GP|Solo Elder Law Committee
Newsletter • Winter 2009

Chairs:
Kenneth Vercammen (Edison, NJ)
Jay Foonberg (Beverly Hills, CA)

In this issue:

1. Spending Down Medicaid Planning
2. Social Networking Websites for Business and Exposure
3. Exempt Medicaid Transfers
1. Spending Down Medicaid Planning
By Thomas D. Begley, Jr., Esquire

The client who engages in Medicaid planning is usually a person of modest means who has been diagnosed with an illness and therefore the option of long-term care insurance is no longer available. A typical client may own a home and have countable assets of between $100,000 and $400,000. Most clients' goals are as follows:

To obtain the best quality of care for the institutionalized person
To maintain the standard of living of the community spouse, including providing sufficient income and assets so that the community spouse can continue to reside in the family home
Avoid Medicaid liens being placed on the home
Preserving a modest legacy for the children
Addressing tax issues, including:
Federal and state income taxes
Federal and state gift taxes
Federal estate tax
State estate tax
State inheritance tax
At the beginning of the initial client meeting, the attorney must begin the process of managing client expectations.

There are many strategies available to obtain or accelerate Medicaid eligibility. Significant factors include whether the client is married; whether the client is in crisis; the nature and extent of the client's assets; and the size of the IRAs of the respective spouses.

Spending Down

Most states limit a Medicaid recipient to approximately $2,000 of countable resources. One way to achieve this limit is to "spend down" all but the permissible amount of countable resources. What clients typically want to avoid is spending all of their assets on nursing home care. There are several ways a client might spend down his assets.

Pay Off Debts

Repayment of a debt is not considered a transfer, because the individual is receiving fair market value, and transfers are penalized only if the transferor does not receive fair market value. Typical debts clients might have include mortgages, home equity loans, car loans, and credit card bills. In order for the spend down to be accomplished, the check must actually be written and delivered. An outstanding debt is simply a liability that does not reduce assets for Medicaid eligibility purposes.

Payment for Services

Payment for services, including medical bills and legal fees, does not constitute a transfer. The services performed by the attorney are the value the client receives for the payment. Therefore, there is no uncompensated transfer of funds.

Prepayment of Real Estate Taxes

In situations where the home is occupied by a community spouse it makes sense to prepay real estate taxes. Since the home is occupied by the community spouse it is a non-countable resource. Expenditure of the funds for payment of the real estate taxes constitutes valid spend down.

Buy Household Goods or Personal Effects

Personal effects and household goods are excluded to the extent that the total equity value of such resources does not exceed $2,000. In practice, Medicaid does not appear to enforce the $2,000 limit.

The personal effects actually should be used by the community spouse. An excellent example of a violation of the "pig principle" is a recent New Jersey case. In that case, a 92-year-old grandmother was penalized for transfer of assets. The grandmother lived in a nursing home and purchased a computer that was kept at her granddaughter's home. The court held that there was no evidence that the Medicaid applicant received anything of value for her $1,478.61 expenditure.

Make Home Improvements

Making home improvements is a way to convert countable assets (i.e., cash and securities) into a non-countable asset (i.e., a personal residence). A home and lot used as a principal residence are excludable resources.

Purchase New Home

Occasionally, when one spouse enters a nursing home, the community spouse decides that the current home is too big and decides to move to a smaller home or a condominium. Since the home is a non-countable resource, if the home is sold and the proceeds of sale from the original principal residence are reinvested into a more expensive home, the additional funds spent on the new home are converted from a countable asset to a non-countable asset. This strategy relies on the principal residence exemption.

Purchase Life Estate from Children

The Deficit Reduction Act-2005 exempts from the transfer of assets penalties the purchase of a life interest in another individual's home if the purchaser resides in the home for a period of at least one year after the date of the purchase. The Act is silent as to how the life estate is to be valued, but elsewhere there are references to the publication of the Office of Chief Actuary of the Social Security Administration.

In a New Jersey case, a parent purchased a life estate in a child's house for $126,665.10. The decision noted that a life estate entitles the person to use and occupy the home. There was no evidence that the daughter or her family vacated the home. The daughter and her family had no legal right to remain in the home absent payment of rent.

The CMS Guidance contains some troubling language: "Unless a state has a provision for excluding the value of life estates in its approved State Medicaid Plan, or the property in which the individual has purchased a life estate qualifies as the individual's exempt home, the value of the life estate should be counted as a resource in determining Medicaid eligibility."

The child would not receive a Section 121 exclusion from the sale of a principal residence, because he did not sell his entire interest in the residence.

Prepaid Funeral

Most states do not count funds in an irrevocable funeral trust as countable assets. Also, most states do not have a dollar limit on the amount that can be expended for the funeral. The monies must be put in an irrevocable trust; the trust must be for the benefit of the Medicaid applicant; and the trust must be established by an individual who reasonably anticipates applying for or receiving Medicaid benefits.

An alternative to an irrevocable funeral trust is an irrevocable assignment of a life insurance policy in exchange for funeral services of the same or greater value as the cash surrender value of the policy. Funeral directors require a paid-up policy.

