THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) Guardianship of REQUEST FOR WAIVER OF PERSONAL APPEARANCE; WRITTEN STATEMENT (RSA 464-A:8, II) I/We, , represent that the proposed ward, , does not express a desire to attend the hearing concerning the finding of incapacity and appointment of a guardian of the person and estate, or the person, or estate. Date Petitioner(s) or Counsel for the proposed ward I certify that on this date I provided this document(s) to the parties who have filed an appearance for Hand-delivery OR US Mail OR this case or who are otherwise interested parties by: Email (E-mail only by prior agreement of the parties based on Circuit Court Administrative Order). Date Signature PHYSICIAN'S AFFIDAVIT (RSA 464-A:8,II) 1. 2. 3. I, , M.D., under oath, hereby depose and say: I am a medical physician at , located at . The proposed ward, , is a patient at . In my opinion, the proposed ward should be excused from attending the hearing concerning the finding of incapacity and appointment of a guardian of the person and estate, or the person, or estate, because: his/her overall physical, emotional or psychological condition is such that he/she is likely to suffer harm if required to attend; and/or he/she has no ability to understand the nature and consequences of the proceedings. Physician Signature (must be in presence of notarial officer) Date State of This instrument was acknowledged before me on , County of by Date Physician Signature of Notarial Officer / Title My Commission Expires Affix Seal, if any ORDER REQUEST FOR WAIVER OF PERSONAL APPEARANCE IS: Date NHJB-2168-P (03/25/2013) GRANTED DENIED Judge Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com