Fill and Sign the Note to Petitioner If You Are Petitioning the Court to Form

STATE OF NORTH CAROLINA CountyFile No. Full Name Of Respondent Telephone No. Of Respondent (Over) In The General Court Of Justice Superior Court DivisionBefore The Clerk PETITION FOR ADJUDICATION OF INCOMPETENCE AND APPLICATION FOR APPOINTMENT OF GUARDIANOR LIMITED GUARDIAN AND INTERIM GUARDIAN IN THE MATTER OF Address Of Respondent The undersigned, being duly sworn, requests that the Court, after notice and hearing, adjudicate the respondent above to be incompetent, and also applies for the appointment of the person(s) named below to serve, in the capacity indicated, as guardian(s) of the respondent. In support of this Petition, the undersigned states: 1. During the past twelve (12) months, the above-named respondent was physically present as follows: Period of Physical Presence (include up to the 12 months prior to the �ling date of the petition; do not list periods of temporary absence) From To Present Location (County, State, and Country) Type of Proceeding File Number 2. (check a. or check and complete b.) (NOTE: In both a. and b., “state” includes a state of the United States, the District of Columbia, Puerto Rico, the United States Virgin Islands, a federally recognized Indian tribe, or any territory or insular possession subject to the jurisdiction of the United States. ) a. There is no other pending proceeding involving the respondent in any court or agency of a state or foreign country. b. There is a pending proceeding(s) involving the respondent in the court or agency of a state or foreign country, as set forth below: 3. A North Carolina court has jurisdiction to rule on this petition and application. 4. The respondent is a resident of this county. domiciled in this county. an inpatient in the facility named above. present in this county, it being impossible to determine his/her county of residence or domicile. G.S. 35A-1105, -1112, -1114, -1210; 35B-17, -18 Name And Address Of Attorney For Petitioner Telephone No. Of Petitioner’s Attorney Name And Address Of Treatment Facility If Respondent Is An Inpatient State Bar No. Name And Address Of Petitioner County Of Residence Of Petitioner Petitioner’s Relationship To Respondent Or Interest In ProceedingRespondent’s Drivers License No. State Telephone No. Of Petitioner Respondent Indigent County Of Residence Of Respondent Date Of Birth Race* Sex* * Race and sex are collected so that this information may be transmitted to NICS in the event of a qualifying adjudication under G.S. 14-409.43(a)(6). Address NOTE TO PETITIONER: If you are petitioning the court to accept guardianship on transfer from another state, this is not an appropriate form to use. AOC-SP-200, Rev. 12/17 © 2017 Administrative Of�ce of the Courts (Over) 6. The respondent’s next of kin, if any, and other persons known to have an interest in this proceeding are: Name And Address Name And Address Name And Address Telephone No. Telephone No. Relationship To Respondent Or Interest In Proceeding Relationship To Respondent Or Interest In Proceeding Relationship To Respondent Or Interest In Proceeding Relationship To Respondent Or Interest In Proceeding Name And Address Telephone No. Telephone No. 7. General statement of respondent’s assets and liabilities, including any income and receivables to which he/she is entitled: Assets Liabilities Income and Receivables Real Property $ Mortgage Loans $ Wages & Salaries $ Tangible Personal Property $ Other Secured Loans $ Rents $ Other Personal Property $ Unsecured Loans $ Pensions $ Allowances $ Insurance & Compensation $ Other (including SSI/SSDI) $ There is a representative payee for government bene�ts. Yes No There is a Durable Power of Attorney in place. Yes No There is a Healthcare Power of Attorney in place. Yes No There is a special needs or other trust in place. Yes No The respondent has health insurance through Medicaid, Yes No Medicare, or a private insurer. 