FORM B 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 Verified Complaint to Appoint Guardian(s) of the Person and Estate (Property) , by way of verified complaint, say: I, I am years of age. I reside at , and State of (AIP) is incapacitated person. , County of . I have domicile (permanent/legal residence) at . My relationship to the alleged incapacitated person . My interest in this action is the welfare of the alleged I am (check one) the only individual bringing this action for guardianship; OR one of two or more individuals bringing this action for guardianship. Below is the name, age, present residence, and permanent/legal residence (domicile) of the other applicant(s). 1. The name, age, present address, permanent/legal residence (domicile), and marital status of the alleged incapacitated person are as follows: Name Present Address How long at this address? Permanent/Legal Residence (Domicile) Spouse's information, if married: Name Present Address Permanent/Legal Residence (Domicile) Age Marital Status Age Revised 02/2017, CN 10558 (Adult Guardianship ­ Person & Estate) Published 02/2017, CN 12015 (Verified Complaint to Appoint Guardian of the Person and Estate) page 1 American LegalNet, Inc. www.FormsWorkFlow.com If applicable: Not Applicable The alleged incapacitated person , has been determined eligible for services from the New Jersey Division of Developmental Disabilities (DDD). If applicable: The alleged incapacitated person has been receiving services from the DDD since Currently, these services consist of: Not Applicable . 3. The alleged incapacitated person, having affidavit or certification of Because of this condition, him/herself to the extent set forth below. , has been diagnosed as , as set forth by the attached , (Physician or Psychologist). lacks sufficient capacity to govern 4. The functional capacity of the alleged incapacitated person is further detailed by one of the following documents, attached to this complaint: (check one) A copy of the Individualized Education Program (IEP) for the alleged incapacitated person; OR An affidavit or certification from the chief executive officer, medical director, or other officer having administrative control over the DDD program from which the alleged incapacitated person is receiving services; OR An affidavit or certification from a designee of the DDD having personal knowledge of the functional capacity of the AIP; OR A second affidavit or certification of a physician or psychologist; OR An affidavit or certification from a licensed care professional having personal knowledge of the functional capacity of the alleged incapacitated person. 5. The names, addresses, relationships and ages of the persons most closely related to the alleged incapacitated person (parents, children, siblings) are as follows: Name Address Relationship to AIP Age If applicable: Not Applicable The name and address of the person or institution having the care and custody of the alleged incapacitated person is as follows: Revised 02/2017, CN 10558 (Adult Guardianship ­ Person & Estate) Published 02/2017, CN 12015 (Verified Complaint to Appoint Guardian of the Person and Estate) page 2 American LegalNet, Inc. www.FormsWorkFlow.com If applicable: Not Applicable If the alleged incapacitated person has lived in an institution, the date(s) of any commitment or confinement and by what authority committed or confined, are as follows: Institution Period(s) of Residence If applicable: Not Applicable The name(s) and address(es) of any person(s) named as an attorney-in-fact in any power of attorney, and/or any person named as health care representative in any health care directive, and/or any person acting as trustee under a trust for the benefit of the alleged incapacitated person, are as follows: Name Role (Attorney-In-Fact, Health Care Representative, Trustee) 6. The name(s), address(es), relationship to the alleged incapacitated person, age and telephone number of the proposed guardian(s) are as follows: (attach additional pages as necessary). Name Address Relationship Name Address Relationship Name Address Relationship Age Telephone No. Age Telephone No. Age Telephone No. 7. Information about the real and personal property and income of the alleged incapacitated person is set forth in the attached Certification of Assets. 8. Guardianship of the person and estate is requested at this time. (check one) I request that the court appoint the Office of the Public Defender Division of Mental Health Advocacy, pro bono (without cost), to represent the alleged incapacitated person. I understand that the guardianship hearing may be scheduled on a later date if the Office of the Public Defender Division of Mental Health Advocacy is appointed as counsel. OR I request that the court appoint a private attorney, potentially for cost, to represent the alleged incapacitated person. I understand that if the assets of the alleged incapacitated person are insufficient to cover the fee charged by the court-appointed attorney, then the court may order that I pay that fee. Revised 02/2017, CN 10558 (Adult Guardianship ­ Person & Estate) Published 02/2017, CN 12015 (Verified Complaint to Appoint Guardian of the Person and Estate) page 3 American LegalNet, Inc. www.FormsWorkFlow.com 9. Request for Guardianship of the Person (check one) Option 1: Request for General (Full) Guardianship of the Person The condition of renders him/her without the necessary cognitive capacity to govern himself/herself in all areas (including medical, legal, residential, educational, and vocational). requires a general (full) guardian of the person. WHEREFORE, the plaintiff(s) demand(s) judgment pursuant to N.J.S.A. 30:4-165.7, declaring to be suffering from a chronic functional impairment that renders him/her incapable of governing himself/herself in all areas, and appointing as general (full) guardian(s) of the person of . OR Option 2: Request for Limited Guardianship of the Person The condition of renders him/her without the necessary cognitive capacity to govern himself/herself in some areas. However, retains the necessary cognitive capacity to make some decisions regarding his/her person and requires a limited guardian. Specifica