Secs. 661 F.C.A.; 1726 S.C.P.A. Form 6-10 (Determination of Incapacity)10/94 FAMILY COURT OF THE STATE OF NEW YORK COUNTY OF Proceedings for the Appointment of a Standby Guardian of the Person of Docket No. DETERMINATION a Minor OF INCAPACITY ..................................... Pursuant to Section 1726 of the Surrogate's Court Procedure Act, I,[name] , state that: 1. I am a physician who is: *(the attending physician, as that term is defined in Section 1726 of the S.C.P.A., to [name] the petitioner in the above-captioned proceeding.) *(acting on behalf of [name , who is the attending physician, as that term is defined in Section 1726 of the S.C.P.A; to [name] , the petitioner in the above-captioned proceeding.) *(familiar with the medical condition of [name] the petitioner in the above-captioned proceeding.) 2. I have determined, based on a reasonable degree of medical certainty, that petitioner is incapacitated, in that (he) (she) suffers from a chronic and substantial inability, as a result of mental impairment, to understand the nature and consequences of decisions concerning the care of (his)(her) minor child(ren), and is consequently unable to care for said child(ren). 3. In my professional opinion, the nature of the petitioner's incapacity, its extent and probable duration, and the date and source of my medical diagnosis are [note: the illness need not be identified]: * Delete inapplicable provisions. American LegalNet, Inc. www.USCourtForms.com Form 6-10 page 2 4. Upon information and belief, petitioner wishes the Court to name as Standby Guardian of (his)(her) minor child(ren); accordingly, I have provided a copy of this Determination of Incapacity to the Standby Guardian. ____________________________________ Signature License No. Hospital: I, [name] , acknowledge receipt of the foregoing Determination of Incapacity. _________________________________________________ f Signature of Standby Guardian Dated: American LegalNet, Inc. www.USCourtForms.com