Fillable Purpose t dates; on sical harm; t is (Family Law Self Help Center)

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Purpose t dates; on sical harm; t is (Family Law Self Help Center)

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Case Number: _________________________
(to be assigned by the Clerk’s Office)
Nevada AOC – Research & Statistics Unit Revised 03/2019
Pursuant to NRS 3.275
CLARK COUNTY, NEVADA
FAMILY COURT COVER SHEET
PARTIES:
Plaintiff/Petitioner Defendant/Respondent/Co-Petitioner/Protected Person
Last Name: Last Name:
First Name: Middle Name: First Name: Middle Name:
Mailing Address: Mailing Address:
City, State, Zip: City, State, Zip:
Phone #: Date of Birth: Phone #: Date of Birth:
Email Address: Email Address:
Attorney Information not applicable Attorney Information not applicable
Name: Bar No. Name: Bar No:
Address: Address:
City, State, Zip: City, State, Zip:
Phone #: Phone #:
CASE TYPE: (Check only one box only for the primary type of case you are filing)
DISSOLUTION
MISC. DOMESTIC RELATIONS
PETITIONS
GUARDIANSHIP OTHER
Annulment
Divorce –No minor child(ren)
Divorce –With minor child(ren)
Foreign Decree
Joint Petition –No minor child(ren)
Joint Petition – With minor child(ren)
Separate Maintenance
Adoption –Minor
Adoption –Adult
Child Custody (non-divorce)
Child Support (private party)
Mental Health
Name Change
Paternity
Permission to Marry
Temporary Protective Order (TPO)
Termination of Parental Rights
(private party)
Termination of Parental Rights
(State initiated)
Visitation (non-divorce)
Other (identify) __________________
Guardianship of an Adult
Person
Estate
Person and Estate
Guardianship of a Minor
Person
Estate
Person and Estate
Guardianship Trust
DA Child Support
DA – UIFSA
DA – Child Support In State
DA Child Dependency
DA – Abuse/Neglect
DA – No Fault
DA – Other (identify)
__________________
Juvenile
Emancipation
CHILDREN INVOLVED IN THIS CASE (if applicable)
Last Name First Name Middle Name Date of Birth Relationship
1.
2.
3.
4.
5.
6.
7.
8.
Does this family have any other current or past case(s) in the Clark County Family Court or Juvenile Court?
YES NO
_________________________________ __________________________________ ________________
Your Printed Name Your Signature Date
/s/
© 2018 Nevada Supreme Court
Page 1 of 2 – Confidential Information Sheet (Adult)
COURT CODE: CISG
Your Name:
Address:
City, State, Zip:
Telephone:
Email Address:
Self-Represented
DISTRICT COURT
CLARK COUNTY, NEVADA
In the Matter of the Guardianship of the:
Person
Estate
Person and Estate
of:
_
___________________________________
(name of adult alleged to need a guardian)
A Proposed Protected Person.
CASE NO.: ____________________
DEPT: ____________________
CONFIDENTIAL INFORMATION SHEET – GUARDIANSHIP
First Guardian (full legal name): __________________________________________________
Identification Attached (check one and attach a copy):
Social Security Number
Valid Driver’s License Number
Valid ID Card Number
Valid Passport Number
Taxpayer Identification
Number
Valid Tribal Identification Card
Number
Second Guardian (full legal name, or “n/a” if none): ___________________________________
Identification Attached (check one and attach a copy):
Social Security Number
Valid Driver’s License Number
Valid ID Card Number
Valid Passport Number
Taxpayer Identification
Number
Valid Tribal Identification Card
Number
Adult (name of adult who needs a guardian): ________________________________________
Identification Attached (check one and attach a copy):
Social Security Number
Valid Driver’s License Number
Valid ID Card Number
Valid Passport Number
Taxpayer Identification
Number
Valid Tribal Identification Card
Number
Page 2 of 2 – Confidential Information Sheet (Adult)
Placement Of Adult: Location Of Guardian(s):
Independently
With Guardian
Family/Friends
Host Family
Supportive Adult Residence / Assisted Living
Skilled Nursing Home
Licensed Group Home
Secured Facility
Out of State
Other
Nevada
Other State (list): _____________________
Proposed Guardian(s) Relationship to the
Adult:
Relative
Public Guardian
Private: License Number: ___________
Other
Adult’s Gender: Adult’s Date Of Birth:
Male
Female
Date of Birth: _______________________
Submitted by:
(Attach copies of the identification indicated for each guardian and the adult)
(Signature)
(Printed Name)
/s/
© 2018 Nevada Supreme Court
Page 1 of 13 – Petition for Appointment of Guardian Including Temporary Guardianship (Adult)
COURT CODE: PTGD
Your Name:
Address:
City, State, Zip:
Telephone:
Email Address:
Self-Represented
DISTRICT COURT
CLARK COUNTY, NEVADA
In the Matter of the Guardianship of:
Person
Estate
Person and Estate
of:
_
___________________________________
(name of adult who needs a guardian)
A Proposed Protected Person.
CASE NO.: ____________________
DEPT: ____________________
PETITION FOR APPOINTMENT OF GUARDIAN(S) OVER ADULT
INCLUDING REQUEST FOR TEMPORARY GUARDIANSHIP
Petitioner(s) (first petitioner’s name) _____________________________________ and
(second petitioner’s name; or “n/a” if only one) ______________________________________
request the Court approve a guardianship for the above-named adult. In accordance with
Chapter 159 of the Nevada Revised Statutes, Petitioner(s) respectfully represents the following
to this Honorable Court:
Information Regarding the Proposed Protected Person
(the person you are seeking a guardianship over, or the “adult”)
1. Adult’s full legal name: ____________________________________________________.
2. Adult’s date of birth: ___________________________; current age: _______.
3. Address. Adult’s residence address:
___________________________________________________
Address
___________________________________________________
City, State, Zip Code
Page 2 of 13 – Petition for Appointment of Guardian Including Temporary Guardianship (Adult)
Adult’s mailing address (if different than residence address):
___________________________________________________
Address
___________________________________________________
City, State, Zip Code
4. Residency. The adult named above has been a resident of the State of (state)
_____________________ since (date) ______________ and has lived at the above
address since (date) ______________.
