Fillable ities (DDD) (NJ Judiciary)

Fill Online, Printable, Fillable, Blank ities (DDD) (NJ Judiciary) Form

Use Fill to complete blank online NJ JUDICIARY (NJ) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

ities (DDD) (NJ Judiciary)

On average this form takes 104 minutes to complete

The ities (DDD) (NJ Judiciary) form is 52 pages long and contains:

  • 0 signatures
  • 29 check-boxes
  • 401 other fields

Country of origin: US
File type: PDF

U.S.A. forms for NJ Judiciary

BROWSE NJ JUDICIARY (NJ) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Published 02/2017, CN 12009 (Adult Guardianship – Person Only) page 1 of 34
Chancery – Probate
How to Apply for Guardianship of the Person of an Individual Eligible for Services from the Division of Developmental Disabil
ities (DDD)
February 2017
How to Apply for Guardianship of the Person of an Individual Eligible for
Services from the Division of Developmental Disabilities (DDD)
(Title 30 Guardianship)
(Superior Court of New Jersey - Chancery Division - Probate Part)
Who Should Use This Packet?
You may
use this packet if you are seeking appointment of a guardian of the person for an individual with a
developmental disability who has been determined eligible for services from the Division of Developmental
Disabilities (DDD).
You should
only use this packet if ALL of the following statements are true:
• The person alleged to be incapacitated is eligible for and/or receiving services from the DDD;
AND
• You are requesting that the court appoint a guardian of the person only – not a guardian of the
estate (property).
You should
NOT use this packet if you are seeking appointment of a guardian of the person AND estate
(property) of someone eligible for DDD services. If you wish to be guardian of the person and estate, you
should use the packet entitled “
How to Apply for Guardianship of the Person and Estate (Property) of an
Individual Eligible for Services from the Division of Developmental Disabilities (DDD)
.”
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
at njcourts.gov. However, you are ultimately responsible for the content of your court papers.
Completed forms are to be submitted to the Surrogate’s Office in the county where you are filing your
case. A list of Surrogates’ Offices is provided at njcourts.gov/courts/civil/guardianship.html.
Published 02/2017, CN 12009 (Adult Guardianship – Person Only) page 2 of 34
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. The law, the proofs
necessary to present your case, and the procedural
rules governing cases in the Chancery Division,
Probate Part are complex. Since the civil rights,
well-being or financial security of an alleged or
adjudicated incapacitated person may be at stake,
many litigants appearing in the Chancery Division,
Probate Part have a lawyer. It is recommended that
you make every effort to obtain the assistance of a
lawyer. 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 online or 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. That 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
will sometimes consult with you at a reduced fee.
There are also organizations of minority lawyers
throughout New Jersey, as well as 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.
If you decide to proceed without an attorney, these
materials explain the procedures that must be
followed to have your papers properly filed and
considered by the court. These materials do not
provide information nor other procedural and
evidentiary rules governing guardianship matters.
What You Should Expect If You Represent
Yourself
While you have the right to represent yourself in
court, you should not expect special treatment, help
or attention from the court. The following is a list
of some things court staff can and cannot do for
you. Please read it carefully before asking 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 copies of all completed forms and
documents related to your case.
Published 02/2017, CN 12009 (Adult Guardianship – Person Only) page 3 of 34
Definitions of Words Used in This Packet
Alleged Incapacitated Person (AIP) - The alleged incapacitated person (or AIP) is the individual over whom the
plaintiff(s) is/are seeking guardianship.
Certification - A certification is a statement that certain facts are true to the best of the knowledge of the person
making the statement. It is like an affidavit, but it is not sworn before a notary or other authorized person.
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 AIP’s county of residence at the time of application
for DDD services. However, it is possible that the county of residence and county of settlement may be different
depending on the residential history of the AIP.
County Surrogate – The county surrogate is an elected Constitutional Officer who serves as judge of the Surrogate’s
Court for uncontested probate and estate matters. A Surrogate also serves as Deputy Clerk to the Superior Court for the
Probate Part, including guardianships of incapacitated adults, as well as adoptions in the Family Part.
Docket Number - A docket number is the number the court assigns to your case so that it may be identified and located
easily. Once you have a docket number, you must include it on all your communications with the court.
File - To file means to give the appropriate forms and fee to the court to begin the court’s handling of your case.
General Guardianship - general guardianship is a “complete in every respect” type of guardianship in which the
guardian is able to exercise all rights and powers of the incapacitated person in terms of the area of responsibility he or
she is granted. Also known as full or plenary guardianship.
Guardian – a guardian is an individual appointed by the court with authority over the person and/or the estate of an
adjudicated incapacitated person. A guardian may have general or limited authority.
Guardian of the Estate – An individual appointed by the court to handle the financial affairs of another person who
has been adjudicated incapacitated. Unlike a guardian of the person, a guardian of the estate is not responsible for
decisions regarding the personal well-being of the protected person. Rather, the guardian of the estate handles assets,
income, expenses and liabilities.
Guardian of the Person - An individual appointed by the court to handle the personal affairs of another person who
has been adjudicated incapacitated. Unlike a guardian of the estate, a guardian of the person does not manage the
financial affairs of the incapacitated person, except that a guardian of the person may serve as representative payee for
Social Security benefits.
Guardianship Monitoring Program (GMP) - In New Jersey, the Guardianship Monitoring Program is a statewide
monitoring program implemented in all 21 counties as of 2014. Through the GMP, trained volunteers review the
reports filed by guardians of incapacitated persons and flag issues that require further attention.
Incapacity - Inability to govern oneself and/or to manage one’s affairs. Incapacity may be general (as to all areas) or
limited (as to specific areas only).
Incapacitated Person - An individual adjudicated by the court as unable to govern himself or herself and/or unable to
manage his or her affairs. Also known as a protected person or ward. Formerly referred to as an incompetent.
Interested Parties - A person or agency that has an involvement with the incapacitated person who is the subject of the
guardianship. Interested parties (or parties in interest) are typically the same individuals entitled to notice of the initial
application for guardianship – i.e., the incapacitated person’s spouse, parent, adult child, county of settlement, DDD.
Judgment - The official decision of a court in a case. For purposes of guardianship, Judgment refers to the Judgment
of Incapacity and Guardian Appointment, also known as the Judgment of Incapacity and Order Appointing Guardian.
Published 02/2017, CN 12009 (Adult Guardianship – Person Only) page 4 of 34
Definitions of Words Used in This Packet (continued)
Letters of Guardianship - Letters of Guardianship are documents issued by the County Surrogate upon an
individual’s qualification as guardian, after the entry of a Judgment by the Superior Court.
Limited Guardianship - A less intrusive, more individualized, type of guardianship in which a guardian is appointed
with authority as to some – but not all – areas. A limited guardianship is established based upon a court’s finding that
the person alleged to be incapacitated lacks the capacity to do some, but not all, of the tasks necessary to care for
himself or herself.
Proof of Service - Proof of Service is documentation showing that parties actually received the papers that you sent to
them. Service is established for all parties other than the alleged incapacitated person by a certification that the
documents were sent by regular mail and certified mail, and the regular mail was not returned to you. If the signed
return receipt (green cards) are received, these may be attached to the certification of service. As to the alleged
incapacitated person, you must file a certification stating that he or she was personally served.
Qualification - A process conducted before the County Surrogate, or Surrogate’s staff, following entry of a Judgment
of Incapacity and Guardian Appointment. As part of qualification, the person appointed as guardian affirms his or her
willingness to fulfill the duties of a guardian. If a bond is required, the bond must be posted in order for the guardian to
qualify and obtain Letters of Guardianship.
Restricted Assets - Assets over which a guardian of the estate does not exercise full control. The most common
restricted asset is real property. The restriction can be found in the Judgment and sometimes the Letters of
Guardianship. It typically provides that the guardian of the estate “cannot sell, transfer, mortgage, or otherwise
encumber the real property of the incapacitated person absent court approval.”
Service - Delivery of papers in a legally appropriate way. For example, notice of an application for appointment of a
guardian is served upon the alleged incapacitated person by personal service, meaning that copies of the papers are
personally delivered.
Short Certificates - Short forms of the Letters of Guardianship, stating that by judgment of a particular date, the
guardian was appointed with authority of the person and/or estate of the named incapacitated person. A short
certificate will state that as of the date it was issued, the guardianship remains in effect. Additional short certificates
may be purchased by a guardian, from the Surrogate, for $5.00 each as long as the guardianship remains in effect.
