STATE OF SOUTH CAROLINA COUNTY OF: IN THE MATTER OF: ) ) ) ) ) ) IN THE PROBATE COURT DOCTOR’S AFFIDAVIT REGARDING CAPACITY CASE NUMBER: PERSONALLY APPEARED BEFORE ME Physician who being duly sworn deposes and says: I am (Please set forth your medical credentials): Business address and phone: Date and Place of this examination: I have had previous opportunities to evaluate the patient? Yes No (If yes, indicate dates and circumstances within the last year and/or reference if you have been the patient’s personal physician for a period of time and the time frame.) Is the patient oriented to time and place? Yes No What is the physical condition and age of the patient? (Detail any other significant factors that may be relevant to the Court.) Set forth the results of any tests which bear on the issue of incapacity and date of test: BASED UPON MY EVALUATION OF THIS PATIENT: I DO NOT believe this patient is an “ incapacitated person”.1. I do not find any impairment by reason of mental illness, mental deficiency, physical illness or disability, advanced age, chronic use of drugs, chronic intoxication, or other cause to the extent that he/she lacks sufficient understanding or capacity to make or communicate responsible decisions concerning his/her person, property, or finances. I DO BELIEVE THIS PATIENT IS AN “INCAPACITATED PERSON” and in need of a Guardian and/or Conservator as I find him/her to be impaired by reason of (CHECK ALL THAT APPLY AND SET OUT AND DESCRIBE THE LIMITATIONS RESULTING FROM EACH.) Mental Illness Mental Deficiency Physical Illness or Disability Advanced Age Chronic Use of Drugs Chronic Intoxication Other 1 ”Incapacitated person” means any person who is impaired by reason of mental illness, mental deficiency, physical illness or disability, advanced age, chronic use of drugs, chronic intoxication, or other cause to the extent that he lacks sufficient understanding or capacity to make or communicate responsible decisions concerning his person or property. (Section 62-5-101 of the South Carolina Code of Laws) FORM #541PC (2/2004) 62-5-303, 62-5-407 Page 1 of 2 American LegalNet, Inc. www.USCourtForms.com Is this condition permanent or temporary? Can Patient perform activities of daily living? What other information do you believe would assist the Court in making a determination of capacity? FURTHER AFFIANT SAYETH NOT. Physician’s Signature: Print Name: Examiner: Credentials (M.D., Ph.D., D.O., R.N.) Address: Telephone: SWORN to before me this day of , 20 Notary Public for South Carolina My Commission Expires: FAILURE TO PROVIDE DETAILED RESPONSES TO THE QUESTIONS ON THIS AFFIDAVIT MAY OBLIGATE YOU TO APPEAR AT THE PROBATE COURT HEARING. All information MUST be typed or clearly printed. FORM #541PC (2/2004) Page 2 of 2 American LegalNet, Inc. www.USCourtForms.com