5. Caretaker. The adult in need of a guardianship is currently under the care of:
___________________________________________________
Name
___________________________________________________
Address
___________________________________________________
City, State, Zip Code
The care provider above is caring for the adult because:
________________________________________________________________________
________________________________________________________________________
6. Medicaid. Does the adult receive Medicaid, or has the adult ever received Medicaid?
( check one)
Yes
No
7. Immediate Need. ( check one and complete)
The adult needs immediate medical attention, specifically (explain) _____________
___________________________________________________________________
but cannot obtain the necessary medical care because (explain)
The adult cannot respond to a substantial and immediate risk of physical harm,
specifically (explain) __________________________________________________
___________________________________________________________________
Page 3 of 13 – Petition for Appointment of Guardian Including Temporary Guardianship (Adult)
but is unable to respond to the risk of harm because (explain)
The adult is facing a substantial and immediate risk of financial harm, specifically
(explain) ___________________________________________________________
___________________________________________________________________
but is unable to respond to the risk of harm because (explain)
8. Need for Permanent Guardianship. The adult needs a guardian because (explain why/if a
guardian will be needed after the current emergency is over):
_________________________________________________________________________
_________________________________________________________________________
________________________________________________________________________.
9. Alternatives. What less restrictive alternatives have been tried before filing this request?
( check all that apply)
Supported Decision Making Agreement
Power of Attorney
Power of Attorney for People with Intellectual Disabilities
Representative Payee Designation
Microboard / Circle of Friends
Other: _____________________________________________________________
Explain why the items marked above are not working:
10. Powers Requested. If appointed, what specific powers, if any, would the guardian need?
(explain if the guardian will need the ability to manage investments, loans, handle business
transactions, sell property, etc.)
_________________________________________________________________________
_________________________________________________________________________
Page 4 of 13 – Petition for Appointment of Guardian Including Temporary Guardianship (Adult)
11. Voting Rights: ( check one)
The adult should keep his/her right to vote.
The adult does not have the mental capacity to vote because he/she cannot
communicate, with or without accommodations, a specific desire to participate in
the voting process.
12. Firearms/Guns: ( check one)
The adult should be allowed to possess a firearm.
The adult should not be allowed to possess a firearm. The adult is a danger to
him/herself or others because of a mental condition, or the adult does not have the
capacity to contract or manage his/her own affairs because of a mental condition.
13. Driving: ( check one)
The adult should be allowed to drive.
The adult should not be allowed to drive.
14. The adult ( check one) is is not a party to any pending criminal or civil lawsuit.
Explain if the adult is a party to litigation:
________________________________________________________________________
________________________________________________________________________
15. This guardianship ( check one) is is not sought for the purpose of initiating a
lawsuit. Explain if guardianship is sought to initiate lawsuit:
________________________________________________________________________
________________________________________________________________________
16. Abuse/Neglect Report: ( check one)
The guardianship IS NOT requested because of an investigation of abuse,
neglect, exploitation, isolation or abandonment of the adult.
The guardianship IS requested because of an investigation of abuse, neglect,
exploitation, isolation or abandonment of the adult. The investigating agency is
(name of agency) _________________________________, which is ( check
one) law enforcement a state agency a county agency.
Page 5 of 13 – Petition for Appointment of Guardian Including Temporary Guardianship (Adult)
17. Documents. The adult executed the following documents, copies of which will be filed
with this Petition: ( check all that apply)
Written nomination of guardian. The nominated guardian is (name of person
nominated to serve as guardian) __________________________________________
_____________________________________________________________________.
NOTICE: The Court will check the Nevada Secretary of State Lockbox to determine if
a guardian has already been designated by the proposed protected person.
Durable power of attorney for financial matters. The agent is ____________________
_____________________________________________________________________
Durable power of attorney for health care. The agent is _________________________
_____________________________________________________________________
Revocable or living trust. The agent is ______________________________________
_____________________________________________________________________
None of the above.
Unknown if the adult has executed any of the above documents.
*Copies of any of the above should be submitted confidentially to the Court for review.
18. Assets. The value of the proposed person’s assets is estimated at: ( check one)
Less than $10,000. If the guardianship is granted, the court should treat this case as
“summary administration” and not require annual accountings or a final accounting.
More than $10,000.
Information Regarding the Petitioner
19. Full legal name: ______________________________________________________.
20. Date of birth: ___________________________; current age: _______.
21. Relationship to adult in need of a guardian: _____________________________________.
If you are the spouse, the date of marriage was: (date) ____________________________.
22. Residence address:
___________________________________________________
Address
___________________________________________________
City, State, Zip Code
Page 6 of 13 – Petition for Appointment of Guardian Including Temporary Guardianship (Adult)
Mailing address (if different than residence address):
___________________________________________________
Address
___________________________________________________
City, State, Zip Code
23. Nomination of Guardian: ( check one)
I want to be the guardian over the adult. I am competent and capable of acting as
guardian of the proposed protected person and consent to act in this capacity.
I do not want to be the guardian. Instead, the Court should appoint (insert name)
_________________________________________ to be the guardian over the adult.
(if you selected this option, skip ahead to #32)
24. If you do not live in the State of Nevada: ( check one)
A person or care provider in this State is providing continuing care and supervision
for the adult;
The adult is in a secured residential long-term care facility in this State;
The guardian will move to the State of Nevada within 30 days of appointment; or
The proposed protected person will move to the guardian’s state of residence within
30 days of appointment.
[NOTE: If a nonresident is appointed as guardian for an adult, the guardian must designate
a registered agent in the State of Nevada in the same manner as a represented entity
pursuant to Nevada Revised Statutes Chapter 77.]
25. Qualifications. (Answer each item listed; “Has” answers must be explained)
The Petitioner: ( check one for each)
has has not been convicted of a crime of moral turpitude, a crime involving
domestic violence or a crime involving the abuse, neglect,
exploitation, isolation or abandonment of a child, his or her spouse,
his or her parent or any other adult.
Explain if Yes: ___________________________________________
________________________________________________________
has has never been convicted of a felony.
Explain if Yes: Petitioner was convicted of (describe conviction)
________________________________________________________
Petitioner ( check one) □ was / □ was not placed on parole and (
check one) □ was / □ was not placed on probation for that felony.
Page 7 of 13 – Petition for Appointment of Guardian Including Temporary Guardianship (Adult)
has has never been suspended for misconduct or disbarred from the practice of law,
the practice of accounting or any other profession which involves the
management or sale of money, investments, securities or real property
and requires licensure in Nevada or any other state.
Explain if Yes: ___________________________________________
________________________________________________________
has has not filed for bankruptcy within the past 7 years.
is is not a party to pending criminal or civil litigation.
