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IN THE CIRCUIT COURT OF COUNTY, WEST VIRGINIA (West Virginia Supreme Court of Appeals)

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BROWSE WEST VIRGINIA SUPREME COURT OF APPEALS (WV) FORMS

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IN THE CIRCUIT COURT OF _______________ COUNTY, WEST VIRGINIA
For Clerk’s Use Only
IN RE: ___________________________________________ CASE NUMBER ___________ - G - __________
AN ALLEGED PROTECTED PERSON
AFFIDAVIT OF PHYSICIAN
[West Virginia Code: § 44A-2-9(c)]
STATE OF _________________________________,
COUNTY OF ______________________________, to-wit:
This day, personally appeared before me the undersigned physician who, having been first duly sworn,
says, represents and certifies as follows:
I, _______________________________________________, a licensed physician in the State of
____________________________, hereby certify that I have examined and/or evaluated the condition of
[insert name of alleged protected person here] _______________________________________________,
and that in my expert opinion, this individual cannot attend the hearing addressing whether a guardian or
conservator should be appointed for this individual for the following reasons [check applicable reasons and
provide supporting facts in spaces provided and attach additional pages, if necessary]:
__________ The presence of the individual is not possible due to a physical inability. The basis for this
opinion is as follows:____________________________________________________________
_____________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
__________ Requiring the presence of the individual would significantly impair the individual's
health.
Explain :________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
C CL GC2010 Form 5 / SCA-GC 902A AFFIDAVIT OF PHYSICIAN-Page 1 of 2
C CL GC2010 Form 5 / SCA-GC 902A AFFIDAVIT OF PHYSICIAN-Page 2 of 2
__________ Other Reason(s):__________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Given under my hand this ________ day of ______________________[month[, _______[year].
______________________________________
SIGNATURE OF PHYSICIAN
The foregoing affidavit was taken, subscribed and sworn to before me by the said
_______________________________________, in my said County and State on this, the ________ day
of __________________________[month], _________[year].
Given under my hand and NOTARIAL SEAL
[AFFIX NOTARIAL SEAL]
__________________________________________
NOTARY PUBLIC
My Commission Expires: ____________________________
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IN THE CIRCUIT COURT OF COUNTY, WEST VIRGINIA (West Virginia Supreme Court of Appeals)

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Completed 25 July 2020

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