Unlike the original Letters of Guardianship, short certificates should be provided to doctors, care facilities, and other
institutions that require proof of a guardian’s authority.
Superior Court Judge - For purposes of guardianships, the judge of the Superior Court, Probate Part, who decides if
the alleged incapacitated person is in fact incapacitated and in need of a guardian. The Superior Court judge makes the
substantive decisions about the guardianship, including the determination of capacity and the choice of guardian. The
Superior Court judge conducts any hearing(s) and signs the Judgment of Incapacity and Guardian Appointment.
Surety Bond - A contract between at least three parties: the obligee (the party who is the recipient of an obligation), the
principal (the primary party who will perform the contractual obligation) and the surety (who assures the obligee that
the principal can perform the task). A bond functions much like an insurance policy so that if the guardian of the estate
steals or misuses the money, or makes some other mistake, the incapacitated person will be protected. The price of that
insurance policy (the bond premium) can be paid from the guardianship estate.
Surrogate’s Court - A county office headed by the County Surrogate that may be in the same location as the Superior
Court or may be in a different location. The Surrogate’s Court is the filing court for Probate Part actions, including
actions to appoint a guardian. It is also where the guardian goes to qualify after entry of the Judgment.
Verified Complaint - A verified complaint is a sworn document in which the plaintiff tells the court the facts of the
case and states what relief is sought.
Published 02/2017, CN 12009 (Adult Guardianship – Person Only) page 5 of 34
Important Information about Guardianship Actions
To apply for guardianship, you must submit several forms to the Superior Court. The forms provided in this
packet are for guardianships of persons eligible for and/or receiving services from the Division of
Developmental Disabilities (DDD). These actions are typically referred to as Title 30 guardianships because
they arise under Title 30 of the New Jersey Statutes Annotated, specifically N.J.S.A. 30:4-165.1 et seq.
You will fill out some of the forms, including the Verified Complaint. Other forms must be completed by other
people.
Under Title 30, an application for guardianship must be supported by an affidavit or certification of a physician
or psychologist who has personally examined the alleged incapacitated person within six (6) months prior to
filing. A second document must also be attached to the verified complaint. This second attachment must be
one (1) of the following:
(a) an affidavit from the chief executive officer, medical director or other officer having administrative
control over the program from which the alleged incapacitated person is receiving functional or other
services provided by the DDD;
(b) an affidavit from a designee of the DDD having personal knowledge of the functional capacity of the
alleged incapacitated person;
(c) a second affidavit from a physician or psychologist;
(d) a copy of the Individualized Education Program, including any medical or other reports, for the alleged
incapacitated person, which shall have been prepared no more than two (2) years prior to the filing of the
verified complaint; or
(e) an affidavit from a licensed care professional having personal knowledge of the functional capacity of
the alleged incapacitated person.
In preparing your application, you should provide the supporting documents – including the certification of
physician or psychologist and, if applicable, second supporting certification – to the individuals who will
complete them. If you choose to submit an Individualized Education Program (IEP) in support of your
application, you should obtain a copy of this document.
Type and Scope of Guardianship
There are different types of guardianships, specifically, guardianship of the person; guardianship of the estate
(property); or guardianship of both the person and the estate (property). The type of guardianship that is
appropriate in a particular case depends on the needs of the incapacitated person. If an incapacitated person has
no assets or income other than Social Security benefits or funds held in trust, then guardianship of the estate is
not necessary. However, if an incapacitated person has assets such as a house or car, or receives income, such
as wages or a pension, then guardianship of the estate may be necessary.
It is important to determine whether it is actually necessary to seek guardianship of the estate of a
developmentally disabled person. This is in part because the court will appoint an attorney to represent the
alleged incapacitated person and, if guardianship of the person only is requested, then the court can appoint the
Office of the Public Defender Division of Mental Health and Guardianship Advocacy free of charge.
If an application seeks guardianship of the estate, then the court will appoint a private attorney who is entitled to
charge a fee for services. Although that fee can be paid from the assets of the alleged incapacitated person,
when the alleged incapacitated person has no assets the fee is often paid by the individuals seeking
guardianship.
Published 02/2017, CN 12009 (Adult Guardianship – Person Only) page 6 of 34
In addition to the distinction between guardianship of the person and guardianship of the estate (property),
applicants for guardianship must consider whether a full or general guardianship is appropriate, or whether the
developmentally disabled person is suitable for a limited guardianship. In a limited guardianship, the
incapacitated person retains rights to handle certain areas of their life, depending upon their ability to handle
such matters independently.
Procedure
Once the verified complaint and supporting documents are filed with the Surrogate, the documents will be
reviewed. If everything is satisfactory, the Order Fixing Hearing Date and Appointing Attorney for Alleged
Incapacitated Person will be entered. This Order schedules the hearing date and appoints counsel for the
alleged incapacitated person. You must serve the Order and other papers on the alleged incapacitated person,
personally, and on the other interested parties, by regular and certified mail. A separate notice must be served
on the alleged incapacitated person stating that the alleged incapacitated person may oppose the guardianship.
The court-appointed attorney will conduct an investigation including a meeting with the alleged incapacitated
person and the proposed guardian. The attorney will then make a recommendation to the court as to the need
for guardianship (including whether a full or limited guardianship is necessary) and the choice of guardian(s).
If the court-appointed attorney does not dispute the need for guardianship or the fitness of the proposed
guardian, the attorney may recommend that the guardian be appointed without any court hearing. If a court
hearing is required, then the alleged incapacitated person, his or her court-appointed attorney, and the
individual(s) seeking guardianship must generally participate. Such participation may be in person, meaning
that everyone appears in the courtroom in front of a judge, or by another method approved by the court, such as
by phone. If the alleged incapacitated person is unable to attend the court hearing, and the court-appointed
attorney agrees, then the hearing may proceed without the alleged incapacitated person in attendance.
Judgment and Letters
Entry of the Judgment by the Superior Court judge establishes the guardianship. Until the guardian(s) qualify
before the County Surrogate, however, he or she cannot act as guardian. For example, a guardian who has not
yet qualified cannot make medical decisions on behalf of the incapacitated person. To qualify, the guardian
must sign certain documents reflecting acceptance of the guardianship. Modest fees must be paid to the
Surrogate for issuance of Letters of Guardianship. Letters should be kept in a secure location and must not be
turned over to any other person or facility. Qualification may occur immediately following the guardianship
hearing and must occur as soon thereafter as possible, but not later than 30 days after entry of the Judgment.
At the time of qualification, or at any time during the guardianship, the guardian(s) may apply to the Surrogate
for up-to-date short certificates. Short certificates contain the basic information set forth in the Letters of
Guardianship, stating that by Judgment of a particular date, the guardian was appointed as guardian of a named
incapacitated person. A short certificate will also state that as of the date it was issued, the guardianship
remains in effect. A guardian of the person may purchase additional up-to-date short certificates to provide to
doctors, care facilities, and other institutions as proof of his or her continuing authority.
Published 02/2017, CN 12009 (Adult Guardianship – Person Only) page 7 of 34
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 printed clearly on 8 ½ “x 11” white paper only. Forms may
not be filed on a different size or color paper.
Steps to Apply for Guardianship of the Person of an Individual Eligible for
Services from the Division of Developmental Disabilities (DDD)
STEP 1: Complete the Adult Guardianship
Case Information Statement (CIS) (Form A).
The Adult Guardianship Case Information
Statement (CIS) is a one-page form that
provides certain basic information about your
application. Complete the CIS by following the
instructions for Form A found on page 10.
Note: Failure to file this required document will
result in the return of your complaint.
STEP 2: Complete the Verified Complaint to
Appoint Guardian(s) of the Person (Form B).
The Verified Complaint to Appoint Guardian(s)
of the Person is the document you must file to
request that the court appoint a guardian for
another person who you believe is incapacitated
and unable to govern himself or herself or to
manage his or her affairs. Complete the
Verified Complaint to Appoint Guardian(s) of
the Person by following the instructions for
Form B starting on page 12.
STEP 3: Complete the Certification of
Assets (Form C).
The Certification of Assets describes the assets
and income, if any, of the alleged incapacitated
person. Complete the Certification of Assets by
following the instructions for Form C found on
page 18.
STEP 4: Have the Certification of Physician
or Psychologist completed by a licensed
physician or psychologist (Form D).