Explain if Yes: ___________________________________________
________________________________________________________
Information Regarding the Co-Petitioner
□ Not Applicable (check if there is only one proposed guardian, and go to #33)
26. Full legal name: ______________________________________________________.
27. Date of birth: ___________________________; current age: _______.
28. Relationship to adult in need of a guardian: _____________________________________.
If you are the spouse, the date of marriage was: (date) ____________________________.
29. Residence address:
___________________________________________________
Address
___________________________________________________
City, State, Zip Code
Mailing address (if different than residence address):
___________________________________________________
Address
___________________________________________________
City, State, Zip Code
30. Nomination of Guardian: ( check one)
I want to be the guardian over the adult. I am competent and capable of acting as
guardian of the proposed protected person and consent to act in this capacity.
I do not want to be the guardian. Instead, the Court should appoint (insert name)
_________________________________________ to be the guardian over the adult.
(if you selected this option, skip ahead to #32)
Page 8 of 13 – Petition for Appointment of Guardian Including Temporary Guardianship (Adult)
31. If you do not live in the State of Nevada: ( check one)
A person or care provider in this State is providing continuing care and supervision
for the adult;
The adult is in a secured residential long-term care facility in this State;
The guardian will move to the State of Nevada within 30 days of appointment; or
The proposed protected person will move to the guardian’s state of residence within
30 days of appointment.
[NOTE: If a nonresident is appointed as guardian for an adult, the guardian must designate
a registered agent in the State of Nevada in the same manner as a represented entity
pursuant to Nevada Revised Statutes Chapter 77.]
32. Qualifications. (Answer each item listed; “Has” answers must be explained)
The Co-petitioner: ( check one for each)
has has not been convicted of a crime of moral turpitude, a crime involving
domestic violence or a crime involving the abuse, neglect,
exploitation, isolation or abandonment of a child, his or her spouse,
his or her parent or any other adult.
Explain if Yes: ___________________________________________
________________________________________________________
has has never been convicted of a felony.
Explain if Yes: The Petitioner was convicted of (describe conviction)
________________________________________________________
The Petitioner ( check one) □ was / □ was not placed on parole and
( check one) □ was / □ was not placed on probation for that felony.
has has never been suspended for misconduct or disbarred from the practice of law,
the practice of accounting or any other profession which involves the
management or sale of money, investments, securities or real property
and requires licensure in Nevada or any other state.
Explain if Yes: ___________________________________________
________________________________________________________
has has not filed for bankruptcy within the past 7 years.
is is not a party to pending criminal or civil litigation.
Explain if Yes: ___________________________________________
________________________________________________________
33. Co
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Page 10 of 13 – Petition for Appointment of Guardian Including Temporary Guardianship (Adult)
I did not notify the following relatives about the temporary guardianship because
the adult would be at immediate risk of physical, emotional and/or financial
harm if notice was provided before the court determines whether to appoint the
temporary guardian (list the people you did not notify because it would put the adult
in danger):
Name of Person Not
Notified
Reason You Did Not Notify
**You must notify the people above within 48 hours if you are appointed a
temporary guardian.**
I did not notify the following relatives about the temporary guardianship because it
is not feasible/practical to notify them at this time (list any relatives you did not
notify because you cannot or do not know where to find them):
Name of Person Not
Notified
Reason You Did Not Notify
**If you find the people above, you must notify them within 48 hours of finding
them. If you can’t find them, you will need to request the judge’s permission to
waive service on these people, or to serve them by publishing a notice in a
newspaper instead.**
Page 11 of 13 – Petition for Appointment of Guardian Including Temporary Guardianship (Adult)
35. I understand that if I am appointed a temporary guardian:
The court will set a hearing within 10 days to decide whether to extend the
temporary guardianship.
I will have to attempt in good faith to notify the adult’s relatives and any other
required person of the temporary guardianship and the hearing to extend the
temporary guardianship. If I do not, the court can terminate the guardianship.
The court can extend the temporary guardianship only if there is clear and
convincing evidence that the adult still needs a temporary guardian. If extended,
the guardianship usually can only be extended for two 60-day periods.
36. Certificate of Incapacity must be filed showing the need for a guardianship over the
proposed protected person. For a temporary guardianship, the certificate must show that the
proposed protected person faces an immediate and substantial risk of physical or financial
harm, or needs immediate medical attention, and is unable to respond to the risk of harm or
obtain the medical care. The certificate must be completed and signed by one of the
following:
A physician who is licensed to practice medicine in this State or who is
employed by the Department of Veterans’ Affairs;
A governmental agency in this State which conducts investigations; or
Any other person whom the court finds qualified to execute a certificate.
37. Confidential Information Sheet – Guardianship must be completed and filed. You must
provide at least one form of identification (listed on the sheet) for each person.
38. Plan of Care must be completed and filed within 60 days of being appointed the guardian.
39. Monthly Budget must be completed and filed if you are requesting guardianship over the
adult’s estate.
40. Exhibit A: List of All of the Adult’s Relatives must be completed and attached to
petition.
Page 12 of 13 – Petition for Appointment of Guardian Including Temporary Guardianship (Adult)
41. Exhibit B: Information Regarding the Adult’s Estate must be completed and attached to
petition if you are requesting guardianship over the adult’s estate. If you are appointed the
Guardian, the Court will determine how to safeguard the protected person’s funds. The
Court will decide whether to:
Require the funds to be placed into a blocked account.
Require you to obtain a bond in an amount equal to the total amount of the
proposed protected person’s liquid assets.
42. Attach any other documentation that supports your request for guardianship.
43. Other: In addition to the above, the Court should also consider (explain anything else the
judge should know when considering your request for guardianship):
Petitioner(s) requests that this guardianship be granted, that the relief requested be
granted as stated herein, and for such other and further relief as the Court may deem just and
proper.
DATED (month) ________________________ (day) _______, 20___.
(Second Petitioner’s Signature)
(Printed Name)
(First Petitioner’s Signature)
(Printed Name)
/s/
/s/
Page 13 of 13 – Petition for Appointment of Guardian Including Temporary Guardianship (Adult)
VERIFICATION
I, (name of first petitioner) ________________________________________, declare
that I am the Petitioner in the within action; that I have read the foregoing Petition For
Appointment of Guardians and know the contents thereof; that the same is true of my
knowledge except as to those matters therein stated upon information and belief and as to those
matters, I believe them to be true.
I declare under penalty of perjury under the law of the State of Nevada that the
foregoing is true and correct.
__________________________________________
FIRST PETITIONER’S SIGNATURE
VERIFICATION
I, (name of second petitioner) ________________________________________, declare
that I am the Co-Petitioner in the within action; that I have read the foregoing Petition For
Appointment of Guardians and know the contents thereof; that the same is true of my
knowledge except as to those matters therein stated upon information and belief and as to those
matters, I believe them to be true.
