SURROGATE222S COURT OF THE STATE OF NEW YORKCOUNTY OF --------------------------------------------------------------------XProceeding for the Appointment of a Guardian forAFFIDAVIT (CERTIFICATION) OF EXAMINING PHYSICIAN OR LICENSED PSYCHOLOGISTFile No. Pursuant to SCPA Article 17-A--------------------------------------------------------------------XSTATE OF NEW YORK)COUNTY OF) ss.:I, , [ ] Physician [ ] Licensed Psychologist,being duly sworn, deposes and says:[PLEASE ANSWER ALL QUESTIONS]1.My license number is : 2.My offices are located at: 3.My professional knowledge and/or background in the care and treatment of persons with [ ] intellectual disabilities[ ] developmental disabilities is as follows:4(a). I have examined the Respondent on: [Set forth date(s).](b). [Check appropriate box(es) and explain where requested]:[ ] I have performed the following tests or evaluations of the Respondent. [Set forth in detail the namesof tests and/or evaluations, dates performed and results.][ ] I have reviewed the following tests or evaluations performed on Respondent. [Set forth in detail thenames of tests and/or evaluations, dates performed, results and names of doctors who performed thetests and/or evaluations.] GMD-2A -1- American LegalNet, Inc. www.FormsWorkFlow.com 5.The mental and physical condition of the Respondent is as follows: [Describe in detail.]6. [Check appropriate box(es)]:INTELLECTUALLY DISABLED[ ]Based upon the foregoing, it is my conclusion the Respondent is an intellectually disabled person andin my opinion incapable of managing himself/herself and/or his/her affairs by reason of an intellectualdisability. The nature and degree of the intellectual disability is as follows:DEVELOPMENTALLY DISABLED[ ]Based upon the foregoing, it is my conclusion that the Respondent is developmentally disabled andin my opinion he/she has an impaired ability to understand and appreciate the nature andconsequences of decisions, which results in Respondent being incapable of managing himself/herselfand/or his/her affairs by reason of developmental disability, and whose disability is attributable to:[ ] (a) Cerebral palsy, which originated before the Respondent attained the age of twenty-two.[Describe, in detail, the nature, degree and origin of the disability.][ ] (b) Epilepsy, which originated before the Respondent attained the age of twenty-two.[Describe, in detail, the nature, degree and origin of the disability.][ ] (c) Neurological impairment, which originated before the Respondent attained the age oftwenty-two.[Describe, in detail, the nature, degree and origin of the disability.]-2- American LegalNet, Inc. www.FormsWorkFlow.com [ ] (d) Autism, which originated before the Respondent attained the age of twenty-two.[Describe, in detail, the nature, degree and origin of the disability.][ ] (e) Traumatic head injury.[Describe, in detail, the nature, degree and origin of the disability.][ ] (f) A condition, which originated before the Respondent attained the age of twenty-two, foundto be closely related to an intellectual disability, because such condition results in similar impairmentof general intellectual functioning or adaptive behavior to that of intellectually disabled persons.[Describe in detail the condition, and the nature, degree and origin of the disability.][ ] (g) Dyslexia resulting from a disability described in subdivision (a) through (f) or an intellectualdisability which condition originated before the Respondent attained the age of twenty-two. [Describein detail the nature, degree and origin of the developmental disability or intellectual disability.]7. [Check appropriate box]:[ ]The condition of the Respondent is permanent in nature or likely to continue indefinitely.[ ]The condition of the Respondent is not permanent in nature nor likely to continue indefinitely.8.[Check appropriate box]:[ ]There are no circumstances warranting Respondent222s nonappearance at the hearing required by thecourt.[ ]Respondent222s presence at the hearing should be dispensed with because he/she is medically incapableof being present to the extent that attendance is likely to result in physical harm to the Respondent.[Explain in detail.]-3- American LegalNet, Inc. www.FormsWorkFlow.com [ ]Respondent222s presence at the hearing should be dispensed with for the following reasons: [Set forthfacts and circumstances which would result in the court finding that the Respondent222s presenceat the hearing would not be in his/her best interest.]9. [Check appropriate box for an intellectually disabled person]:[ ]Based upon the foregoing, it is my conclusion that the Respondent is not capable of understanding andappreciating the nature and consequences of health care decisions, including the benefits and risks of andalternatives to any proposed health care, and of reaching an informed decision in order to promote his/herown well being. A health care decision may include a decision to withhold or withdraw life-sustainingtreatment as defined in Section 1750-b.1 of the Surrogate222s Court Procedure Act. [ ]Based upon the foregoing, it is my conclusion that the Respondent is capable of understanding andappreciating the nature and consequences of health care decisions, including the benefits and risks of andalternatives to any proposed health care, and of reaching an informed decision in order to promote his/herown well being. A health care decision may include a decision to withhold or withdraw life-sustainingtreatment as defined in Section 1750-b.1 of the Surrogate222s Court Procedure Act.10.[Check appropriate box for a developmentally disabled person]:[ ]Based upon the foregoing, it is my conclusion that the Respondent has a developmental disability, as , which includes an intellectual disability, or results in asimilar impairment of general intellectual functioning or adaptive behavior so that such person is incapableof managing himself or herself, and/or his or her affairs by reason of such developmental disability, and thatthe Respondent is not capable of understanding and appreciating the nature and consequences of healthcare decisions, including the benefits and risks of and alternatives to any proposed health care, and ofreaching an informed decision in order to promote his/her own well being. A health care decision mayinclude a decision to withhold or withdraw life-sustaining treatment as defined in Section 1750-b.1 of theSurrogate222s Court Procedure Act. [ ]Based upon the foregoing, it is my conclusion that the Respondent is capable of understanding andappreciating the nature and consequences of health care decisions, including the benefits and risks of andalternatives to any proposed health care, and of reaching an informed decision in order to promote his/herown well being. A health care decision may include a decision to withhold or withdraw life-sustainingtreatment as defined in Section 1750-b.1 of the Surrogate222s Court Procedure Act. Signature of Physician/Licensed PsychologistPrint NameSworn to before me this day of . Notary PublicCommission Expires:(Affix Notary Stamp or Seal)-4- American LegalNet, Inc. www.FormsWorkFlow.com