The Certification of Physician or Psychologist
is completed by a physician or psychologist who
has evaluated the alleged incapacitated person
within the past six (6) months. Arrange for a
licensed physician or psychologist to examine
and evaluate the alleged incapacitated person
and complete the form. Follow the instructions
for Form D found on page 21.
STEP 5: Complete the Cover Page -
Individualized Education Program (IEP)
(Form E-1) OR the Certification in Support of
Guardianship (Form E-2).
A second document which must be filed in
addition to Form D (Certification of Physician
or Psychologist) regarding the functional
capacity of the alleged incapacitated person.
There are several options which will satisfy this
requirement including:
1. A copy of the Individualized Education
Program (IEP) for the alleged incapacitated
person; (instructions can be found on page
24) OR
2. An affidavit or certification from the chief
executive officer (CEO), medical director,
or other officer having administrative
control over the DDD program from which
the alleged incapacitated person is receiving
services; OR
3. An affidavit or certification from a designee
of the DDD having personal knowledge of
the functional capacity of the alleged
incapacitated person; OR
4. A second affidavit or certification of a
physician or psychologist; OR
5. An affidavit or certification from a licensed
care professional having personal
knowledge of the functional capacity of the
alleged incapacitated person.
If submitting an IEP, fill out the Cover Page
(Form E-1). If submitting one of the other
documents, provide the form Certification in
Support of Guardianship (Form E-2) to the
appropriate person for them to complete.
Instructions for Forms E-1 and E-2 are found on
page 24.
Revised 01/2019, CN 12009 (Adult Guardianship – Person Only) page 8 of 34
STEP 6: Complete the Order Fixing
Hearing Date and Appointing Attorney for
Alleged Incapacitated Person (Form F).
The Order Fixing Hearing Date and Appointing
Attorney for Alleged Incapacitated Person is
used by the judge to schedule a hearing and to
appoint an attorney for the subject of the
guardianship action. The judge handling the
case will usually schedule a hearing to evaluate
the need for the proposed guardianship. Please
complete the information at the top of the form.
Note that there are places on the Order Fixing
Hearing Date that the court will complete.
Instructions for Form F can found on page 28.
STEP 7: Complete the Judgment of
Incapacity and Appointment of Guardian(s) of
the Person (Form G).
The Judgment of Incapacity and Appointment of
Guardian(s) of the Person is the official
document that will be completed and signed by
the judge if it is determined that the alleged
incapacitated person requires a guardian. Enter
the information on the top of the form.
Note that there are places on the Judgment that
the court will complete. Instructions for Form
G are found on page 31.
STEP 8: Attach the Filing Fee.
Make a check or money order payable to the
Surrogate of the county in which the
application is filed in the amount of $200. This
is the fee for filing your papers.
STEP 9: Check your completed forms and
make copies.
Check your forms and make sure they are
complete. Remove all instruction sheets. Make
sure you have signed all the forms wherever
necessary. All forms must have an original, ink
signature. You also need to make several
copies of each form. The original and one (1)
copy will be sent to the court. Copies will also
need to be provided to anyone who requires
notice of the action. Please also retain a copy
for your records.
Checklist - In Step 10, you will be directed to
mail your documents to the court. The
following checklist will help ensure your
package is complete:
The original of each of the forms you
filled out: Adult Guardianship Case
Information Statement (Form A);
Verified Complaint to Appoint
Guardian(s) of the Person (Form B);
Certification of Assets (Form C);
Certification of Physician or
Psychologist (Form D); Cover Page
Individualized Education Program OR
Certification in Support of Guardianship
(Form E-1 or E-2); Order Fixing
Hearing Date and Appointing Attorney
for Alleged Incapacitated Person (Form
F); Judgment of Incapacity and
Appointment of Guardian(s) of the
Person (Form G).
one (1) copy of each of the completed
forms.
The filing fee in the amount of $200. It
must be a check or money order payable
to the Surrogate in the county in which
the application is filed.
A self-addressed stamped envelope so
that the court will be able to return the
filed forms to you. Be sure to include
adequate postage.
STEP 10: Mail or deliver the forms to the
court.
You may mail or deliver to the court the original
and one copy of all the forms: Adult
Guardianship Case Information Statement
(Form A); Verified Complaint to Appoint
Guardian(s) of the Person (Form B);
Certification of Assets (Form C); Certification
of Physician or Psychologist (Form D); Cover
Page Individualized Education Program OR
Certification in Support of Guardianship (Form
E-1 or E-2); Order Fixing Hearing Date and
Appointing Attorney for Alleged Incapacitated
Person (Form F); Judgment of Incapacity and
Appointment of Guardian(s) of the Person
(Form G) along with a self-addressed stamped
envelope and the filing fee.
Published 02/2017, CN 12009 (Adult Guardianship – Person Only) page 9 of 34
The addresses of the Surrogates’ office for each
county can be found on the Judiciary’s website,
njcourts.gov/courts/civil/guardianship.html.
If you mail the papers, we recommend that you
use certified mail, return receipt requested.
STEP 11: Appear in court on the date set by
the judge for your hearing.
Keep copies of all papers you provide to the
court or any other party. Make and keep for
yourself copies of all completed forms and any
canceled checks, money orders, receipts, bills,
contract estimates, letters, leases, photographs
and other important papers that relate to your
case.
Published 02/2017, CN 12009 (Adult Guardianship – Person Only) page 10 of 34
Instructions for Completing the Adult Guardianship
Case Information Statement - Form A
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.
Form A
Published 02/2017, CN 12009 (Adult Guardianship – Person Only) page 11 of 34
Published 02/2017, CN 11920 (Adult Guardianship CIS)
New Jersey Judiciary
Adult Guardianship
Case Information Statement
Use for initial Chancery Division Probate Part Pleadings under Rule 4:5-1
Pleading will be rejected for filing, under Rule 1:5-6(c), if information is not
completed or signature is not affixed
For Chambers or Surrogate’s
Office Use Only
Date Filed:
Docket Number:
Chambers:
Surrogate’s Office:
Plaintiff Alleged Incapacitated Person (AIP):
Name (last, first, middle initial)
Name (last, first, middle initial)
Address: Street
Address: Street
City
State
Zip
City
State
Zip
Age
Telephone
Relationship to AIP
Date of Birth
Social Security Number
Case Type
Title 30 (DDD) Title 3B (DD) Title 3B (All Others)
Is the Plaintiff the proposed guardian?
Yes
No
Are any other person(s) proposed guardian(s)?
Yes
No
All person(s) proposed as guardian(s)
: (Attach additional sheets if necessary to list all proposed guardian(s))
Name (last, first, middle initial)
Name (last, first, middle initial)
Address: Street
Address: Street
City
State
Zip
City
State
Zip
Age
Telephone
Relationship to AIP
Age
Telephone
Relationship to AIP
Other person(s) or entities to be noticed: (Attach additional sheets if necessary to list all parties to be noticed, including DDD
Administrator and County Adjuster, if applicable)
Name (last, first, middle initial)
Name (last, first, middle initial)
Address: Street
Address: Street
City
State
Zip
City
State
Zip
Age
Telephone
Relationship to AIP
Age
Telephone
Relationship to AIP
Does any party need an interpreter?
If yes, for whom and for what language?
Yes No
Does any party need an accommodation for a disability?
If yes, please identify the party and requested accommodation
Yes No
I certify that I have completed this form to the best of my knowledge and ability, and will supplement this form
as may be necessary should additional information become available. I further certify that, except as required
on this page, confidential personal identifiers have been redacted from documents now submitted to the
court, and will be redacted from all documents submitted in the future in accordance with Rule 1:38-7(b).
Date
Attorney/Plaintiff Signature
Save
Print ALL forms
Clear ALL forms
Published 02/2017, CN 12009 (Adult Guardianship – Person Only) page 12 of 34
Instructions for Verified Complaint to Appoint Guardian(s) of the Person
Form B
1. At the top left of the form, enter your name, address, and daytime phone number. If you are not an attorney, leave the
Attorney ID and Law Firm/Agency Name fields blank.
2. On the line above Name of Alleged Incapacitated Person (AIP), fill in the full legal name of the alleged incapacitated
person for whom you are seeking a guardianship.
3. On the line labeled County, enter the county in which the alleged incapacitated person resides. This will be the county
where the action is filed.