I declare under penalty of perjury under the law of the State of Nevada that the
foregoing is true and correct.
__________________________________________
SECOND PETITIONER’S SIGNATURE
/s/
/s/
EXHIBIT A: List All of the Adult’s Relatives
Spouse:
Name: ____________________________
Address: __________________________
____________________________
□ Address Unknown □ Deceased
Parents:
Name: ____________________________
Address: __________________________
____________________________
□ Address Unknown □ Deceased
Name: ____________________________
Address: __________________________
____________________________
□ Address Unknown □ Deceased
Brothers and Sisters:
Name: ____________________________
Address: __________________________
____________________________
□ Address Unknown □ Deceased
Name: ____________________________
Address: __________________________
____________________________
□ Address Unknown □ Deceased
Name: ____________________________
Address: __________________________
____________________________
□ Address Unknown □ Deceased
Grandparents:
Name: ____________________________
Address: __________________________
____________________________
□ Address Unknown □ Deceased
Name: ____________________________
Address: __________________________
____________________________
□ Address Unknown □ Deceased
Children:
Name: ____________________________
Address: __________________________
____________________________
□ Address Unknown □ Deceased
Name: ____________________________
Address: __________________________
____________________________
□ Address Unknown □ Deceased
Name: ____________________________
Address: __________________________
____________________________
□ Address Unknown □ Deceased
Name: ____________________________
Address: __________________________
____________________________
□ Address Unknown □ Deceased
Grandchildren:
Name: ____________________________
Address: __________________________
____________________________
□ Address Unknown □ Deceased
Name: ____________________________
Address: __________________________
____________________________
□ Address Unknown □ Deceased
Grandparents:
Name: ____________________________
Address: __________________________
____________________________
□ Address Unknown □ Deceased
Name: ____________________________
Address: __________________________
____________________________
□ Address Unknown □ Deceased
EXHIBIT B: Information Regarding the Proposed Protected Person’s Estate
Complete this page only if you are requesting guardianship over the estate.
1. The proposed protected person ( check all that apply)
Has no assets or income
Has assets and income (list below)
Is entitled or will be entitled to assets or income (list below)
2. The proposed protected person receives income from the following: (include all income,
including Social Security, Department of Veteran’s Affairs, pensions, etc. If none, write
“N/A”. If there are not enough lines below, write “SEE ATTACHED” and attach a page
with the additional income sources.) (check and answer all that apply)
Social Security Yes No monthly: $_______________________
Veterans Affairs Yes No monthly: $_______________________
a. __________________________________ monthly: $_______________________
b. __________________________________ monthly: $_______________________
c. __________________________________ monthly: $_______________________
3. Is there a Representative Payee receiving benefits on behalf of the proposed protected
person? No Yes, the person is (name) ____________________________________.
4. The proposed protected person’s assets are: (include all assets including checking / savings
/ investment accounts, real estate, vehicles, inheritances, including insurance policies, etc.
If none, write “N/A”. If there are not enough lines below, write “SEE ATTACHED” and
attach a page containing the additional assets.)
a. __________________________________ value: $_______________________
b. __________________________________ value: $_______________________
c. __________________________________ value: $_______________________
d. __________________________________ value: $_______________________
e. __________________________________ value: $_______________________
f. __________________________________ value: $_______________________
g. __________________________________ value: $_______________________
h. __________________________________ value: $_______________________
i. __________________________________ value: $_______________________
You will be required to file a detailed Inventory listing all of the protected person’s assets
within 60 days of your appointment.
© 2018 Nevada Supreme Court
Page 1 of 2 – Citation to Appear and Show Cause (Adult Guardianship)
COURT CODE: CIEI
Your Name:
Address:
City, State, Zip:
Telephone:
Email Address:
Self-Represented
DISTRICT COURT
CLARK COUNTY, NEVADA
In the Matter of the Guardianship of the:
Person
Estate
Person and Estate
of:
_
___________________________________
(name of adult alleged to need a guardian)
A Proposed Protected Person.
CASE NO.: ____________________
DEPT: ____________________
CITATION TO APPEAR AND SHOW CAUSE
TO: (Name of Adult Who Needs a Guardian)
ALL KNOWN RELATIVES OF THE ADULT:
(Write each relative’s name on a separate line)
ANY PERSON HAVING THE CARE, CUSTODY, AND CONTROL OF THE ADULT
DIRECTOR OF THE DEPARTMENT OF HEALTH AND HUMAN SERVICES
DEPARTMENT OF VETERANS AFFAIRS
PLEASE TAKE NOTICE that the following person(s) (proposed guardian’s name)
_____________________________________________ and (proposed co-guardian’s name)
_____________________________________________ petitioned the court to be appointed the
Page 2 of 2 –
Citation to Appear and Show Cause (Adult Guardianship)
guardian(s) of the proposed protected person named above. The proposed guardian(s) may be
awarded the full management, care, and control of the proposed protected person.
The proposed protected person may be determined to be incapacitated or of limited
capacity, and a guardian may be appointed for the proposed protected person.
The rights of the proposed protected person may be affected as specified in the petition.
The proposed protected person has the right to appear at the hearing and to oppose the
petition.
The proposed protected person has the right to be represented by an attorney, who may be
appointed by the court if the proposed protected person is unable to retain one.
At any time after the filing of a Petition to Appoint Guardian, the court may appoint: (1)
an attorney; (2) a guardian ad litem or an advocate; or (3) an investigator, if found to be
appropriate or necessary in the best interest of the proposed protected person.
DATE AND TIME OF COURT APPEARANCE
(the court clerk will fill this out)
YOU ARE DIRECTED TO APPEAR AND SHOW CAUSE why a guardian should
not be appointed for the proposed protected person on the:
_____ day of ____________________, 20____, at _______ □ a.m. □ p.m., at the courthouse of
the 8
th
Judicial District Court, in Courtroom number _____, located at
Regional Justice Center, 200 Lewis Avenue, Las Vegas, NV 89101
Family Court, 601 N. Pecos Rd., Las Vegas, NV 89101
DATED this _____ day of ___________________, 20___.
CLERK OF COURT
BY: ____________________________________
DEPUTY CLERK
NOTE: After filing this document, a neutral person who is not related to anyone in this case must hand-
deliver a copy of this document (with the court date included) plus a copy of the Petition for Appointment
of Guardian to the adult proposed protected person.
