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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 services 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 initiate

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 named. 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 Disabilities services.

NOTE: These materials have been prepared by the New Jersey Administrative Office 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 rules. 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 responsible for the content

of your court papers.

Click Here for the NJ Surrogates Web Page

Revised 02/01/2002, CN 10558-English

2

THINGS 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

Referral 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.

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3

DEFINITIONS 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 charge incurred for

services provided to persons unable to pay. Typically, this is the alleged incapacitated

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 be 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 alleged

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 Disabilities 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 those 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 person and mailed

to the parties in interest and the attorney appointed to represent the alleged incapacitated

person.

Verified

Complaint: A verified complaint is a document in which you briefly tell the court the facts in your case and

the relief you want the court to grant. This is filed by the plaintiff.

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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

Title 30 requires that one medical

physician or psychologist examine or

evaluate the individual and submit a written

report under oath. A second report under

oath 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

regulations 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

psychologist and the Division of

Developmental Disabilities official’s

affidavits or certifications are filed with the

Surrogate, a hearing date is set to

determine 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.

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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).

++++++

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HOW 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 Certification 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.

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STEP 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

determine 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

certification (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.

++++++

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INSTRUCTIONS 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 you are seeking to be

appointed guardian.

B. In paragraph #2 type or print the name of the person over whom guardianship 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 certification (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 guardianship is sought and indicate

where he/she is receiving services from the New Jersey Division of Developmental 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 sought owns any real or

personal property and his or her monthly income, if any. Type or print any employer’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 training the alleged incapacitated

person attends.

H.

In paragraph #9 type or print the name of the person over whom guardianship is sought. Use the first

paragraph #9A if a plenary (full) guardianship is requested; use the second paragraph #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 limited guardianship is

requested.

J. Sign and date the form where it asks you to do so.

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INSTRUCTIONS FOR FORM B -- PHYSICIAN CERTIFICATION

You must have a New Jersey licensed medical physician or psychologist complete a certification 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.

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 certification 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 guardianship 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 that you are seeking to be

appointed guardian over the alleged incapacitated person and that you need him/her 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 guardianship of the person is sought. If

you seek guardianship of the person and the estate or the public defender 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.

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10

INSTRUCTIONS 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 incapacitated 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 or 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.

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11

FORM A -- VERIFIED COMPLAINT TO APPOINT GUARDIAN

Plaintiff(s) Type your name(s)

Address:

Telephone Number:

SUPERIOR COURT OF NEW JERSEY

CHANCERY 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

, residing 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 incapacitated 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

Revised 02/01/2002, CN 10558-English

Print All Forms

Clear All Forms

12

2. has been diagnosed as suffering from

as shown by the attached affidavit or certification

of (Medical Physician or Psychologist). Because

of this condition, lacks sufficient capacity to

govern himself/herself and manage his/her affairs.

3. has been receiving services from 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 Disabilities 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 (custodian, county

adjuster, DDD program administrator) are as follows:

Name Address Relationship Age

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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

Revised 02/01/2002, CN 10558-English

0.00

14

7. (If applicable) , the alleged incapacitated

person, attends classes at .

8. The alleged incapacitated person does not have an attorney. It is requested that the

court appoint an attorney to serve as legal counsel for the alleged incapacitated person.

9A. Because of ’s condition, he/she is

without the necessary cognitive capacity to understand personal, financial, health and medical

matters that affect his/her well-being and, therefore, he/she lacks the capacity 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 areas:

.

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 chronic

functional impairment and as a result is incapable and unable to govern himself/herself 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/herself and

manage his/her affairs with respect to :

;

Revised 02/01/2002, CN 10558-English

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 aware 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

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16

FORM B -- PHYSICIAN’S CERTIFICATION

Plaintiff(s)

TYPE YOUR NAME(s)

Address:

Telephone Number:

SUPERIOR COURT OF NEW JERSEY

CHANCERY 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 licensed

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 of the mentally ill at which

he/she 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 , 20 .