4. Leave Docket Number blank. It will be assigned and filled in by the Court upon filing.
5. Fill in the blank spaces in the first paragraph indicating your full legal name, age, residence, county, state, domicile
(this may be the same as your residence). and relationship to the alleged incapacitated person.
6. Select the appropriate checkbox indicating whether you are the only person bringing this action or whether it is being
brought by multiple people. If multiple people are bringing the action, fill in their name, age, and present residence
and permanent/legal residence in the space provided.
7. Item #1: Fill in the information for the alleged incapacitated person and their spouse (if applicable).
8. Item #2: If the alleged incapacitated person has been determined eligible for services from the New Jersey Division of
Developmental Disabilities (DDD), fill in the alleged incapacitated person’s name. If not applicable, check the box for
Not Applicable. If applicable, indicate when the alleged incapacitated person began receiving services from the New
Jersey Division of Developmental Disabilities (DDD) and describe what services the alleged incapacitated person
receives. If not applicable, check the box for Not Applicable.
9. Item #3: Fill in the requested information. Reminder: include a copy of the Certification of Physician or Psychologist
completed by a licensed physician or psychologist (Form D) with your Verified Complaint.
10. Item #4: Check the appropriate response as to which document will be used to further support your application for the
appointment of a guardianship of the person. Reminder: include a copy of the chosen document (Form E-1 or Form
E-2) with your Verified Complaint.
11. Item #5: This section identifies people who may have an interest in the guardianship proceeding and should receive
Notice of the action. Fill in the name, address, relationship to the alleged incapacitated person, and age for all those
that should receive notice of this action. List all known persons closely related to the alleged incapacitated person
(i.e. parents, children, siblings).
If another individual or institution currently has care and custody of the alleged incapacitated person, please provide
their name and address in the appropriate section. If not applicable, check the box for Not Applicable.
If the alleged incapacitated person previously lived in an institution, please provide the name of the institution, dates
of residency, and identify the authority which permitted or required the commitment. If not applicable, check the box
for Not Applicable.
If any person has been named as an attorney-in fact in any power of attorney document, health care representative in
any health care directive, and/or a trustee in a trust for the benefit of the alleged incapacitated person, please provide
the requested information. If not applicable, check the box for Not Applicable.
12. Item #6: Provide the name(s), address(es), relationship(s), age(s) and telephone number(s) for the person(s) proposed
as guardian(s).
13. Item #7: Include a copy of the Certification of Assets (Form C).
14. Item #8: The interests of the alleged incapacitated person must be represented at the guardianship hearing. Select the
appropriate option whether you are requesting that the court appoint an attorney from the Office of the Public
Published 02/2017, CN 12009 (Adult Guardianship – Person Only) page 13 of 34
Defender Division of Mental Health Advocacy for no charge, or whether you are requesting that the court appoint a
private attorney.
Please note that your hearing date may be delayed if you request an attorney from the Public Defender’s office.
Please also note that if you are requesting the court appoint a private attorney, the Court may order that the attorney’s
fees come out of the assets of the incapacitated person. Should the incapacitated person not have available funds to
cover these fees, the Court may order that you pay them.
15. Item #9: A guardianship of the person is appropriate where the alleged incapacitated person is unable to make
decisions about their personal well-being, such as their residence and/or medical care. A full guardianship of the
person is appropriate where the alleged incapacitated person is impaired to the point where they are unable to govern
themselves in all areas related to their personal well-being. A limited guardianship of the person is appropriate
where the alleged incapacitated person is able to govern themselves in some areas, but lacks the capacity to make
decisions in other areas. (For example, the alleged incapacitated person is able to make decisions regarding their
residence, but unable to make decisions regarding their health care.)
• Select Option 1
if you are seeking a full guardianship of the person, and enter the alleged incapacitated
person’s full name in the two blank areas
. Complete the “Wherefore” paragraph by entering the full legal
name of the alleged incapacitated person in the first blank space, the full legal name(s) of the proposed
guardian(s) in the second blank space, and the full legal name of the alleged incapacitated person in the final
blank space.
• Select Option 2 if you are seeking a limited guardianship of the person, and enter the alleged
incapacitated person’s full name in the three blank areas.
Note: If selecting this option, check the boxes to
show areas where the alleged incapacitated person is able to make their own decisions
. Complete the
“Wherefore” paragraph by entering the full legal name of the alleged incapacitated person in the first blank
space, the full legal name(s) of the proposed guardian(s) in the second blank space, and the full legal name of
the alleged incapacitated person in the final blank space
.
Verification: Fill out and sign the verification.
IMPORTANT NOTE: If the complaint or any of the copies of papers that you attach to the complaint contain a Social
Security number, driver’s license number, vehicle plate number, insurance policy number, active financial account
number or active credit card number, you must redact (black out) this information so that it cannot be seen, unless any
such personal identifier is required to be included by statute, rule, administrative directive or court order. If an active
financial account is the subject of your case and cannot otherwise be identified, you may use the last four digits of the
account to identify it. Do not redact (black out) this information in the original papers that you are keeping since you may
have to show them to the court at some point.
Form B
Published 02/2017, CN 12009 (Adult Guardianship – Person Only) page 14 of 34
Published 02/2017, CN 12010 (Verified Complaint to Appoint Guardian of the Person)
Filing Attorney Information or Pro Se Litigant:
Name
NJ Attorney ID Number
Law
Firm/Agency Name
Address
Telephone Number
Superior Court of New Jersey
Chancery Division - Probate Part
In the Matter of,
County
,
Docket Number
Civil Action
Verified Complaint to Appoint
Guardian(s) of the Person
Name of Alleged Incapacitated Person (AIP)
an
Alleged Incapacitated Person
I,
, by way of verified complaint, say:
I am
years of age. I reside at , County of
, and State of . I have domicile (permanent/legal residence) at
. My relationship to the allege
d incapacitated person
(AIP) is
. My interest in this action is the welfare of the alleged
incapacitated person.
I am (check one)
the only individual bringing this action for guardianship; OR
one of two or more individuals bringing this action for guardianship. Below is the name, age,
present residence, and permanent/legal residence (domicile) of the other applicant(s).
1.
The name, age, present address, permanent/legal residence (domicile), and marital status of the
alleged incapacitated person are as follows:
Name
Age
Present Address
How long at this address?
Marital Status
Permanent/Legal Residence (Domicile)
Spouse’s information, if married:
Name
Age
Present Address
Permanent/Legal Residence (Domicile)
Published 02/2017, CN 12009 (Adult Guardianship – Person Only) page 15 of 34
Published 02/2017, CN 12010 (Verified Complaint to Appoint Guardian of the Person)
If applicable:
Not Applicable
The alleged incapacitated person , has been determined eligible
for services from the New Jersey Division of De
velopmental Disabilities (DDD).
If applicable:
Not Applicable
The alleged incapacitated person has been receiving services from the DDD since .
Currently, these services consist of:
3.
The alleged incapacitated person, , has been diagnosed as
having
, as set forth by the attached
affidavit or certification of
, (Physician or Psychologist).
Because of this condition,
lacks sufficient capacity to govern
him/herself to the extent set forth below.
4.
The functional capacity of the alleged incapacitated person is further detailed by one of the
following documents, attached to this complaint:
(check one)
A copy of the Individualized Education Program (IEP) for the alleged incapacitated person; OR
An affidavit or certification from the chief executive officer, medical director, or other officer
having administrative control over the DDD program from which the alleged incapacitated
person is receiving services;
OR
An affidavit or certification from a designee of the DDD having personal knowledge of the
functional capacity of the AIP;
OR
A second affidavit or certification of a physician or psychologist; OR
An affidavit or certification from a licensed care professional having personal knowledge of the
functional capacity of the alleged
incapacitated person.
5.
The names, addresses, relationships and ages of the persons most closely related to the alleged
incapacitated person (parents, children, siblings) are as follows:
Name
Address
Relationship to AIP
Age
If applicable:
Not Applicable
The name and address of the person or institution having the care and custody of the alleged
incapacitated person is as follows:
Published 02/2017, CN 12009 (Adult Guardianship – Person Only) page 16 of 34
Published 02/2017, CN 12010 (Verified Complaint to Appoint Guardian of the Person)
If applicable:
Not Applicable
If the alleged incapacitated person has lived in an institution, the date(s) of any commitment or
confinement and by what authority committed or confined, are as follows:
Institution
Period(s) of Residence
If applicable:
Not Applicable
The name(s) and address(es) of any person(s) named as an attorney-in-fact in any power of attorney,
and/or any person named as health care representative in any health care directive, and/or any person
acting as trustee under a trust for the benefit of the alleged incapacitated person, are as follows:
Name
Role (Attorney-In-Fact, Health Care Representative, Trustee)
6.