The proposed guardian(s) and the proposed protected person (unless excused by a physician) must attend
the scheduled hearing; all other interested parties do not need to attend unless they want to oppose the
guardianship and enter an objection.
© 2018 Nevada Supreme Court
Page 1 of 3 – Order Appointing Temporary Guardian(s) (Adult)
COURT CODE: _____________________
Your Name:
Address:
City, State, Zip:
Telephone:
Email Address:
Self-Represented
DISTRICT COURT
CLARK COUNTY, NEVADA
In the Matter of the Guardianship of the:
Person
Estate
Person and Estate
of:
_
___________________________________
(name of adult who needs a guardian)
A Protected Person.
CASE NO.: ____________________
DEPT: ____________________
ORDER APPOINTING TEMPORARY GUARDIAN(S) OVER ADULT
DATE OF EXPIRATION:
______________
UPON REVIEW of the verified Petition for Appointment of Guardian(s) submitted by
the Petitioners, the same having been reviewed by the Court, and there being good cause to
believe that a temporary guardianship is necessary, and good cause appearing therefore:
THE COURT FINDS that the proposed protected person, (name of adult who needs a
guardian) _________________________________________ faces a substantial and immediate
risk of financial loss or physical harm to which he or she is unable to respond and/or needs
immediate medical attention and will not be afforded such attention unless this temporary
guardianship is issued.
THE COURT FURTHER FINDS that the Court has jurisdiction to enter this order as the
proposed protected person is a resident of the State of Nevada or the proposed protected person
is physically present in the State of Nevada and an emergency requires the appointment of a
temporary guardian.
© 2018 Nevada Supreme Court
Page 2 of 3 – Order Appointing Temporary Guardian(s) (Adult)
THE COURT FURTHER FINDS that Petitioner(s) have made a good faith effort to
contact the proposed protected person’s relatives within the second degree of consanguinity
and/or any other person or agency having the care, custody, and control of the proposed
protected person, or, in the alternative, has/have presented evidence that such contact would put
the welfare of the proposed protected person in jeopardy or is impractical under the
circumstances.
THE COURT FURTHER FINDS that (the judge will enter specific finding if needed)
IT IS HEREBY ORDERED that Petitioner (first guardian’s full name)
_____________________________________________ and Co-Petitioner (co-guardian’s
name; if only one guardian, write “N/A”) __________________________________________,
are appointed Temporary Guardian(s) of the above named protected person.
IT IS FURTHER ORDERED that the powers of the Temporary Guardian(s) are limited
to those necessary to respond to the immediate threat, specifically, the Temporary Guardian(s)
are limited to: (judge will check applicable boxes)
Provide consent to the provision of immediate medical attention.
Respond to a substantial and immediate risk of physical harm.
Respond to a substantial and immediate risk of financial loss by taking the
following action:
IT IS FURTHER ORDERED that the protected person’s financial accounts: (judge will
check applicable boxes)
Shall be frozen until further court order.
Shall not be affected at this time.
IT IS FURTHER ORDERED that: (judge will check applicable boxes)
Bond is not applicable at this time.
Bond is ordered in the amount of $________________.
Bond is waived at this time.
A blocked account is ordered in lieu of a bond.
© 2018 Nevada Supreme Court
Page 3 of 3 – Order Appointing Temporary Guardian(s) (Adult)
NOTICE OF HEARING FOR EXTENSION OF TEMPORARY GUARDIANSHIP
PLEASE TAKE NOTICE that the court will determine whether to extend this temporary
guardianship at a hearing on the (the court will fill in a hearing date) _____ day of
_________________, 20____, at _______ a.m. p.m., in Courtroom _____ located at
(court address) Regional Justice Center, 200 Lewis Avenue, Las Vegas, NV 89101.
IT IS FURTHER ORDERED that Temporary Letters of Guardianship shall issue to the
Guardian(s) upon the taking of the oath of office as required by law.
IT IS FURTHER ORDERED that this Order shall automatically terminate and have no
further force and effect after the hearing set forth above. If the court finds by clear and
convincing evidence that the protected person continues to be in need of a temporary guardian,
the court may extend the guardianship until a general guardian is appointed pursuant to NRS
159.0523 or NRS 159.0525.
IT IS FURTHER ORDERED that the Temporary Guardian(s) shall attempt in good faith
to notify the persons entitled to notice regarding this temporary guardianship and the hearing set
forth above.
NOTICE IS HEREBY GIVEN that if the court determined that advance notice was not
required because the protected person would have been exposed to an immediate risk of
physical and/or financial harm had the Guardian(s) provided notice, the Guardian(s) shall notify
the persons entitled to notice without undue delay, but not later than 48 hours after the
appointment of a temporary guardian or not later than 48 hours after he/she discovers the
existence, identity and location of the persons entitled to notice. If the Guardian(s) fail(s) to
provide such notice, the court may terminate the temporary guardianship.
DATED this _____ day of ______________________, 20___.
Respectfully Submitted by:
DISTRICT COURT JUDGE
(Your Signature)
(Printed Name)
/s/
© 2018 Nevada Supreme Court
Page 1 of 1 – Confidential Medical/Educational Documents
COURT CODE: _____________________
Your Name:
Address:
City, State, Zip:
Telephone:
Email Address:
Self-Represented
DISTRICT COURT
_______________ COUNTY, NEVADA
In the Matter of the Guardianship of the:
Person
Estate
Person and Estate
of:
_
___________________________________
(name of person who has a guardian)
A Protected Person.
CASE NO.: ____________________
DEPT: ____________________
CONFIDENTIAL MEDICAL / EDUCATIONAL DOCUMENTS
The following confidential, non-public documentation is attached for the Court’s
review:
Physician’s Certificate
Medical Records
Estate Planning Documents (power of attorney, will, trust, etc.)
School Records / Report Card
Other: (describe) _______________________________________________
This information is to be filed as presumptively confidential as required by ADKT 410.
DATED (month) ________________________ (day) _______, 20___.
Submitted By: (your signature) _______________________________
(print your name) _______________________________
PCRT
CLARK
/s/
© 2018 Nevada Supreme Court
Page 1 of 6 – Physician’s Certificate
PHYSICIAN’S CERTIFICATE WITH NEEDS ASSESSMENT
(Please answer all questions)
I, ________________________________________, am qualified to complete this form because:
Physician’s Full Name (please print legibly)
( check one)
I am a physician licensed to practice in the State of Nevada.
I am a physician employed by the Department of Veterans Affairs.
I am employed by the following Nevada governmental agency that conducts
investigations
*
(agency name): _______________________________________________.
