with the court, ____________________________ shall pay ________________________ ______, court-appointed attorney for _________________________, a fee of $ for professional services rendered and $ for expenses incurred, which disbursements are hereby approved. 7. is hereby directed to advise the Surrogate of _______________ County within ten (10) days of any changes in the address or telephon\ e number of himself or herself and/or the incapacitated person or of the d\ eath of the incapacitated person. 8. shall cooperate fully with any c\ ourt staff or volunteers until the guardianship is terminated by the death or return \ to competency of or the guardian’s death, removal or discharge. 9. The plaintiff shall serve a copy of this Judgment upon all interested parti\ es and attorneys of record within seven (7) days from the receipt hereof. ________________________________________ , J.S.C. 24FORM F NOTICE OF PENDING HEARING Plaintiff(s) TYPE YOUR NAME(s) Address: Telephone Number: SUPERIOR COURT OF NEW JERSEYCHANCERY DIVISION COUNTY PROBATE PART In the Matter of TYPE INCAPACITATED PERSON’S NAME An Alleged Incapacitated Person Docket No. CIVIL ACTION NOTICE OF PENDING HEARING, RIGHT TO APPEAR AND RIGHT TO REQUEST A JURY TRIAL TO: Be advised that a verified complaint has been filed with the New Jersey \ Superior Court, Chancery Division, Probate Part seeking to have you declared to b\ e an incapacitated person and have a guardian appointed. If a guardian is ap\ pointed, you could lose your individual rights. The matter has been set down for a hearing on \ at a.m./p.m. in the \ County Court House, , New Jersey. You have the right to be present in court. You have the right to be re\ presented by an attorney of your own choosing. You may appear in person or through l\ egal counsel to oppose the relief sought. You have the right to demand a trial by jury.\ If either you or the attorney appointed for you do not dispute the need \ for a guardianship or the fitness of the proposed guardian, and if you do not \ request a plenary hearing, the court may summarily appoint \ as guardian(s) without the necessity of a hearing. Date: Date: ________________________________________ ____________________________________________ Signature of Plaintiff Signature of Plaintiff Type Name Type Name 25FORM G PROOF OF SERVICE Pro Se Plaintiff(s) TYPE YOUR NAME (s) Address: Telephone Number: SUPERIOR COURT OF NEW JERSEYCHANCERY DIVISION COUNTY PROBATE PART In the Matter of TYPE INCAPACITATED PERSON’S NAME an Alleged Incapacitated Person Docket No. CIVIL ACTION PROOF OF SERVICE 1. I, \ , of full age, hereby certify and say: 2. On \ , I personally served \ , the alleged incapacitated person, at \ with copies of the following documents regarding the above captioned matter: A.Verified Complaint B. Division of Development Disabilities Official’s Certification C. (Check one) Physician’s Certification or Psychologist’s Certification D. Order for Hearing E. Notice of Pending Hearing, Right to Appear and Right to Request a Jury Trial. 3. The alleged incapacitated person has been afforded the opportunity to appear personally or through an attorney in this matter, and he/she has \ been given or afforded assistance to communicate with friends, relatives or attorneys \ concerning this matter. 26 4. On , I served a copy\ of the Verified Complaint, DDD official’s Certification, (check one) Physician’s C\ ertification or Psychologist’s Certification and Order for Hearing by certified maile\ d, return receipt requested, and regular mail on: Name Address Date Served 5. Copies of all return receipt cards for certified mail are attached. I hereby certify that the statements made by me are true. I am aware th\ at if any are wilfully false, I am subject to punishment. Date: ____________________________________ signature type name 2002 Surrogates CLICK HERE TO RETURN TO FO\ RM Atlantic County Surrogate 1201 Bacharach Blvd. Atlantic City, NJ 08402 Bergen County Surrogate Justice Center 10 Main Street Hackensack, NJ 07601-7691 Burlington County Surrogate Court Complex, First Floor 49 Rancocas Road Mount Holly, NJ 08060-1827 Camden County Surrogate Hall of Justice 101 South Fifth Street Camden, NJ 08103-4001 Cape May County Surrogate 4 Moore Road Cape May Court House, NJ 08210 Cumberland Co. Surrogate Cumberland County Courthouse 60 West Broad Street Bridgeton, NJ 08302 Essex County Surrogate 206 Hall of Records 469 Dr. MLK, Jr. Boulevard Newark, NJ 07102 Gloucester County Surrogate Surrogate's Building P. O. Box 177 Woodbury, NJ 08096-7177 Hudson County Surrogate 107 Administration Building 595 Newark Avenue Jersey City, NJ 07306 Hunterdon County Surrogate Hunterdon County Justice Center 65 Park Avenue, PO Box 2900 Flemington, NJ 08822-2900 Mercer County Surrogate Mercer County Courthouse 175 South Broad Street, P O Box 8068 Trenton, NJ 08650-0068 Middlesex County Surrogate Administration Building, First Floor 75 Bayard Steet New Brunswick, NJ 08903 Monmouth County Surrogate Hall of Records 1 East Main Street, PO Box 1265 Freehold, NJ 07728-1265 Morris County Surrogate Administration & Records Building P.O. Box 900 Morristown, NJ 07963-0900 Ocean County Surrogate Ocean County Courthouse 118 Washington Street, P O Box 2191 Toms River, NJ 08754 Passaic County Surrogate Passaic County Old Courthouse 71 Hamilton Street Paterson, NJ 07505-2018 Salem County Surrogate Salem County Courthouse 92 Market Street Salem, NJ 08079-9856 Somerset County Surrogate Administration Building 20 Grove Street, P O Box 3000 Somerville, NJ 08876-1262 Sussex County Surrogate 4 Park Place Newton, NJ 07860-1795 Union County Surrogate Union County Courthouse 2 Broad Street, 2nd floor Elizabeth, NJ 07207-6001 Warren County Surrogate Warren County Courthouse 413 Second Street Belvidere, NJ 07823