The name(s), address(es), relationship to the alleged incapacitated person, age and telephone number
of the proposed guardian(s) are as follows:
(attach additional pages as necessary).
Name
Address
Relationship
Age
Telephone No.
Name
Address
Relationship
Age
Telephone No.
Name
Address
Relationship
Age
Telephone No.
7.
Information about the real and personal property and income of the alleged incapacitated person is
set forth in the attached Certification of Assets
.
8.
Guardianship of the person only is requested at this time. (check one)
I request that the court appoint the Office of the Public Defender Division of Mental Health
Advocacy,
pro bono (without cost), to represent the alleged incapacitated person. I understand
that the guardianship hearing may be scheduled on a later date if the Office of the Public
Defender Division of Mental Health Advocacy is appointed as counsel.
OR
I request that the court appoint a private attorney, potentially for cost, to represent the alleged
incapacitated person. I understand that if the assets of the alleged incapac
itated person are
insufficient to cover the fee charged by the court
-appointed attorney, then the court may order
that I pay that fee.
Published 02/2017, CN 12009 (Adult Guardianship – Person Only) page 17 of 34
Published 02/2017, CN 12010 (Verified Complaint to Appoint Guardian of the Person)
9.
Request for Guardianship of the Person (check one)
Option 1:
Request for General (Full) Guardianship of the Person
The condition of renders him/her without the necessary
cognitive capacity to govern himself/herself in
all areas (including medical, legal, residential,
educational, and vocational).
requires a general (full)
guardian of the person
.
WHEREFORE, the plaintiff(s) demand(s) judgment pursuant to N.J.S.A. 30:4-165.7, declaring
to be suffering from a chronic functional impairment that
renders him/her incapable of governing himself/herself in all areas, and appoin
ting
as general (full) guardian(s) of the person of
.
OR
Option 2:
Request for Limited Guardianship of the Person
The condition of renders him/her without the necessary
cognitive capacity to govern himself/herself in
some areas. However,
retains the necessary cognitive capacity to make some
decisions regarding his/her person and requires a limited guardian.
Specifically,
retains the capacity to make decisions
regarding the following
areas: (check all that apply)
medical decision making legal decision making financial decision making
residential decision making
educational decision making
vocational decision making
other (voting, driving, etc.)
WHEREFORE, the plaintiff(s) demand(s) judgment pursuant to N.J.S.A. 30:4-165.7, declaring
to be suffering from a chronic functional impairment that
renders him/her incapable of governing himself/herself in some areas,
and appointing
as limited guardian(s) of the person of
.
Date
Signature
Print Name
Verification
I/We hereby certify and say:
1.
I/We am/are the plaintiff(s).
2.
The contents of the Verified Complaint for Guardianship are true to the best of my/our knowledge.
Date
Signature
Print Name
Date
Signature
Print Name
Published 02/2017, CN 12009 (Adult Guardianship – Person Only) page 18 of 34
Instructions for Completing the Certification of Assets
Form C
1. At the top left of the form, enter your name, address, and daytime phone number. If you are not an attorney, leave the
Attorney ID and Law Firm/Agency Name fields blank.
2. On the line above Name of Alleged Incapacitated Person (AIP), fill in the full legal name of the alleged incapacitated
person for whom you are seeking a guardianship.
3. On the line labeled County, enter the county in which the alleged incapacitated person resides. This will be the county
where the action is filed.
4. Leave Docket Number blank. It will be assigned and filled in by the Court upon filing.
5. Fill in the blank spaces in the first paragraph indicating your full legal name and the full legal name of the alleged
incapacitated person.
6. Select the appropriate checkbox as to whether or not the alleged incapacitated person possesses property.
• If you select the first option (the alleged incapacitated person possesses no property, or possesses only Social
Security benefits, etc.), enter the alleged incapacitated person’s full legal name on the line. Note: If you select
this option, be sure to check “None” in Schedules A through F. If the alleged incapacitated person possesses
Social Security benefits, describe them in Schedule G; if not, check “None”.
• If you select the second option (the alleged incapacitated person possesses property, or possesses money other
than Social Security benefits, a State-funded Personal Needs Allowance, and/or funds held in trust for their
benefit), you must provide a complete and accurate statement and valuation of all real and personal property and
income of the alleged incapacitated person.
o A diligent inquiry must be performed to identify the requested information. All Schedules (A through G)
must be completed to the best of your ability. The proper entry for any schedule without assets is “None.”
If you are unsure whether a particular type of asset exists, the proper entry is “Unknown.” Should
additional information regarding the alleged incapacitated person’s assets be discovered, this form should
be supplemented.
7. Schedule A: Identify the incapacitated person’s interests in real property (i.e. homes or land). This includes land held
jointly or in common with other individuals. Provide the most recent municipal tax assessed value and market value
for the property. The market value may be estimated rather than based upon a new appraisal.
8. Schedule B: Identify the incapacitated person’s interest in stocks, bonds, mutual funds, securities and investment
accounts. This includes any interest held jointly or in common with other individuals, or in trust. For Schedule B,
you are asked to provide face value, if applicable, and market value. Some assets, like bonds, will have both a face
value and a market value. For those assets, list both the face value and market value. Other assets will only have a
market value.
9. Schedule C: Identify any checking accounts, savings accounts, certificates of deposit in banks, notes or other
indebtedness due the alleged incapacitated person.
10. Schedule D: List any pension or retirement accounts.
11. Schedule E: List any other personal property including, but not limited to, any motor vehicles, recreation vehicles,
collections, interests in partnerships/ unincorporated businesses, etc.
12. Schedule F: List any secured debts or encumbrances on the above assets (i.e. mortgage on a home, car loan).
13. Schedule G: List all sources of monthly income.
14. Complete the Certification at the bottom.
Form C
Published 02/2017, CN 12009 (Adult Guardianship – Person Only) page 19 of 34
Revised 01/2018, CN 12011 (Certification of Assets)
Filing Attorney Information or Pro Se Litigant:
Name
NJ Attorney ID Number
Law Firm/Agency Name
Address
Telephone Number
Superior Court of New Jersey
Chancery Division - Probate Part
In the Matter of,
County
,
Docket Number
Civil Action
Certification of Assets
Name of Alleged Incapacitated Person (AIP)
an Alleged Incapacitated Person
I,
, of full age, hereby certify as follows:
This certification is made by me in support of an application for a declaration of i
ncapacity for
. (Check one)
The alleged incapacitated person, , possesses no property, or
possesses only Social Security benefits
, a State-funded Personal Needs Allowance, and/or funds held in
trust for his/her benefit.
(Note: If you select this option, check “None” Schedules A-F below. If the alleged
incapacitated person possesses Social Security benefits, describe them in Schedule G; if not, check “None
”.)
OR
The following schedules contain a complete and accurate statement and valuation of all real and personal
property and income
of , based upon my diligent inquiry.
Schedule A: Real Property
None
Unknown
All interests in real property including real property held in common or jointly with other(s) and, if held jointly,
describe the interest.
#
Description: Address (include county and state)
Municipal Tax
Assessed Value
Market Value
1.
$
$
2.
$
$
Total Schedule A
$
Schedule B: Stocks, Bonds, Mutual Funds, Securities and Investment Accounts
None
Unknown
Include all interests in stocks, bonds, mutual funds, securities and investment accounts including int
erests held in
common or jointly with other(s) or in trust, and, if held jointly, describe the interest.
#
Description (include name of financial institution, account type, number of
shares or last four digits of account and date value fixed)
Face Value Market Value
1.
$
$
2.
$
$
Total Schedule B
$
0.00
0.00
Published 02/2017, CN 12009 (Adult Guardianship – Person Only) page 20 of 34
Published 02/2017, CN 12011 (Certification of Assets)
Schedule C: Money on Hand
None
Unknown
Checking and savings accounts and certificates of deposit in banks and notes or other indebtedness due the
alleged incapacitated person.
#
Description (include name of financial institution, account type, last four digits of account and
date value fixed)
Value
1.
$
2.