I am a person who is otherwise qualified to execute this certificate (subject to the court’s
determination).
*
My qualifications are as follows:
________________________________________________________________________
________________________________________________________________________
SECTION 1: Examination Information, Diagnosis and Condition
I last examined ___________________________________, an adult, on __________________,
Patient’s Full Name (“Patient”) Date of Exam
at ______________________________________________. I have been the Patient’s physician
Name of Facility or Address of Office or Residence
since _________________; Patient ( check one) is / is not under my continuing care/treatment.
Date of First Encounter
A. Prior to the examination, I informed the Patient that my communications with him or her
would not be privileged: ......... ( check one) Unable to Comprehend Yes No
B. In addition to examining the Patient, I reviewed the following documents: ______________
__________________________________________________________________________
__________________________________________________________________________
C. I ( check one) AM / AM NOT aware of the existence of a healthcare directive, living
will, power of attorney, guardian nomination, or other similar document executed by the
Patient.
If you ARE aware of such a document, provide additional information (location of document,
identity of designated agent, etc.)
: ___________________________________________________
__________________________________________________________________________
__________________________________________________________________________
D. Was the Patient given or diagnosed using any generally accepted cognitive assessment exam
or tool, including but not limited to Folstein’s mini-mental status exam? If YES, please
attach a copy. ..................................................................................................... Yes No
*
Before the court can appoint a guardian, a licensed physician must complete an assessment of the Patient’s needs
that identifies limitations of capacity and how such limitations affect the Patient’s ability to maintain safety and
basic needs.
© 2018 Nevada Supreme Court
Page 2 of 6 – Physician’s Certificate
E. The Patient’s physical diagnosis (DSM or ICD Diagnoses) and condition is: ____________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Prognosis is: _______________________________________________________________
Severity/Degree is: ( check one) Mild Moderate Severe
F. The Patient’s mental diagnosis (DSM or ICD Diagnoses) and condition is: _____________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Prognosis is: ______________________________________________________________
Severity/Degree is: ( check one) Mild Moderate Severe
G. Which of the following descriptions apply to the patient’s degree of cognitive impairment
( check all that apply)?
The patient has a sufficient loss or total loss of executive function resulting in a
barrier to meaningful understanding or rational response.
The Patient is able to make independently some but not all of the decisions necessary
for his or her own care and management of property.
The patient is unable to execute on desires, preferences, or stated goals, preventing
the ability to pursue the patient’s own best interest.
The patient is unable to receive or evaluate information.
The patient is unable to make or communicate decisions to such an extent that the
patient lacks the ability to meet essential requirements for physical health, safety, or
self-care without proper assistance.
None of the above.
H. Is the Patient facing an immediate need for medical attention? ....................... Yes No
If YES, is the Patient unable to respond to the need for medical attention? ..... Yes No
If YES, explain the immediate attention needed and why the Patient is unable to respond:
__________________________________________________________________________
__________________________________________________________________________
I. Is the Patient facing a substantial and immediate risk of physical harm? ......... Yes No
If YES, is the Patient unable to respond to that risk of physical harm? ............ Yes No
If YES, explain the immediate risk and why the Patient is unable to respond:
__________________________________________________________________________
__________________________________________________________________________
© 2018 Nevada Supreme Court
Page 3 of 6 – Physician’s Certificate
J. Is the Patient facing a substantial and immediate risk of financial loss? .......... Yes No
If YES, is the Patient unable to respond to that risk of financial loss? ............. Yes No
If YES, explain the immediate risk and why the Patient is unable to respond:
__________________________________________________________________________
__________________________________________________________________________
K. Does the Patient present a danger to himself/herself? ..................................... Yes No
Does the Patient present a danger to others? .................................................... Yes No
If YES, explain:
__________________________________________________________________________
__________________________________________________________________________
L. Has the Patient been subjected to abuse, neglect, or exploitation? ................... Yes No
If YES, explain:
__________________________________________________________________________
__________________________________________________________________________
M. Is the Patient capable of living independently? ( check one)
Yes, without assistance Yes, with assistance No
If WITH ASSISTANCE, describe the assistance needed; if NO, explain why not:
__________________________________________________________________________
__________________________________________________________________________
N. Attached to this certificate is ( check all that apply, if applicable):
A copy of my report of the above exam which includes my findings, opinion, and
diagnosis regarding the Patient and his/her mental condition and/or capacity.
A copy of the Patient’s chart notes which support and/or detail my findings, opinion,
and diagnosis regarding the Patient and his/her mental condition and/or capacity.
A letter, signed by me, detailing my findings, opinion, and diagnosis regarding the
Patient and his/her mental condition and/or capacity.
SECTION 2: Ability to Appear at Hearing
A. Would the Patient’s attendance at a hearing for appointment of a guardian be detrimental to
the Patient’s mental health? ................................................................................ Yes No
If YES, why?
__________________________________________________________________________
__________________________________________________________________________
B. Would attending the hearing for appointment of a guardian be detrimental to the Patient’s
physical health? ................................................................................................. Yes No
If YES, why?
__________________________________________________________________________
__________________________________________________________________________
© 2018 Nevada Supreme Court
Page 4 of 6 – Physician’s Certificate
C. Is the patient able to appear at a court hearing? ................................................. Yes No
If NO, why not?
