Published 02/2017, CN 11920 (Adult Guardianship CIS)
Instructions for Completing the Adult Guardianship
Case Information Statement
The Adult Guardianship Case Information Statement (CIS) is a one-page form that provides certain basic information
about your application. You must complete all of this form except for the area in the upper right corner labeled “For
Chambers or Surrogate’s Office Use Only.” Please leave that field blank.
Follow these instructions to complete the CIS:
1. In the boxes under Plaintiff, fill in your information as the plaintiff, that is, the party applying to have a guardian
appointed. Include your full name, street address, city, state, zip, age, telephone number (including area code), and
relationship to the individual for whom guardianship is being sought.
2. In the boxes under Alleged Incapacitated Person, fill in all information about the person alleged to be incapacitated
and in need of a guardian, which includes their full name, street address, city, state, zip, date of birth and social
security number.
3. Under Case Type, select the check box to indicate the type of guardianship application that is being brought. A Title
30 (DDD) application is one where the alleged incapacitated person is eligible for, or receiving services from, the
Division of Developmental Disabilities (“DDD”). This application type is brought under N.J.S.A. 30:4-165.1, et. seq.
A Title 3B (DD) application is one where the alleged incapacitated person is developmentally disabled, but is not
eligible for or receiving services from DDD. This application type is brought under N.J.S.A. 3B:12-1, et. seq. For all
other applications, select Title 3B (all other).
4. Select the appropriate checkbox as to whether or not you are seeking to be appointed as guardian.
5. Select the appropriate checkbox to indicate if anyone else is proposed to serve as guardian(s).
6. In the section marked All person(s) proposed as guardian(s), print the full name, street address, city, state, zip, age,
phone number (including area code), and relationship to the alleged incapacitated person for each person, or entity,
who is a proposed guardian of the alleged incapacitated person; including yourself. If necessary, attach additional
sheets listing the individuals or entities you seek to have appointed as guardian(s).
7. In the section marked Other person(s) or entities to be noticed, fill in all information for any person(s) or entity(ies) to
be notified of the guardianship application. This must include the County Adjuster in the county where the alleged
incapacitated person has legal settlement. It should also include other relatives of the alleged incapacitated person
including spouse, parents, adult children, and persons of the same relationship to the alleged incapacitated person as
the plaintiff. For example, if you are a sibling of the alleged incapacitated person, then you should list any other
sibling(s). If the application type is Title 30 (DDD), this section must also include the Regional Administrator for the
DDD.
8. If either you, any proposed guardian, or the alleged incapacitated person require an interpreter, check “Yes”,
otherwise, check “No.” If you check “Yes”, indicate for whom the interpreter is needed, and specify the language.
9. If either you, any proposed guardian, or the alleged incapacitated person are requesting any accommodation for a
disability, check “Yes”, otherwise, check “No.” If you check “Yes”, indicate what is needed and by whom.
10. The Adult Guardianship Case Information Statement is not a public document and all information on the form will be
kept confidential. Therefore, all requested information, including any requested personal identifying information,
such as a Social Security number, must be filled out, if known. However, other documents filed with the court may
be public and any confidential personal identifiers should be redacted. The final box of this document contains the
statement by which you certify that you will remove any confidential personal identifiers in future court submissions,
unless such confidential personal identifiers are required by statute, court rule or court order. It also contains a
statement by which you certify that you have completed this form to the best of your knowledge and ability, and that
you will supplement the form as may be necessary should additional information become available. Sign below the
statement.