$
Total Schedule C
$
Schedule D: Pensions, retirement accounts
None
Unknown
IRA’s, 401(k), annuities, profit sharing plans, etc. Include last four digits of account.
#
Description (include name of financial institution, account type, last four digits of account and
date value fixed)
Value
1.
$
2.
$
Total Schedule D
$
Schedule E: Miscellaneous Personal Property
None
Unknown
Tangible personal property, motor vehicles, recreation vehicles, employment bonus or award, interest i
n a
partnership or unincorporated business, articles or collections have either artistic or intrinsic value, etc.
# Description Value
1.
$
2.
$
Total Schedule E
$
Schedule F: Liabilities/Encumbrances
None
Unknown
If any asset listed in this certification has a secured associated debt, such as a mortgage or a car l
oan, indicate
below. List all other debts.
# Description
Encumbrance
Amount
1.
$
2.
$
Total Schedule F
$
Schedule G: Sources of Monthly Income
None
Unknown
# Description Value
1.
$
2.
$
Total Schedule G
$
I hereby certify and say that the foregoing statements made by me are true to the best of my knowledge, and that I
will supplement this form as may be necessary should additional information become available.
I am aware that
if any of the foregoing statem
ents made by me are willfully false, I am subject to punishment.
Date
Signature
Print Name
0.00
0.00
0.00
0.00
0.00
Published 02/2017, CN 12009 (Adult Guardianship – Person Only) page 21 of 34
Instructions for Completing the Certification of Physician or Psychologist - Form D
This is a form certification which should be provided to the physician or psychologist who will be supporting
your application for declaration of incapacity. Provide this certification to the physician or psychologist to be
filled out. Should additional room be needed, the physician or psychologist may attach a separate report.
Remember to include this certification with your Verified Complaint.
1. At the top left of the form, enter your name, address, and daytime phone number. If you are not an attorney,
leave the Attorney ID and Law Firm/Agency Name fields blank.
2. On the line above Name of Alleged Incapacitated Person (AIP), fill in the full legal name of the alleged
incapacitated person for whom you are seeking a guardianship.
3. On the line labeled County, enter the county in which the alleged incapacitated person resides. This will be
the county where the action is filed.
4. Leave Docket Number blank. It will be assigned and filled in by the Court upon filing.
5. The remainder of the form is to be filled out by the certifying physician or psychologist.
Form D
Published 02/2017, CN 12009 (Adult Guardianship – Person Only) page 22 of 34
Published 02/2017, CN 12012 (Certification of Physician or Psychologist)
Filing Attorney Information or Pro Se Litigant:
Name
NJ Attorney ID Number
Law Firm/Agency Name
Address
Telephone
Number
Superior Court of New Jersey
Chancery Division - Probate Part
In the Matter of,
County
,
Docket Number
Civil Action
Certification of
Physician or Psychologist
Name of Alleged Incapacitated Person (AIP)
an
Alleged Incapacitated Person
I,
, (check one) M.D., D.O., Ph.D., Psy.D., of full age,
hereby certify as follows:
1.
This certification is made by me in support of an application for a declaration of incapacity for
, an alleged incapacitated person.
2.
was born on . S/He is years old. S/He
weighs
pounds and is approximately in height. S/He has hair and
eyes.
3.
Select one:
I am a (check one) physician psychologist licensed to practice in the State of . I
currently maintain an office at
. I
am, and have been, in the actual practice of for years.
OR
I am an employee of the Division of Developmental Disabilities authorized to conduct
psychological evaluations as part of my duties
.
4.
I earned a degree in , from .
in
. I received my license to practice in the State of in . My area of specialty is
.
5.
I examined the alleged incapacitated person on . This examination took place at
.
6.
Select one:
I have been treating the alleged incapacitated person for ,
since .
OR
I am not treating the alleged incapacitated person for , but have
merely examined her/him for the purpose of evaluating her/his mental capacity.
Published 02/2017, CN 12009 (Adult Guardianship – Person Only) page 23 of 34
Published 02/2017, CN 12012 (Certification of Physician or Psychologist)
7.
During my examination, I observed that s/he was (describe findings or attach report)
8.
As a result of my examination and a review of her/his history, my diagnosis is
. The prognosis for recovery is .
9.
In my opinion, the alleged incapacitated person is:
unfit and unable to govern herself/himself and to manage her/his affairs in all areas.
OR
unfit and unable to govern herself/himself and to manage her/his affairs in some areas but does
have capacity in the areas listed below (select all that apply):
medical decision making legal decision making residential decision making
educational decision making vocational decision making financial decision making
other (please describe)
10.
My opinion is based upon the examination of the alleged incapacitated person, and the history of
her/his condition. The factual basis for my diagnosis and prognosis, and my opinion as to any areas
in which the individual retains capacity, is: (describe or attach report)
11.
It is my opinion that the alleged incapacitated person (check one)
is is not capable of
attending the court hearing in this matter. If the alleged incapacitated
person is not capable of
attending the court hearing the following are the reasons for the individual’s inability:
12.
I am not related either through blood or marriage, to the alleged incapacitated person, nor to a
proprietor, director or chief
executive officer of any institution for the care and treatment of the
mentally ill in which the alleged incapacitated person is living or in which it is proposed to place
her/him; nor am I professionally employed by the management thereof as a resident ph
ysician or
psychologist; nor am I financially interested therein
.
I hereby certify and say that the foregoing statements made by me are true to the best of my
knowledge, and that I will supplement this form as may be necessary should additional information
become available.
I am aware that if any of the foregoing statements made by me are willfully false,
I am subject to punishment
.
Date
Signature
Print Name
Published 02/2017, CN 12009 (Adult Guardianship – Person Only) page 24 of 34
Instructions for Completing the
Cover Page - Individualized Education Program (IEP) - Form E-1
Use this form only if providing an Individualized Education Program as a supporting document:
1. At the top left of the form, enter your name, address, and daytime phone number. If you are not an attorney, leave the
Attorney ID and Law Firm/Agency Name fields blank.
2. On the line above Name of Alleged Incapacitated Person (AIP), fill in the full legal name of the alleged incapacitated
person for whom you are seeking a guardianship.
3. On the line labeled County, enter the county in which the alleged incapacitated person resides. This will be the county
where the action is filed.
4. Leave Docket Number blank. It will be assigned and filled in by the Court upon filing.
5. Fill out the requested information including the academic year for which the IEP was developed. Attach a copy of the
IEP including all medical and other reports.
Instructions for Completing the
Certification in Support of Guardianship - Form E-2
Form E-2 is a form certification which can be provided to the person making the certification or affidavit supporting your
application for declaration of incapacity. You may provide this certification to the appropriate person to be filled out, or
they may provide their own certification including the same information. Remember to include the original certification
or affidavit with your Verified Complaint.
If not providing an Individualized Education Program as a supporting document to your application, one of the following
affidavits or certifications must be provided:
• An affidavit or certification from the chief executive officer (CEO), medical director, or other officer having
administrative control over the DDD program from which the alleged incapacitated person is receiving
services; OR
• An affidavit or certification from a designee of the DDD having personal knowledge of the functional
capacity of the alleged incapacitated person; OR
• A second affidavit or certification of a physician or psychologist; OR
• An affidavit or certification from a licensed care professional having personal knowledge of the functional
capacity of the alleged incapacitated person.
1. At the top left of the form, enter your name, address, and daytime phone number. If you are not an attorney, leave the
Attorney ID and Law Firm/Agency Name fields blank.
2. On the line above Name of Alleged Incapacitated Person (AIP), fill in the full legal name of the alleged incapacitated
person for whom you are seeking a guardianship.
3. On the line labeled County, enter the county in which the alleged incapacitated person resides. This will be the county
where the action is filed.
4. Leave Docket Number blank. It will be assigned and filled in by the Court upon filing.
5. The remainder of the form is to be filled out by the certifying person.
Form E-1
Published 02/2017, CN 12009 (Adult Guardianship – Person Only) page 25 of 34
Published 02/2017, CN 12014 (Certification in Support of Guardianship - IEP)
Filing Attorney Information or Pro Se Litigant:
Name
NJ Attorney ID Number
Law Firm/Agency Name
Address
Telephone Number
Superior Court of New Jersey
Chancery Division - Probate Part
In the Matter of,
County
,
Docket Number
Civil Action
Cover Page
Individualized Education Program
(IEP)
Name of Alleged Incapacitated Person (AIP)
an
Alleged Incapacitated Person
Attached is a copy of the Individualized Education Program (IEP) for
.
