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Petition For Adjudication Of Incompetence And Application For Appointment Of Guardian And Interim Guardian SP-200 - North Carolina

Petition For Adjudication Of Incompetence And Application For Appointment Of Guardian And Interim Guardian Form. This is a North Carolina form and can be used in Special Proceedings Statewide .
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File No. STATE OF NORTH CAROLINA In The General Court Of Justice Superior Court Division County Before the Clerk IN THE MATTER OF: PETITION FOR ADJUDICATION OF Name And Address Of Respondent INCOMPETENCE AND APPLICATION FOR APPOINTMENT OF GUARDIAN OR LIMITED GUARDIAN AND INTERIM GUARDIAN County Of Residence Of Respondent Date Of Birth G.S. 35A-1105, -1112, -1114, -1210, -1113Name And Address Of Petitioner Name And Address Of Attorney For PetitionerCounty Of Residence Of Petitioner Telephone No. Of PetitionerTelephone No. Of Petitioners Attorney State Bar No.Petitioners Relationship To Respondent Or Interest In Proceeding Name And Address Of Treatment Facility If Respondent Is An Inpatient Drivers License No. State Respondent Indigent Jury Trial Requested 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. 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. 2. 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.) he/she was adjudicated incompetent in another state in the proceeding identified below. (Attach certified copy of the order from the other state.) Date Of Adjudication State And County File Or Other ID No. (Over) AOC-SP-200, Rev. 6/04 2004 Administrative Office of the Courts <<<<<<<<<********>>>>>>>>>>>>> 2 3.The respondents next of kin, if any, and other persons known to have an interest in this proceeding are: Name And Address Name And Address Telephone No. Telephone No. Relationship To Respondent Or Interest In Proceeding Relationship To Respondent Or Interest In ProceedingName And Address Name And Address Telephone No. Telephone No. Relationship To Respondent Or Interest In Proceeding Relationship To Respondent Or Interest In Proceeding 4. General statement of respondents 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 $ There is a representative payee for government benefits. Yes No Insurance & Compensation $ There is a Durable Power of Attorney in place. Yes No Other (including SSI/SSDI) $ There is a special needs or other trust in place. Yes No 5. CAPACITY INFORMATION Check here if in a coma, persistent vegetative state, or non-responsive and move on to Item 6. 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: AOC-SP-200, Side Two, Rev. 6/04 2004 Administrative Office of the Courts <<<<<<<<<********>>>>>>>>>>>>> 3 File No. IN THE MATTER OF Name Of Respondent 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 personl 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: 6. RECOMMENDED GUARDIAN(S) Name And Address Of Proposed Guardian Name And Address Of Proposed Guardian Of The Estate Of The Person General Guardian Of The Estate Of The Person General Guardian 7. MOTION FOR APPOINTMENT OF INTERIM GUARDIAN NOTE: Do not complete unless an emergency requires immediate intervention. 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 respondents interest. (Set forth facts, in addition to those above, which demonstrate need for immediate intervention. Be specific.) VERIFI
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