NOTICE: This is a not a public document. The information entered on this form will be kept confidential. You therefore must enter all requested information, including any requested personal identifying information, such as your Social Security number, driver's license number, or active bank or credit card accounts. New Jersey Judiciary For Chambers or Surrogate's Office Use Only Date Filed: Docket Number: Chambers: Surrogate's Office: 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 Plaintiff Name (last, first, middle initial) Address: Street City Age Telephone State Relationship to AIP Zip Alleged Incapacitated Person (AIP): Name (last, first, middle initial) Address: Street City Date of Birth State Social Security Number Zip Case Type Title 30 (DDD) Is the Plaintiff the proposed guardian? Are any other person(s) proposed guardian(s)? Title 3B (DD) Title 3B (All Others) Yes Yes No No All person(s) proposed as guardian(s): (Attach additional sheets if necessary to list all proposed guardian(s)) Name (last, first, middle initial) Address: Street City Age Telephone State Relationship to AIP Zip Name (last, first, middle initial) Address: Street City Age Telephone State Relationship to AIP Zip 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) Address: Street City Age Telephone State Relationship to AIP Zip Name (last, first, middle initial) Address: Street City Age Telephone State Relationship to AIP Zip Does any party need an interpreter? Yes No If yes, for whom and for what language? 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 Published 02/2017, CN 11920 (Adult Guardianship CIS) American LegalNet, Inc. www.FormsWorkFlow.com