__________________________________________________________________________
__________________________________________________________________________
D. Would the patient comprehend the reason for a hearing? .................................. Yes No
E. Would the patient contribute to a hearing? ......................................................... Yes No
SECTION 3: Limitations, Abilities, and Needs
A. The Patient’s level of needed supervision is as follows: Locked Facility
24-hour supervision
Independent living with some
supervision
No supervision
No supervision when taking
medication
B. My opinion as to the Patient’s everyday functions is as follows:
Independent
Needs Support
Needs Substantial Assistance
Needs Total Care
Unknown
CARE OF SELF (Activities of Daily Living (ADLs) and related
activities)
Bathe and shower
Personal hygiene and grooming (e.g., brushing teeth, hair)
Dress self
Toilet hygiene (getting to toilet, cleaning self, getting back up)
Functional mobility (e.g., walking, transferring to/from bed or chair)
Feed self and eat for adequate nutrition
Identify physical abuse or neglect and protect self from harm
FINANCIAL
Manage, deposit, withdraw, dispose of, and invest money and assets
Protect, and spend small amounts of cash
Employ persons to advise or assist him/her
Identify financial exploitation, coercion, undue influence
Protect self from financial exploitation, coercion, undue influence
Give gifts and donations
© 2018 Nevada Supreme Court
Page 5 of 6 – Physician’s Certificate
Independent
Needs Support
Needs Substantial Assistance
Needs Total Care
Unknown
MEDICAL
Give/withhold medical consent to medical, dental, psychological
Admit self to health facility
Make or change an advance directive or healthcare power of attorney
Manage medications
Contact help if ill or in medical emergency
HOME AND COMMUNITY LIFE
Choose/establish residence
Maintain reasonably safe and clean shelter
Drive or use public transportation
Prepare food/meals, cleanup
Shop for groceries and necessities
Use telephone or other forms of communication
Make and communicate choices about roommates
Avoid environmental dangers such as stove, poisons
Maintain and pay household bills, utilities, mortgage/rent, taxes
SECTION 4: Civil and Legal
A. In my opinion, the Patient lacks the capacity necessary to ( check all that apply):
Enter into a contract, financial commitment, or lease arrangement
Make or modify a will or power of attorney
Participate in mediation
B. Is the Patient capable of driving? .............................................. Yes No Uncertain
C. Would the Patient present a risk or threat to self or others if Patient were to own or purchase
a firearm? .................................................................................. Yes No Uncertain
D. Does the Patient have the capacity necessary to understand and complete voter registration
forms and vote? ......................................................................... Yes No Uncertain
© 2018 Nevada Supreme Court
Page 6 of 6 – Physician’s Certificate
SECTION 5: Remarks and Recommendations
A. If you have any remarks concerning other sections, or if you believe the court should be
aware of other concerns about the Patient which are not included above, please explain:
__________________________________________________________________________
__________________________________________________________________________
B. If you have any recommendations for needed treatment or services which are not included
above, please explain:
__________________________________________________________________________
__________________________________________________________________________
(This certificate must be signed by the physician, agency employee, or other person identified at the top of page 1 of
the certificate.)
I declare under penalty of perjury under the law of the State of Nevada that the foregoing
is true and correct.
Date: __________________ Signature: _________________________________________
Print Name: __________________________________________
Address: _________________________________________
__________________________________________
Telephone: __________________________________________
The following psychologist, nurse, nurse practitioner, physicians’ assistant, social worker, case
manager, or other assisted in completion of this form (print all names below, if applicable):
________________________________________
________________________________________
________________________________________
This page explains what you need to do to get your Emergency Guardianship Order.
Mail: Send your forms to Clerk of Court, 601 N Pecos, Las Vegas, NV 89101.
Online: You can upload your documents at https://nevada.tylerhost.net/OfsWeb/. There is a $3.50
fee to e-file your documents. The Order Appointing Temporary Guardian should not be
efiled, but it can be emailed after you efile the other forms. See Step 2 for more information.
You can submit in one of the ways below. The judge’s staff will notify you of the judge’s decision
.
Mail it to the courthouse: Mail it to: Family Court, 601 N. Pecos Rd., Las Vegas, NV 89101
Email it to your judge: Find the letter that your case is assigned to (for example, Dept C, Dept
F, etc.). Insert the department letter where the _ is in the following email format:
dept_inbox@clarkcountycourts.us and send it by email.
There are different ways to serve different people:
The adult you want to be the guardian over has to be
personally served
.
Someone who is not involved in this case must hand-deliver the Petition and Citation to the
adult. Do this even if the adult doesn’t understand what’s happening.
The rest of the relatives can sign and notarize a
consent
agreeing to make you the
guardian. If they won’t consent, send them a copy of the filed Petition and the Citation
by
certified mail, return receipt requested
. Use the “green cards” at the post office.
o All the relatives age 14 and older listed on Exhibit A.
o Medicaid (if the adult receives Medicaid – address is provided on the form)
o Veteran’s Affairs (if the adult receives VA benefits – address is provided on the form)
o The Hospital/Care Facility where the adult is located (if applicable)
YOU MUST SERVE ALL OF THE PEOPLE LISTED ABOVE; NO EXCEPTIONS!
If you don’t know how to contact someone, visit https://www.familylawselfhelpcenter.org/self-
help/guardianship/filing-for-guardianship-over-an-adult/149-serving-the-relatives for other options.
Complete the Temporary Letters of Guardianship and file them. This is what gives you
the power to act as the temporary guardian.
Check the Order for the court date and plan to attend the hearing. The court date is on
page 3. Notify the relatives of the court date since they are allowed to attend. At the hearing,
the judge may extend your temporary guardianship or may end it if the emergency is over.
© 2018 Nevada Supreme Court
Page 1 of 2 – Temporary Letters of Guardianship (Adult)
COURT CODE: _____________________
Your Name:
Address:
City, State, Zip:
Telephone:
Email Address:
Self-Represented
DISTRICT COURT
CLARK COUNTY, NEVADA
In the Matter of the:
Temporary Guardianship of the Person
Temporary Guardianship of the Estate
Temporary Guardianship of the Person
& Estate
Temporary Special Guardianship
of:
_
___________________________________
(name of adult who needs a guardian)
A Protected Person.
CASE NO.: ____________________
DEPT: ____________________
LETTERS OF TEMPORARY GUARDIANSHIP
Expiration Date: _________________
On (month) ____________________ (day) ________, 20___, a Court Order was entered
appointing (name of first guardian) _________________________________________________
and (name of second guardian, or “n/a”) ____________________________________ as
Temporary Guardian(s) of the above named protected person. The named Guardians, having
duly qualified, are authorized to act and have authority to perform the duties of Temporary
Guardian for a period not to exceed 10 days, unless an Order Extending Temporary
Guardianship has been entered by the Court.
In testimony of which, I have this date signed these Letters and affixed the Seal of the
Court.
CLERK OF COURT
DATED ____________________________ BY: _____________________________________
DEPUTY CLERK
LETG
Page 2 of 2 – Temporary Letters of Guardianship (Adult)
OATH OF GUARDIAN
I, (name of guardian) _________________________________________________,
residing at (street/city/state/zip): ___________________________________________________
whose mailing address is (street/city/state/zip): _______________________________________
solemnly affirm that I will well and faithfully perform the duties of Temporary Guardian
according to law. I affirm that any matters stated in any petition, document or court proceeding
are true of my own knowledge or if any matters are stated on information or belief, I believe
them to be true.
I declare under penalty of perjury under the law of the State of Nevada that the foregoing
is true and correct.
EXECUTED this _____ day of _______________, 20___.
(Repeat Oath for Each Guardian; Attach Separate Sheets if Necessary)
(Guardian’s Signature)
(Printed Name)
This page explains what you need to do while you wait for your regular guardianship
“citation” hearing.
