FORM 10 IN THE MATTER OF: An Alleged Incapacitated Person IN THE COURT OF COMMON PLEAS CHESTER COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION NO. DEPOSITION BY INDIVIDUAL QUALIFIED IN EVALUATION OF INCAPACITATED PERSON The deposition of on day of , Pennsylvania. , a witness, made , at Q. A. What is your name and your professional address? My name is my professional address is , Q. Please describe your education, training, and background with particular emphasis on your expertise in evaluating individuals with incapacities. I received my college degree at and my post-graduate training at and I have practiced (e.g. medicine, psychiatry, psychology, gerontological social work etc.) since special qualifications and training with respect to evaluating persons with incapacities consists of . My A. American LegalNet, Inc. www.FormsWorkFlow.com FORM 10 Q. In your capacity as (e.g. physician, psychologist, social worker, etc.) have you had the opportunity to meet with, examine, speak with and otherwise become acquainted with (name) and if so, upon what occasions and in what fashion have you been able to do so? I first became acquainted with (name) in the month of , when she/he was brought to my attention by means of have since that time (visited/spoken with/examined/treated) her/him on other occasions with an average frequency of time per day/week/month/year . A. Q. Is (name) ability to receive and evaluate information effectively and communicate decisions in any way impaired to such a significant extent that she/he is partially or totally unable to manage her/his financial resources or to meet essential requirements for her/his physical health and safety? Yes, I believe it is. A. Q. Please describe the type and severity of (name) impairments. A. (name) impairments are as follows: -----------------------------Check One---------------------------- Impairment a) b) c) d) e) f) g) h) None Mild Moderate Severe American LegalNet, Inc. www.FormsWorkFlow.com FORM 10 Q. A. Is (name) partially or totally unable to manage her/his financial resources? ability to manage her/his financial resources is impaired (not at all, partially, (name) totally) as follows: Q. A. Is (name) able to meet essential requirements for her/his physical health and safety? (name) ability to meet essential requirements for her/his physical health and safety is impaired (not at all, partially, totally) as follows: Q. Can you please evaluate the present condition of (name) with respect to incapacities of the type alleged in the Petition. In particular, could you please comment on the nature and extent of the alleged incapacities and disabilities and also, insofar as you are able, (name) mental, emotional and physical condition, her/his adaptive behavior, and her/his social skills? Based upon my education, training and experience, as well as my acquaintance with (name) incapacity's and disabilities are as stated above, it is my opinion that her/his A. Her/His mental condition is Her/His emotional and physical condition are Her/His adaptive behavior is Her/His social skills are American LegalNet, Inc. www.FormsWorkFlow.com FORM 10 Q. What recommendations would you make concerning services necessary to meet the essential requirements for (name) physical health and safety? I would recommend that her/his physical health and safety be protected by A. Q. What recommendations would you make concerning management of financial resources? I would recommend (name) A. Q. What recommendations would you make concerning the development or regaining of (name) physical or mental abilities? I would recommend the following: A. Q. What types of assistance do you think are required by (name) ? A. I believe she/he needs assistance with Q. A. Why is it that no less restrictive alternatives would be appropriate? Less restrictive alternatives would not be appropriate because American LegalNet, Inc. www.FormsWorkFlow.com FORM 10 Q. What is the probability that the extent of significantly lessen or change? (name) incapacity's may A. In my judgment, and based upon my training, experience and acquaintance with (name) I believe the probability that her/his incapacities may significantly lessen or change is: Q. Would the physical or mental condition of presence in open Court? I believe that (name) (name) be harmed by her/his A. presence in open Court (1) would be (2) would not be (circle 1 or 2) harmful to her/him because: American LegalNet, Inc. www.FormsWorkFlow.com FORM 10 VERIFICATION I verify that the statements made in the foregoing DEPOSITION BY INDIVIDUAL QUALIFIED IN EVALUATION OF INCAPACITATED PERSONS are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa. C.S. �4904, relating to unsworn falsification to authorities. Dated: Signature American LegalNet, Inc. www.FormsWorkFlow.com