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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 same 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 decisions 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 of 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 aforementioned

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 subject to punishment.

Date: _______________________________ M.D.

type name

Revised 02/01/2002, CN 10558-English

18

FORM C -- PSYCHOLOGIST’S CERTIFICATION

Plaintiff(s) TYPE YOUR NAME(s)

Address:

Telephone Number:

SUPERIOR COURT OF NEW JERSEY

CHANCERY DIVISION

COUNTY

PROBATE 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 of 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 .

Revised 02/01/2002, CN 10558-English

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 same 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 decisions 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 aforementioned

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

Revised 02/01/2002, CN 10558-English

20

FORM D -- ORDER FOR HEARING

Plaintiff(s)

TYPE YOUR NAME(S)

Address:

Telephone Number:

SUPERIOR COURT OF NEW JERSEY

CHANCERY 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 appropriate 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 issue of the legal

incapacity of and for the determination of the appointment 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.

Revised 02/01/2002, CN 10558-English

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, examine the medical

records, make inquiries of persons having knowledge of the alleged incapacitated person’s

circumstances, make reasonable inquiries to locate any will, powers of attorney or health care

directive previously executed by the alleged incapacitated person and prepare a written report

of findings and recommendations to be filed in court and with the plaintiff(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 either the need for

the guardianship or the fitness of the proposed guardian and the alleged

incapacitated person does not request a plenary hearing.

______________________________________

, J.S.C.

Revised 02/01/2002, CN 10558-English

22

FORM E -- JUDGMENT APPOINTING GUARDIAN

Plaintiff(s) TYPE YOUR NAME(S)

Address:

Telephone Number:

SUPERIOR COURT OF NEW JERSEY

CHANCERY 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 certifications of

, M.D., (or licensed

psychologist) and , Division of Developmental Disabilities official,

and the report of , Esq., and it appearing that

suffers from a chronic functional impairment and that

he/she lacks cognitive capacity and as a result is incapable of governing 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 modified for good cause,

is able at this time to govern himself /herself

and manage his/her own affairs with respect to the following areas:

_______________________________________________________________________

______________________________________________________________________

_____________________________________________________________________.

Revised 02/01/2002, CN 10558-English

Clear form

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 Court 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 decisions

regarding including, but not limited to, the authority to consent or withhold

consent to surgical procedures and such other procedures reasonably attendant thereto, and

all decisions concerning withdrawal or denial of life support shall be exercised 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 duties of

a guardian as allowed by law, except as limited herein or in areas herein above set forth

where retains decision making rights.

5. The Guardian(s) of the Estate may not alienate, mortgage, transfer or otherwise

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 of

, 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 telephone

number of himself or herself and/or the incapacitated person or of the death of the

incapacitated person.

8. shall cooperate fully with any court 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 parties and

attorneys of record within seven (7) days from the receipt hereof.

________________________________________

, J.S.C.

Revised 02/01/2002, CN 10558-English

24

FORM F NOTICE OF PENDING HEARING

Plaintiff(s) TYPE YOUR NAME(s)

Address:

Telephone Number:

SUPERIOR COURT OF NEW JERSEY

CHANCERY 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 be an

incapacitated person and have a guardian appointed. If a guardian is appointed, 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 represented by

an attorney of your own choosing. You may appear in person or through legal 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

Revised 02/01/2002, CN 10558-English

Clear form

25

FORM G PROOF OF SERVICE

Pro Se Plaintiff(s)

TYPE YOUR NAME(s)

Address:

Telephone Number:

SUPERIOR COURT OF NEW JERSEY

CHANCERY 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.

Revised 02/01/2002, CN 10558-English

Clear form

26

4. On , I served a copy of the Verified Complaint,

DDD official’s Certification, (check one) Physician’s Certification or

Psychologist’s Certification and Order for Hearing by certified mailed, 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 that if

any are wilfully false, I am subject to punishment.

Date:

____________________________________

signature

type name

Revised 02/01/2002, CN 10558-English

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