File your proof of service at least 1 week before your permanent guardianship
hearing. File the following documents to show all required people were notified:
Declaration of Service (required). This is the proof that the adult was served
with the Petition and Citation. Whoever served the adult fills out this form.
Consents (if applicable). Any relative can sign a notarized consent if they want
you to be the guardian and will waive formal service of the documents. The SHC
has consent forms available. Any relative who will not sign a consent must get
the Petition and the Citation by certified mail, return receipt requested.
Certificate of Mailing (required for anyone who won’t consent). This is
the proof that other relatives and agencies were served with the Petition and
the Citation.
o You must mail file-stamped copies of the Petition and the Citation to
the relatives and required agencies.
o Send the documents by certified mail, return receipt requested.
Use the “green cards” at the post office.
o File the Certificate of Mailing at least 1 week before your hearing.
Attach copies of the signed green cards when you receive them back
from each person.
You may attend by phone or video. You can find forms to request a phone or video
appearance here: https://www.familylawselfhelpcenter.org/self-
help/guardianship/filing-for-guardianship-over-an-adult/148-the-hearing
The adult also needs to participate in the hearing (unless the doctor’s certificate
excuses the adult from attending).
An attorney will be present to represent the adult you are seeking to be the guardian
over.
© 2018 Nevada Supreme Court
Page 1 of 2 – Declaration of Service on Proposed Protected Person
COURT CODE: AOS
Your Name: _________________________
Address: ____________________________
City, State, Zip: ______________________
Phone: ______________________________
Email: ______________________________
Self-Represented
DISTRICT COURT
CLARK COUNTY, NEVADA
In the Matter of the Guardianship of the:
Person
Estate
Person and Estate
of:
_
___________________________________
(name of adult alleged to need a guardian)
A Proposed Protected Person.
CASE NO.: ____________________
DEPT: ____________________
DECLARATION OF SERVICE ON ADULT PROPOSED PROTECTED PERSON
A copy of the Petition for Appointment of Guardian and the Citation to Appear and Show Cause
must be personally served to the adult who allegedly needs a guardian.
A neutral person, not involved in this case or related to the parties, must personally serve the
documents directly to the adult. If that is not possible, the server can personally serve the
documents on someone of suitable age and discretion who lives with the adult.
The proposed guardians or relatives cannot do this.
The person who serves the documents must complete this form.
I, (name of person who served the documents) _______________________________________,
declare (complete EVERY SECTION below):
1. I am not a party to or interested in this action and I am over 18 years of age.
2. I am not a licensed process server; I am a natural person serving legal process without
compensation, not more than three times per year, on behalf of a litigant who is a natural
person, and therefore I am not required to be licensed pursuant to NRS 648.063(2) (2017
Nevada Laws Ch. 126 (A.B. 128)).
© 2018 Nevada Supreme Court
Page 2 of 2 – Declaration of Service on Proposed Protected Person
3. What Documents You Served. I served a copy of the ( check all that apply)
Petition for Appointment of Guardian
Citation to Appear and Show Cause
Other: ____________________________________________________________
4. Who & Where You Served. I personally delivered and left the documents with:
( check one)
The Adult Who Is the Subject of This Case. I served the documents on the
adult at the location below. (complete the details below)
_________________________________________
Name of Person Served
_________________________________________
Address Where Served
_________________________________________
City, State, Zip Code
A Person Who Lives with the Adult. This is a person of suitable age and
discretion who lives with the adult. (complete the details below)
_________________________________________
Name of Person Served
_________________________________________
Address Where Served
_________________________________________
City, State, Zip Code
5. When You Served. I personally served the documents on (date you served the
documents) (month) ___________________________ (day) _______, 20____ at the
hour of (time) ____:____ a.m. p.m.
I declare under penalty of perjury under the law of the State of Nevada that the foregoing
is true and correct.
DATED (month) ___________________________ (day) _______, 20____.
Server’s Signature:
Server’s Printed Name:
Residential / Business Address:
City, State, Zip:
Server’s Phone Number:
/s/
© 2018 Nevada Supreme Court
Page 1 of 2 – Certificate of Mailing (Adult)
COURT CODE: CERT
Your Name:
Address:
City, State, Zip:
Telephone:
Email Address:
Self-Represented
DISTRICT COURT
CLARK COUNTY, NEVADA
In the Matter of the Guardianship of the:
Person
Estate
Person and Estate
of:
_
___________________________________
(name of adult alleged to need a guardian)
A Proposed Protected Person.
CASE NO.: ____________________
DEPT: ____________________
CERTIFICATE OF MAILING FOR THE
PETITION FOR APPOINTMENT OF GUARDIANS
I HEREBY CERTIFY that I served the: ( check all that apply):
Petition for Appointment of Guardian
Citation to Appear and Show Cause
Other: ________________________________
on (month) _____________________ (day) _____, 20___, by depositing a copy of the same in
the U.S. Mail, enclosed in sealed envelopes, prepaid Certified Mail, Return Receipt Requested,
addressed to:
Relatives / Required Notices:
Name: ____________________________
Address: __________________________
____________________________
Name: ____________________________
Address: __________________________
____________________________
Name: ____________________________
Address: __________________________
____________________________
Name: ____________________________
Address: __________________________
____________________________
© 2018 Nevada Supreme Court
Page 2 of 2 – Certificate of Mailing (Adult)
Name: ____________________________
Address: __________________________
____________________________
Name: ____________________________
Address: __________________________
____________________________
Name: ____________________________
Address: __________________________
____________________________
Name: ____________________________
Address: __________________________
____________________________
Name: ____________________________
Address: __________________________
____________________________
Name: ____________________________
Address: __________________________
____________________________
If the adult is in a hospital or in a public or private care facility, mail to the care provider:
Name: ____________________________
Address: ___________________________
____________________________
If the adult receives or has received Medicaid, check the following box and mail to:
Director of the Department of Health and Human Services
4126 Technology Way, Suite 100
Carson City, Nevada 89706-2009
If the adult receives Veteran’s benefits or payments, check the following box and mail to:
Department of Veteran’s Affairs
5460 Reno Corporate Drive
Reno, Nevada 89511
I declare under penalty of perjury under the law of the State of Nevada that the
foregoing is true and correct.
DATED (month) ________________________ (day) _______, 20___.
ATTACH THE SIGNATURE RECEIPTS (GREEN CARDS FROM THE
POST OFFICE) TO THIS FORM WHEN RECEIVED
(Signature)
(Printed Name)
/s/
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Completed 9 February 2021

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