FORM 2 ________________________________________ IN THE MATTER OF: } } } } } } IN THE COURT OF COMMON PLEAS CHESTER COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION NO: AN ALLEGED INCAPACITATED PERSON PETITION FOR ADJUDICATION OF INCAPACITY AND APPOINTMENT OF GUARDIAN TO THE HONORABLE, THE JUDGE OF SAID COURT: Petitioner, ______________________________________ respectfully represents that: 1. The Petitioner, ________________________________________, resides at _______________________________________________________________________, and is the _______________________________________ (state relationship, if any, to alleged incapacitated person) of the alleged incapacitated person. 2. _________________________________________, an alleged incapacitated person, resides at ___________________________________________________________, which address is also the alleged incapacitated person's postal address. (If postal address is different from residence, state here: _______________________________________ ), and is __________ years of age, having been born on____________________________. 3. The name and address of the alleged incapacitated person's spouse is as follows: American LegalNet, Inc. www.FormsWorkFlow.com FORM 2 4. The name and address of the parents of the alleged incapacitated person are as follows: (if both parents are deceased, so state) 5. are as follows: The names and addresses of the presumptive adult heirs of the incapacitated person 6. The name and address of the person/institution providing residential services to the alleged incapacitated person is as follows: 7. The names and addresses of all other service providers to the alleged incapacitated person are as follows: 8. Petitioner requests that _______________________________ be appointed guardian of ______________________________. The proposed guardian's address is as follows: 9. The proposed guardian has no interest adverse to the alleged incapacitated person. 10. The petitioner believes that a guardian should be appointed for the alleged incapacitated person for the following reason: American LegalNet, Inc. www.FormsWorkFlow.com FORM 2 11. The physical condition of the alleged incapacitated person is as follows: 12. The mental condition of the alleged incapacitated person is as follows: 13. The following is a description of the functional limitations of the alleged incapacitated person: 14. The petitioner and/or others have made the following steps to find less restrictive alternatives to an adjudication of incapacity: 15. incapacity: Petitioner requests that a guardian be assigned powers over the following areas of Estate _____ ; Person _____. 16. The proposed guardian is qualified to serve as such for the following reason: American LegalNet, Inc. www.FormsWorkFlow.com FORM 2 17. 18. follows: The gross value of the alleged incapacitated person's estate is $ ________________. The net monthly income of the alleged incapacitated person from all sources is as 19. No other Court has ever assumed jurisdiction in a proceeding to determine the incapacity of ________________________________________. 20. The alleged incapacitated person's ability to receive and evaluate information effectively and communicate decisions in any way is impaired to such a significant extent that he/she is partially or totally unable to manage his/her financial resources or to meet essential requirements for his/her physical health and safety. WHEREFORE, your Petitioner prays your Honorable Court to issue a citation directed to __________________________________ to show cause why he/she should not be adjudicated an incapacitated person and a limited/plenary guardian of his/her estate/person be appointed to serve. ______________________________________ American LegalNet, Inc. www.FormsWorkFlow.com