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. Filing Attorney Information or Pro Se Litigant: Name NJ Attorney ID Number Law Firm/Agency Name Address Telephone Number In the Matter of, , Name of Alleged Incapacitated Person (AIP) Superior Court of New Jersey Chancery Division - Probate Part County Docket Number Civil Action an Alleged Incapacitated Person I, hereby certify as follows: , (check one) M.D., Certification of Physician or Psychologist D.O., Ph.D., Psy.D., of full age, 1. This certification is made by me in support of an application for a declaration of incapacity for , an alleged incapacitated person. 2. weighs was born on pounds and is approximately eyes. . S/He is in height. S/He has years old. S/He hair and 3. Select one: I am a (check one) physician psychologist licensed to practice in the State of currently maintain an office at am, and have been, in the actual practice of for years. OR I am an employee of the Division of Developmental Disabilities authorized to conduct psychological evaluations as part of my duties. , from 4. I earned a degree in in . I received my license to practice in the State of . 5. I examined the alleged incapacitated person on . 6. Select one: I have been treating the alleged incapacitated person for since . OR , .I .I . in . My area of specialty is . This examination took place at I am not treating the alleged incapacitated person for , but have merely examined her/him for the purpose of evaluating her/his mental capacity. Published 02/2017, CN 12012 (Certification of Physician or Psychologist) American LegalNet, Inc. www.FormsWorkFlow.com page 1 of 2 7. During my examination, I observed that s/he was (describe findings or attach report) 8. As a result of my examination and a review of her/his history, my diagnosis is . The prognosis for recovery is . 9. In my opinion, the alleged incapacitated person is: unfit and unable to govern herself/himself and to manage her/his affairs in all areas. OR unfit and unable to govern herself/himself and to manage her/his affairs in some areas but does have capacity in the areas listed below (select all that apply): medical decision making educational decision making other (please describe) legal decision making vocational decision making residential decision making financial decision making 10. My opinion is based upon the examination of the alleged incapacitated person, and the history of her/his condition. The factual basis for my diagnosis and prognosis, and my opinion as to any areas in which the individual retains capacity, is: (describe or attach report) 11. It is my opinion that the alleged incapacitated person (check one) is is not capable of attending the court hearing in this matter. If the alleged incapacitated person is not capable of attending the court hearing the following are the reasons for the individual's inability: 12. I am not related either through blood or marriage, to the alleged incapacitated person, nor to a proprietor, director or chief executive officer of any institution for the care and treatment of the mentally ill in which the alleged incapacitated person is living or in which it is proposed to place her/him; nor am I professionally employed by the management thereof as a resident physician or psychologist; nor am I financially interested therein. I hereby certify and say that the foregoing statements made by me are true to the best of my knowledge, and that I will supplement this form as may be necessary should additional information become available. I am aware that if any of the foregoing statements made by me are willfully false, I am subject to punishment. Date Signature Print Name Published 02/2017, CN 12012 (Certification of Physician or Psychologist) American LegalNet, Inc. www.FormsWorkFlow.com page 2 of 2