This IEP was prepared for the 20
/20 Academic Year.
All medical and other reports included in this IEP are attached
.
I hereby certify and say that the foregoing st
atements made by me are true to the best of my knowledge,
and that I will supplement this form as may be necessary should additional information become
available
. I am aware that if any of the foregoing statements made by me are willfully false, I am
subject to punishment.
Date
Signature
Print Name
Form E-2
Published 02/2017, CN 12009 (Adult Guardianship – Person Only) page 26 of 34
Published 02/2017, CN 12014 (Certification in Support of Guardianship)
Filing Attorney Information or Pro Se Litigant:
Name
NJ Attorney ID Number
Law Firm/Agency Name
Address
Telephone Number
Superior Court of New Jersey
Chancery Division - Probate Part
In the Matter of,
County
,
Docket Number
Civil Action
Certification in Support of
Guardianship
Name of Alleged Incapacitated Person (AIP)
an
Alleged Incapacitated Person
I,
, of full age, hereby certify as follows:
I am (check one)
the chief executive officer, medical director, or other officer having administrative control over
the program from which
is receiving functional or other
services provided by the Division of Developmental Disabilities;
OR
a designee of the Division of Developmental Disabilities having personal knowledge of the
functional capacity of
; OR
a licensed physician or psychologist; OR
a licensed care professional having personal knowledge of the functional capacity of
.
1.
This certification is made by me in support of an application for a declaration of incapacity for
, an alleged incapacitated person.
2.
I am personally familiar with the functional capacity of the alleged incapacitated person. My
knowledge of his/her functional capacity is based upon:
3.
In my opinion, the alleged incapacitated person is:
unfit and unable to govern herself/himself and to manage her/his affairs in all areas.
OR
unfit and unable to govern herself/himself and to manage her/his affairs in some areas but does
have capacity in the areas listed below (select all that apply):
medical decision making legal decision making financial decision making
residential decision making educational decision making vocational decision making
other (please describe)
4.
My opinion is based upon:
Form E-2
Published 02/2017, CN 12009 (Adult Guardianship – Person Only) page 27 of 34
Published 02/2017, CN 12014 (Certification in Support of Guardianship)
5.
It is my opinion that the alleged incapacitated person (check one) is is not capable of
attending the court hearing in this matter. If the alleged incapacitated person is not capa
ble of
attending the court hearing the following are the reasons for the individual’s inability:
6.
I am not related either through blood or marriage, to the alleged incapacitated person, nor to a
proprietor, director or chief executive officer of
any institution for the care and treatment of the
mentally ill in which the
alleged incapacitated person is living or in which it is proposed to place
her/him; nor am I professionally employed by the management thereof as a resident physician or
psychologi
st; nor am I financially interested therein.
I hereby certify and say that the foregoing statements made by me are true
to the best of my
knowledge, and that I will supplement this form as may be necessary should additional information
become available
. I
am aware that if any of the foregoing statements made by me are willfully false,
I am subject to punishment
.
Date
Signature
Print Name
Published 02/2017, CN 12009 (Adult Guardianship – Person Only) page 28 of 34
Instructions for Completing the Order Fixing Hearing Date and Appointing Attorney for
Alleged Incapacitated Person - Form F
1. At the top left of the form, enter your name, address, and daytime phone number. If you are not an attorney,
leave the Attorney ID and Law Firm/Agency Name fields blank.
2. On the line above Name of Alleged Incapacitated Person (AIP), fill in the full legal name of the alleged
incapacitated person for whom you are seeking a guardianship.
3. On the line labeled County, enter the county in which the alleged incapacitated person resides. This will be
the county where the action is filed.
4. Leave Docket Number blank. It will be assigned and filled in by the Court upon filing.
5. In the first paragraph, fill in your full legal name as the plaintiff. Fill in the alleged incapacitated person’s
full legal name on the second blank line.
6. Leave the remainder of the document blank. The court will use this document to schedule and order a
hearing on the guardianship application as well as appoint an attorney to represent the interests of the
alleged incapacitated person.
Form F
Published 02/2017, CN 12009 (Adult Guardianship – Person Only) page 29 of 34
Published 02/2017, CN 12013 (Order Fixing Guardianship Hearing Date and Appointing Attorney for AIP)
Filing Attorney Information or Pro Se Litigant:
Name
NJ Attorney ID Number
Law Firm/Agency Name
Address
Telephone Number
Superior Court of New Jersey
Chancery Division - Probate Part
In the Matter of,
County
,
Docket Number
Civil Action
Order Fixing Guardianship Hearing
Date and Appointing Attorney for
Alleged Incapacitated Person
an Alleged Incapacitated Person
THIS MATTER having been opened to the court by , plaintiff(s), for a
judgment declaring , an incapacitated person and appointing a guardian of
the person and/or estate (property) pursuant to applicable New Jersey statutes and Rules of Court, and for such
other relief as the court may deem just, and the court having read and considered the verified complaint, the
supporting certifications or affidavits, and all other papers and pleadings filed in this matter, and for good cause
shown:
IT IS on this day of , 20 , ORDERED that:
1. This matter be set down for hearing before this court at the County Courthouse,
, New Jersey on the day of , 20 , at a.m. p.m. or
as soon thereafter as plaintiff may be heard, to determine the issues of incapacity of
and the appointment of a guardian.
2. A copy of the verified complaint, supporting affidavits or certifications and this Order, shall be served on
the alleged incapacitated person, by personally serving the same at least 20 days prior to the date scheduled for the
hearing.
3. A separate notice shall be personally served on the alleged incapacitated person stating that if he/she
desires to oppose the action he/she may appear either in person or by attorney and may demand a trial by jury.
4. A copy of the verified complaint, supporting affidavits or certifications and this Order shall also be served
on all the next-of-kin and other parties-in-interest identified in the verified complaint by certified mail, return
receipt requested at least 20 days prior to the date scheduled for the hearing. If applicable, a copy of the verified
complaint, supporting affidavits or certifications and this Order shall be served on the County Adjuster and the
Regional Administrator for the Division of Developmental Disabilities.
5. , Esquire office address ,
telephone number , be and hereby is appointed as attorney for the alleged incapacitated person.
Said attorney shall personally interview the alleged incapacitated person, examine the medical records, make
inquiry of persons having knowledge of the alleged incapacitated person’s circumstances, his/her physical and
mental state and his/her property, make reasonable inquiries to locate any Will or other testamentary substitutes,
powers of attorney or health care directives previously executed by the alleged incapacitated person, or to
Published 02/2017, CN 12009 (Adult Guardianship – Person Only) page 30 of 34
Published 02/2017, CN 12013 (Order Fixing Guardianship Hearing Date and Appointing Attorney for AIP)
discover any interests the alleged incapacitated person may have as a beneficiary of a will or trust. Said attorney
shall prepare a written report of findings and recommendations (and, if applicable, an affidavit of services) to be
filed with the Court and with the plaintiff(s) and other parties who have filed a written response at least ten (10)
days prior to the hearing.
SELECT ONE:
The attorney appointed to represent the alleged incapacitated person is appointed pro bono (without cost);
OR
The attorney appointed to represent the alleged incapacitated person is to be paid. Pursuant to
R. 4:86-4(d), the court may direct that counsel be paid from the assets of the alleged incapacitated person,
or if such assets are insufficient, then from the party seeking guardianship or otherwise.
6. If the alleged incapacitated person obtains counsel other than that appointed by the above paragraph, such
counsel shall notify the court and appointed counsel at least ten (10) days prior to the hearing date.
7. A copy of the verified complaint, supporting affidavits or certifications and this Order shall be
immediately served on the attorney for the alleged incapacitated person by personal service, certified mail, return
receipt requested. If acceptable to the court-appointed attorney, service may be via facsimile, by regular mail,
and/or by email.
8. The attorney above appointed to represent the alleged incapacitated person is hereby regarded as a
HIPAA (Health Insurance Portability and Accountability Act) representative for the alleged incapacitated person
and shall have the right and power to examine complete medical records, including medical and psychiatric
records and written charts, pertaining to the alleged incapacitated person, and to visit and confer with the alleged
incapacitated person.
9. The attorney above appointed to represent the alleged incapacitated person shall have the right and power
to examine financial and legal documents and records pertaining to the alleged incapacitated person.
