FORM T-42 03/2019 PAGE 1 OF 2 SEND TO: ATTORNEYS: FILE WITH AN IC FILE NUMBER VIA EDFP HTTP://WWW.IC.NC.GOV/DOCFILING.HTML OR IF NO IC FILE NUMBER, FOLLOW PLAINTIFF FILING OPTIONS. PLAINTIFFS: Email to: dockets@ic.nc.gov Or Mail to: NCIC 226 Dockets 1236 Mail Service Center Raleigh, NC 27699-1236 Main Telephone: (919) 807-2500 Helpline: (800) 688-8349 Website: http://www.ic.nc.gov FORM T-42 North Carolina Industrial Commission IC File #TA- A PPLICATION FOR APPOINTMENT OF GUARDIAN A D LITEM The use of this Form is required under Rule 11 NCAC 23B .0203. v. Plaintiff (s) Defendant (s) TO THE NORTH CAROLIN A INDUSTRIAL COMMISSION: The undersigned respectfully shows unto the North Carolina Industrial Commission that is an infant or incompetent without general or testamentary guardian in this State, and that by reason thereof can bring an action only by a guardian ad litem; that the infant or incompetent has a cause of action against the defendants on account of the following matter and things: The undersigned is a reputable person closely connected with the infant or incompetent having the relationship with the infant o r incompetent as follows: WHEREFORE, the undersigned prays the Commission that a fit and p r oper person be appointed Guardian Ad Litem for the infant or incompetent for the purpose of bringing onhis or her behalf an action as above set out. Signature of Applicant Date (Please complete page 2 of form) ORDER APPOINTING GUARDIAN AD LITEM It appearing to the North Carolina Industrial Commission from the above application that is an infant or incompetent having no general or testamentary guardian within this State and that said infant or incompetent appears to have a good cause ofaction against the defendant(s); and it further appearing to the Commission after due inquiry that is a fit and proper person to be appointed guardian ad litem for the infant or incompetent for the purpose of bringing this action onhis or her behalf; IT IS THEREFORE ORDERED that be and ishereby appointed guardian ad litem of to bring this action on his or her behalf. This day of . Commissioner or Deputy Commissioner American LegalNet, Inc. www.FormsWorkFlow.com FORM T-42 03/2019 PAGE 2 OF 2 SEND TO: ATTORNEYS: FILE WITH AN IC FILE NUMBER VIA EDFP HTTP://WWW.IC.NC.GOV/DOCFILING.HTML OR IF NO IC FILE NUMBER, FOLLOW PLAINTIFF FILING OPTIONS. PLAINTIFFS: Email to: dockets@ic.nc.gov Or Mail to: NCIC 226 Dockets 1236 Mail Service Center Raleigh, NC 27699-1236 Main Telephone: (919) 807-2500 Helpline: (800) 688-8349 Website: http://www.ic.nc.gov FORM T-42 PLEASE TYPE OR PRINT: Full name and address of minor or incompetent: Birth date of minor: Full name and address of proposed guardian ad litem: IMPORTANT INFORMATION FOR PARTIES Parties should take notice of the provisions set forth in Rule 11 NCAC 23B .0203. 11 NCAC 23B .0203 INFANTS AND INCOMPETENTS (a) Persons seeking to appear on behalf of an infant or incompetent in accordance with G.S. 1A-1, Rule 17 shall apply on a Form T-42 Application for Appointment of Guardian ad Litem. The Commission shall appoint a guardian ad litem if it is in the best interest of the minor or incompetent. The Commission shall appoint the guardian ad litem only after due inquiry as to the fitness of the person to be appointed. (b) The Commission may assess a fee to be paid to an attorney who serves as a guardian ad litem for actual services rendered upon receipt of an affidavit of actual time spent in representation of the minor or incompetent as part of the costs assessed pursuant to G.S. 247 143-291.2(a) or Rule 17(b)(2) of the North Carolina Rules of Civil Procedure. American LegalNet, Inc. www.FormsWorkFlow.com