Fill and Sign the Request for Waiver of Personal Appeareance New Form

NHJB-2168-P (03/25/2013) Page 1 of 1 THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) Guardianship of REQUEST FOR WAIVER OF PERSONAL APPEARANCE; WRITTEN STATEMENT (RSA 464- A:8, II ) I/We, , represent that the proposed ward, , does not express a desire to attend the hearing concerning the finding of incapacity and appointment of a guardian of the person and estate, or the person, or estate. Date Petitioner(s) or Counsel for the proposed ward I certify that on this date I provided this document (s) to the parties who have filed an appearance for this case or who are otherwise interested parties by: Hand-delivery OR US Mail OR Email (E-mail only by prior agreement of the parties based on Circuit Court Administrative Order). Date Signature PHYSICIAN'S AFFIDAVIT (RSA 464-A:8,II) I, , M.D., under oath, hereby depose and say: 1. I am a medical physician at , located at . 2. The proposed ward, , is a patient at . 3. In my opinion, the proposed ward should be excused from attending the hearing concerning the finding of incapacity and appointment of a guardian of the person and estate, or the person, or estate, because: his/her overall physical, emoti onal or psychological condition is such that he/she is likely to suffer harm if required to attend; and/or he/she has no ability to understand the natur e and consequences of the proceedings. Date Physician Signature (must be in presence of notarial officer) State of , County of This instrument was acknowledged bef ore me on by Date Physician My Commission Expires Affix Seal, if any Signature of Notarial Officer / Title ORDER REQUEST FOR WAIVER OF PERSONAL APPEARANCE IS: GRANTED DENIED Date Judge