10. The plaintiff shall file with the County Surrogate a proof of service of the pleadings required by this order
to be served on the alleged incapacitated person and the parties in interest no later than ten (10) days before the
date this matter is scheduled to be heard.
11. Any next-of-kin and other party-in-interest who wishes to be heard with respect to any of the relief
requested in the verified complaint shall file with the Surrogate of County at the following location:
, together with the applicable filing fee and serve upon the
attorney for the plaintiff and the attorney for the alleged incapacitated person at the address set forth above, a
written answer, an answering affidavit, a motion returnable on the date this matter is scheduled to be heard or
other written response ten (10) days before the date this matter is scheduled to be heard.
12. If applicable, any proposed guardian shall complete guardianship training as promulgated by the
Administrative Director of the Courts, by viewing or otherwise reviewing the Court Appointed Guardian Tutorial
posted on the Judiciary’s website at njcourts.gov/courts/civil/guardianship.html and receiving copies of the
relevant guardianship training guide(s).
J.S.C.
Published 02/2017, CN 12009 (Adult Guardianship – Person Only) page 31 of 34
Instructions for Completing the Judgment of Incapacity and Appointment of
Guardian(s) of the Person - Form G
1. At the top left of the form, enter your name, address, and daytime phone number. If you are not an attorney,
leave the Attorney ID and Law Firm/Agency Name fields blank.
2. On the line above Name of Alleged Incapacitated Person (AIP), fill in the full legal name of the alleged
incapacitated person for whom you are seeking a guardianship.
3. On the line labeled County, enter the county in which the alleged incapacitated person resides. This will be
the county where the action is filed.
4. Leave Docket Number blank. It will be assigned and filled in by the Court upon filing.
5. Leave the remainder of the document blank. The court will use this document if your application for a
guardianship is granted. This document will set the terms for the guardianship.
Form G
Published 02/2017, CN 12009 (Adult Guardianship – Person Only) page 32 of 34
Published: 02/2017, CN 11988 (Judgment of Incapacity and Appointment of Guardian(s) of the Person)
Filing Attorney Information or Pro Se Litigant:
Name
NJ Attorney ID Number
Law Firm/Agency Name
Address
Telephone Number
Superior Court of New Jersey
Chancery Division - Probate Part
In the Matter of:
County
,
Docket No.
Civil Action
Judgment of Incapacity and
Appointment of Guardian(s) of the
Person
an Incapacitated Person
THIS MATTER
being opened to the Court by , plaintiff(s),
by and through
his/her attorney
, , in the presence of ,
attorney for the then alleged incapacitated person, and
, the then alleged
incapacitated person, and no demand having been made for a jury trial, and the Court sitting without a jury having
found from the report of counsel together with the report of the examining physician or psychologist and other
supporting document and proofs given that
is an incapacitated person who
lacks sufficient capacity to govern himself/herself, and it further appearing tha
t ,
consents
to serve as Guardian(s) of the Person of , and for good cause
shown:
IT IS on this day of , 20 , ORDERED AND ADJUDGED that:
1.
GENERAL (FULL) GUARDIANSHIP: , is an incapacitated person
and is unfit and unable to govern himself/herself and manage his/her affairs in all areas relating to his/her
person.
OR
LIMITED GUARDIANSHIP: , is an incapacitated person and is
unfit
and unable to govern himself/herself and manage his/her affairs in all areas relating to his/her
person
except that is fully able at this time to govern
himself/herself and manage his/her own affairs with respect to the following areas:
Check if applicable:
The subject of this guardianship is incapacitated as a result of developmental disability.
Firearms: Pursuant to 18 U.S.C. 922(g)(4), the incapacitated person does not retain the right to possess
firearms
.
Published 02/2017, CN 12009 (Adult Guardianship – Person Only) page 33 of 34
Published: 02/2017, CN 11988 (Judgment of Incapacity and Appointment of Guardian(s) of the Person)
2. GUARDIAN APPOINTMENT: be and hereby is/are appointed
Guardian(s) of the Person of the incapacitated person
and that Letters of Guardianship of the Person be issued
upon his/her/their (a) qualifying according to law, (b) acknowledging to the Surrogate completion of
guardianship training and receipt of the guardianship training guides.
3. Upon qualifying, the Surrogate shall issue Letters of Guardianship of the Person to
and thereupon the guardian(s) be and hereby is/are authorized to
perform all the functions and duties of a Guardian of the Person as allowed by law, except as limited herein or
in areas where the incapacitated person retains decision making rights.
4. In exercising the authority conferred by this Judgment, the guardian(s) shall:
• Ascertain and consider those characteristics of the incapacitated person which define his/her uniqueness
and individuality, including but not limited to likes, dislikes, hopes, aspirations, and fears;
• Encourage the incapacitated person to express preferences and participate in decision-making;
• Give appropriate deference to the expressed wishes of the incapacitated person;
• Protect the incapacitated person from injury, exploitation, undue influence, and abuse;
• Promote the incapacitated person’s right to privacy, dignity, respect, and self-determination; and
• Make reasonable efforts to maximize opportunities and individual skills to enhance self-direction.
5. GUARDIAN LIMITATIONS: If applicable: the authority of the guardian(s) is limited as follows, and all
limitations shall be stated in the Letters of Guardianship.
6.
The guardian(s) appointed hereunder shall be considered the personal representatives under the Standards for
Privacy of Individually Identifiable Health Information ("Privacy Rule") issued pursuant to the Health
Insurance Portability and Accountability Act of 1996 ("HIPAA"), and shall have full and complete access to
all records of the incapacitated person.
7. REPORTING:
, as Guardian(s) of the Person, is/are hereby directed to file annually
a report of the well-being of the incapacitated person, along with a Report of Guardian Cover Page.
OR
The filing of a report of well-being is hereby waived for the reasons stated on the record.
8. The report indicated in paragraph 7 above is to be filed not later than fourteen (14) days after the anniversary
date of this judgment with the County Surrogate. The report to be filed by the guardian(s) shall be filed by
the Surrogate and shall be made available by the Surrogate to any party in interest entitled to review pursuant
to R. 1:38-3(e), as well as to the following parties or persons: , and the
reference in this Judgment shall constitute a showing of a special interest as required by R. 1:38-3(e) for the
purpose of reviewing such reports.
9. The Guardian(s) of the Person is/are hereby directed to advise the County Surrogate within ten (10) days of
any changes in the address or telephone number of himself or herself or the incapacitated person or within
thirty (30) days of the incapacitated person’s death or of any major change in status or health. If the
incapacitated person dies during the guardianship, the Guardian(s) will notify the Surrogate in writing and
forward a copy of the death certificate upon receipt.
Published 02/2017, CN 12009 (Adult Guardianship – Person Only) page 34 of 34
Published: 02/2017, CN 11988 (Judgment of Incapacity and Appointment of Guardian(s) of the Person)
10. The Guardian(s) of the Person is/are agent(s) of the court and shall cooperate fully with any court staff,
Surrogate staff, or volunteers until the guardianship is terminated by the death or return to capacity of the
incapacitated person, or the Guardian’s death, removal or discharge.
11. COUNSEL FOR INCAPACITATED PERSON:
The court-appointed attorney for the alleged incapacitated person, having reported to the court and
advocated on behalf of the incapacitated person, is hereby discharged with the appreciation of the court
for his or her pro bono services, with no further obligation to act as attorney for the incapacitated person.
OR
The court having reviewed the affidavit or certification of services of ,
Esquire, previously filed with the court, the Guardian of the Person shall,
within days of the date of
date of this Judgment, pay
, Esquire, court-appointed attorney for
the then alleged incapacitated person, a fee of
$ for professional services rendered and
$
for expenses incurred, which disbursements from the funds of the incapacitated person’s
estate are hereby approved. Court
-appointed counsel, having reported to the court and advocated on
behalf of the incapacitated person, be and hereby is discharged with no further obligation to act as
attorney for the incapacitate
d person.
12. Any power of attorney previously executed by the incapacitated person, other than a power of attorney
relating to the financial affairs of the incapacitated person, be and hereby is revoked. Any advance directive
for healthcare previously executed by the incapacitated person is voided as to proxy designation, but the
guardian(s) shall consider the preferences expressed in such advance directive.
13. Plaintiff(s) shall serve a Judgment upon the Guardian(s) and all interested parties and attorneys of record
within seven (7) days of receipt.
J.S.C.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

ities (DDD) (NJ Judiciary)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 20 May 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document