For e-Filing only
NHJB-2169-Pe (01/01/2018) Page 1 of 2
1. I, under oath, hereby request an
expedited hearing under RSA 464-A:4, IV, and state that:
2. In my/our opinion, an expedited hearing for the finding of incapacity and appointment of a guardian of
the person and estate, or the person, or estate, is necessary for the following reason(s):
MEDICAL EMERGENCY: If the petitioner is a physician and this petition & affidavit is for a medical
emergency, complete items 3, 4 and 5 below.
3. Physician Name
4. I am a physician at
5. I am the physician for
I state that on this date I am sending a copy of this document as required by the rules of the
Circuit Court. I am electronically sending this document through the court’s electronic filing system to
all attorneys and to all other parties who have entered electronic service contacts (email addresses)
in this case. I am mailing or hand-delivering copies to all other interested parties.
Petitioner or Physician Signature:
Name of Filer Signature of Filer Date
Law Firm, if applicable Bar ID # of attorney Telephone
Address E-mail
City State Zip code
State of , County of
This instrument was acknowledged before me on by
Date Petitioner(s) or Physician
My Commission Expires
Affix Seal, if any Signature of Notarial Officer / Title
THE STATE OF NEW HAMPSHIRE
JUDICIAL BRANCH
http://www.courts.state.nh.us
Court Name:
Case Name:
Case Number:
(if known)
PETITION AND AFFIDAVIT FOR EXPEDITED HEARING
(RSA 464-A:4, IV)
Always complete items 1 and 2 below.
