Physicians Affidavit - Guardianship
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Physicians Affidavit - Guardianship Form. This is a Illinois form and can be use in La Salle Local County.
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Tags: Physicians Affidavit - Guardianship, Illinois Local County, La Salle
Physician's Affidavit - Guardianship
UNITED STATES OF AMERICA
STATE OF ILLINOIS
COUNTY OF LASALLE
IN THE CIRCUIT COURT OF THE THIRTEENTH JUDICIAL CIRCUIT
IN THE MATTER OF THE ESTATE OF
_______________________________
Disabled Person
No.______________________
PHYSICIAN'S AFFIDAVIT - GUARDIANSHIP
___________________________________________, on oath states:
1.
I am licensed to practice medicine in all its branches in Illinois.
2.
On _________________________, 20______, I examined __________________________
3.
In
my opinion he/she
is _____________________________________________________
(physically) (and) (mentally)
incapable of
managing
his ___________________________________________________
(person) (estate) (person and estate)
4.
My opinion based on these facts: (Facts must correspond to Section 11a-9, Chapter 110 ½)
Signed and Sworn to before me
_______________________________, 20______
__________________________________________
_______________________________________
M.D.
Notary Public
_______________________________________
Address
Name: __________________________________
_______________________________________
Attorney for: _____________________________
Address: _________________________________
City
_______________________________________
Telephone
City: ____________________________________
Telephone: _______________________________
LASALLE COUNTY CIRCUIT CLERK
OTTAWA, ILLINOIS 61350
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