STATE OF NORTH CAROLINA CountyFile No. Full Name Of RespondentTelephone No. Of Respondent(Over)In The General Court Of JusticeSuperior Court DivisionBefore The ClerkPETITION FOR ADJUDICATION OFINCOMPETENCE AND APPLICATION FORAPPOINTMENT OF GUARDIANOR LIMITED GUARDIAN AND MOTION FOR APPOINTMENT OF INTERIM GUARDIAN (AOC-SP-198) IN THE MATTER OF Address Of RespondentThe undersigned, being duly sworn, requests that the Court, after notice and hearing, adjudicate the respondent above to be incompetent, and also applies for the appointment of the person(s) named below to serve, in the capacity indicated, as guardian(s) of the respondent.In support of this Petition, the undersigned states: 1. During the past twelve (12) months, the above-named respondent was physically present as follows: Period of Physical Presencepetition; do not list periods of temporary absence)FromToPresent Location (County, State, and Country)Type of ProceedingFile Number 2. (check a. or check and complete b.) (NOTE: In both a. and b., 223state224 includes a state of the United States, the District of Columbia, Puerto Rico, the ) a. There is no other pending proceeding involving the respondent in any court or agency of a state or foreign country. b. There is a pending proceeding(s) involving the respondent in the court or agency of a state or foreign country, as set forth below: 3. A North Carolina court has jurisdiction to rule on this petition and application. 4. The respondent is a resident of this county. domiciled in this county. an inpatient in the facility named above. present in this county, it being impossible to determine his/her county of residence or domicile.G.S. 35A-1105, -1112, -1114, -1210; 35B-17, -18 Name And Address Of Attorney For PetitionerTelephone No. Of Petitioner222s AttorneyName And Address Of Treatment Facility If Respondent Is An Inpatient State Bar No. Name And Address Of PetitionerCounty Of Residence Of PetitionerRespondent222s Drivers License No.StateTelephone No. Of Petitioner County Of Residence Of RespondentDate Of Birth Race*Sex** Race and sex are collected so that this information may be transmitted to NICS in the event of a AddressNOTE TO PETITIONER: If you are petitioning the court to accept guardianship on transfer from another state, this is not an appropriate form to use. AOC-SP-200, Rev. 4/18 American LegalNet, Inc. www.FormsWorkFlow.com (Over) 6. The respondent222s next of kin, if any, and other persons known to have an interest in this proceeding are:Name And Address Name And AddressName And Address Name And Address 7. General statement of respondent222s assets and liabilities, including any income and receivables to which he/she is entitled:Assets Liabilities Income and ReceivablesReal Property $ Mortgage Loans $ Wages & Salaries $ Tangible Personal Property $ Other Secured Loans $ Rents $ Other Personal Property $ Unsecured Loans $ Pensions $ Allowances $ Insurance & Compensation $ Other $ Yes No There is a Durable Power of Attorney in place. Yes No There is a Healthcare Power of Attorney in place. Yes No There is a special needs or other trust in place. Yes NoThe respondent has health insurance through Medicaid, Yes No Medicare, or a private insurer. 5. The respondent is incompetent in that he/she lacks sufficient capacity to manage his/her own affairs or to make or communicate important decisions concerning his/her person, family, or property, as shown by the following facts: (Set forth the facts which tend to show that the respondent is incompetent. Include cause of incompetence, which may be mental illness, mental retardation, epilepsy, cerebral palsy, County Of ResidenceTelephone No. County Of ResidenceTelephone No. County Of ResidenceTelephone No. County Of ResidenceTelephone No. AOC-SP-200, Side Two, Rev. 4/18 American LegalNet, Inc. www.FormsWorkFlow.com File No.IN THE MATTER OF Name Of Respondent A. Language and Communication (understands/participates in conversations, can read and write, understands signs such as 223keep out,224 223men,224 223women224) has capacity. lacks capacity. Comment: B. Nutrition (makes independent decisions re: eating, prepares food, purchases food) has capacity. lacks capacity. Comment: C. Personal Hygiene (bathes, brushes teeth, uses proper hygiene when using the restroom) has capacity. lacks capacity. Comment: D. Health Care (makes and communicates choices re: medical treatment/caregivers, notifies others of illness, follows medication instructions, reaches emergency health care) has capacity. lacks capacity. Comment: E. Personal Safety (recognizes danger and seeks assistance as needed, protects self from exploitation/personal harm) has capacity. lacks capacity. Comment: F. Residential (makes and communicates decisions re: residence/roommates, maintains safe shelter) has capacity. lacks capacity. Comment: G. Employment (makes and communicates decisions re: employment, demonstrates vocational skills such as neatness and punctuality, writes or dictates application form) has capacity. lacks capacity. Comment: H. Independent Living (follows a daily schedule, conducts housekeeping chores, uses community resources such as bank, store, post office) has capacity. lacks capacity. Comment: I. Civil (knows to contact advocate if being exploited, understands consequences of committing a crime, registers to vote) has capacity. lacks capacity. Comment: J. Financial 1. Makes and communicates decisions about paying bills and spending discretionary money, and makes change for $1, $5, and $20 has capacity. lacks capacity. Comment: 2. Makes and communicates decisions regarding management of a personal bank account, savings, investments, real estate, and other substantial assets has capacity. lacks capacity. Comment: 3. Can resist attempts at financial exploitation by others has capacity. lacks capacity. Comment: (Over) 8. CAPACITY INFORMATION American LegalNet, Inc. www.FormsWorkFlow.com I, the undersigned petitioner, have read this Petition and state that its contents are true to my own knowledge except those matters stated on information and belief, which I believe are true. VERIFICATION DateSWORN/AFFIRMED AND SUBSCRIBED TO BEFORE MEDateDate My Commission Expires Deputy CSC Assistant CSC Clerk Of Superior Court NotarySEAL 9. RECOMMENDED GUARDIAN(S) NOTE: 10. MOTION FOR APPOINTMENT OF INTERIM GUARDIAN Of The Estate Of The Estate Of The Person Of The Person AOC-SP-200, Page Two, Side Two, Rev. 4/18 American LegalNet, Inc. www.FormsWorkFlow.com