5. The respondent is incompetent in that he/she lacks sufficient capacity to manage his/her own affairs or to make or communicate important decisions concerning his/her person, family, or property, as shown by the following facts: (Set forth the facts which tend to show that the respondent is incompetent. Include cause of incompetence, which may be mental illness, mental retardation, epilepsy, cerebral palsy, autism, inebriety, senility, disease, injury, or other cause and give facts demonstrating lack of capacity. Be specific.) AOC-SP-200, Side Two, Rev. 12/17 © 2017 Administrative Of�ce of the Courts File No. IN THE MATTER OF Name Of Respondent Check here if in a coma, persistent vegetative state, or non-responsive and move on to Item 9. A. Language and Communication (understands/participates in conversations, can read and write, understands signs such as “keep out,” “men,” “women”) has capacity. lacks capacity. Comment: B. Nutrition (makes independent decisions re: eating, prepares food, purchases food) has capacity. lacks capacity. Comment: C. Personal Hygiene (bathes, brushes teeth, uses proper hygiene when using the restroom) has capacity. lacks capacity. Comment: D. Health Care (makes and communicates choices re: medical treatment/caregivers, notifies others of illness, follows medication instructions, reaches emergency health care) has capacity. lacks capacity. Comment: E. Personal Safety (recognizes danger and seeks assistance as needed, protects self from exploitation/personal harm) has capacity. lacks capacity. Comment: F. Residential (makes and communicates decisions re: residence/roommates, maintains safe shelter) has capacity. lacks capacity. Comment: G. Employment (makes and communicates decisions re: employment, demonstrates vocational skills such as neatness and punctuality, writes or dictates application form) has capacity. lacks capacity. Comment: H. Independent Living (follows a daily schedule, conducts housekeeping chores, uses community resources such as bank, store, post office) has capacity. lacks capacity. Comment: I. Civil (knows to contact advocate if being exploited, understands consequences of committing a crime, registers to vote) has capacity. lacks capacity. Comment: J. Financial 1. Makes and communicates decisions about paying bills and spending discretionary money, and makes change for $1, $5, and $20 has capacity. lacks capacity. Comment: 2. Makes and communicates decisions regarding management of a personal bank account, savings, investments, real estate, and other substantial assets has capacity. lacks capacity. Comment: 3. Can resist attempts at financial exploitation by others has capacity. lacks capacity. Comment: (Over) 8. CAPACITY INFORMATION AOC-SP-200, Page Two, Rev. 12/17, © 2017 Administrative Of�ce of the Courts I, the undersigned petitioner, have read this Petition and state that its contents are true to my own knowledge except those matters stated on information and belief, which I believe are true. VERIFICATION Date SWORN/AFFIRMED AND SUBSCRIBED TO BEFORE ME Date Date My Commission Expires Signature Of Petitioner Signature Of Person Authorized To Administer Oaths Deputy CSC Assistant CSC Clerk Of Superior Court County Where Notarized Notary SEAL Name And Address Of Recommended Guardian Name And Address Of Recommended Guardian 9. RECOMMENDED GUARDIAN(S) NOTE: Do not complete unless an emergency requires immediate intervention. Do not complete if basis for the petition is special jurisdiction as set forth in G.S. 35B-18. Interim guardian appointment is not available in cases of special jurisdiction. The petitioner also moves that the Court appoint an interim guardian because there is reasonable cause, as shown by the following facts, to believe that the respondent is incompetent and needs an interim guardian to intervene on his/her behalf prior to the adjudication hearing in that: (Check all that apply) he/she is in a condition that constitutes or reasonably appears to constitute an imminent or foreseeable risk of harm to his/her physical well-being and requires immediate intervention. there is or reasonably appears to be an imminent or foreseeable risk of harm to his/her estate that requires immediate intervention in order to protect the respondent’s interest. (Set forth facts, in addition to those above, which demonstrate need for immediate intervention. Be specific.) 10. MOTION FOR APPOINTMENT OF INTERIM GUARDIAN Of The Estate Of The Estate Of The Person Of The Person General Guardian General Guardian AOC-SP-200, Page Two, Side Two, Rev. 12/17 © 2017 Administrative Of�ce of the Courts