FORM #522GC (01/2019) 62-5-108 STATE OF SOUTH CAROLINA ) ) COUNTY OF ) ) ) IN THE MATTER OF: ) PROBATE COURT USE ONLY , ) ) IN THE PROBATE COURT an alleged incapacitated individual. ) ) CASE NUMBER - GC - - ) ) EMERGENCY OR TEMPORARY ) PROCEEDINGS I examined , the alleged incapacitated individual (A.I.I.), as follows: DATE OF EXAMINATION: PLACE OF EXAMINATION: 1. As of the date of the examination, to a reasonable degree of medical certainty the A.I.I.: (check applicable boxes) is able to effectively receive, evaluate or respond to information or to make or communicate decisions with appropriate, reasonably available supports and assistance [as defined in S. C. Code Ann. 247 62-5-101(23)] in order to: meet the essential requirements for his/her physical health, safety, or self-care. manage property or financial affairs to provide for his/her support or the support of his /her legal dependents. is unable to effectively receive, evaluate or respond to information or to make or communicate decisions with appropriate, reasonably available supports and assistance [as defined in S.C. Code Ann. 247 62-5-101(23)] in order to: meet the essential requirements for his/her physical health, safety, or self-care. manage property or financial affairs to provide for his/her support or the support of his /her legal dependents. 2. There is a likelihood of irreparable or substantial harm to the As health, safety, or welfare due to his/her inability to make or communicate decisions as follows: SWORN to before me this day of Physician Signature: , 20 . Print Name: Practice Name: Address: Print Name: Notary Public for: Telephone: (State) Email: My Commission Expires: (Date) American LegalNet, Inc. www.FormsWorkFlow.com