Irrevocable policies issued by companies, such as Choices or Forethought, are also acceptable to Medicaid and to most funeral homes. One of the nice features of these policies is that insurance companies having significant assets back them and they can be used in most funeral homes.
Purchase of burial spaces for adult children and their spouses do not constitute transfers for Medicaid penalty purposes. The burial space resource exemption applies to burial spaces for the Medicaid Applicant and also any member of his or her immediate family. Immediate family means an individual's minor or adult children, including adopted children and stepchildren, an individual's brothers, sisters, parents, adoptive parents, and the spouses of those individuals. Neither dependency nor living in the same household will be a factor in determining whether a person is an immediate family member.
Purchase New Car

Frequently, when one spouse enters a nursing home, the other spouse is driving an old car with high mileage. A good strategy is to have the community spouse purchase a new car as part of the spend down. Under current law the best time to purchase the car would be after the institutionalized spouse enters a nursing home. Under federal law, the first $4,500 of the value of a car is excluded from the calculation of countable assets. However, if the car is used for medical transportation or transportation in connection with employment, the entire value of the car is non-countable. Many states simply permit one car to be non-countable regardless of value or use.

Copyright 2008 by Begley & Bookbinder, P.C., an Elder & Disability Law Firm with offices in Moorestown, Stone Harbor and Lawrenceville, New Jersey and Oxford Valley, Pennsylvania and can be contacted at 800-533-7227. The firm services southern and central New Jersey and eastern Pennsylvania. Tom Begley Jr. is one of the speakers with Kenneth Vercammen at the NJ State Bar Association's Annual Nuts & Bolts of Elder Law and co-author with Kenneth Vercammen, martin Spigner and Kathleen Sheridan of the 400 plus page book on Elder Law.

The Firm provides services in connection with protecting assets from nursing home costs, Medicaid applications, Estate Planning and Estate Administration, Special Needs Planning and Guardianships. If you have a legal problem in one of these areas of law, contact Begley & Bookbinder at 800-533-722

2. Social Networking Websites for Business and Exposure

A newer way to connect with friends and obtain business is become active in online social networking websites. At the ABA Annual meeting the GP Solo Division held a program which looked at online social networking. For example, schedule a free seminar on Probate & Estate Planning for Accountants and Financial Planners. Visit some of the below Social networking site for ideas. These are examples of Ken Vercammen’s profile. :

Facebook:
http://www.facebook.com/event.php?sid=f89130f4cec290fe43c099fe37a58d31&eid=56435283974

Linkedin.com:
http://www.linkedin.com/in/kennethvercammen

Myspace:
http://www.myspace.com/kennethvercammen

Twitter:
http://twitter.com/vercammen

Meet the Elite:
http://www.MeetTheElite.net/vercammen

Google:
http://www.google.com/s2/profiles/105523288807097339409

Flickr:
http://www.flickr.com/photos/kenvercammen/

YouTube:
http://www.youtube.com/user/kvercammen

Justia Lawyer Directory:
http://lawyers.justia.com/lawyer/mr-kenneth-albert-vercammen-esq-1171249/

JD Supra:
http://www.jdsupra.com/profile/KennethVercammen/

Athlinks:
http://www.athlinks.com/racer.aspx?rid=23481836

Avvo Legal rating:
http://www.avvo.com/attorneys/08817-nj-kenneth-vercammen-571594.html?edit=true

Friendfeed.com:
http://friendfeed.com/vercammen

Gather:
http://vercammen.gather.com/

Mixx:
http://www.mixx.com/users/vercammen

Orkut:
http://www.orkut.com/Main#Profile.aspx?rl=ls&uid=17513593040289518671

Plaxo:
http://KennethVercammen.myplaxo.com/

Virb.com:

http://www.virb.com/backend/kenvercammen/events


3. Exempt Medicaid Transfers
By Thomas D. Begley, Jr., Esquire

As a general rule, when assets are transferred to third parties, the transfer results in a period of Medicaid ineligibility. Some transfers, however, are exempt and do not result in the imposition of a period of ineligibility for Medicaid. It is important to make transfers that are consistent with the estate planning goals of the client. If inconsistent transfers are made, they may result in litigation from beneficiaries of the estate who consider themselves to be treated unfairly.

1. The Family Home

There are four exceptions from the general transfer rules relating to a principal residence. These transfers are exempt.

Community Spouse
The residence can be transferred to the community spouse without penalty. A married couple can simply deed the house to the community spouse. There is no transfer penalty because the transfer is between spouses. In a typical situation, husband and wife own the home as tenants by the entirety. If one spouse enters a nursing home, and the community spouse predeceases that spouse, then by operation of law, title to the home will vest in the institutionalized spouse. The institutionalized spouse would then be required to sell the home and use the proceeds for nursing home care. In states that have a broad definition of estate for purposes of Medicaid estate recovery, the home should always be transferred to the community spouse to avoid Medicaid estate recovery.

If the property is deeded to the community spouse, and that spouse dies first, the property can be left by the will of the community spouse to a special needs trust for the benefit of the institutionalized spouse or to the children. The elder law attorney must also be aware of the state elective share statute, which prohibits a person from disinheriting a spouse. Medicaid could, conceivably, take the position that failure of the surviving spouse to exercise his rights under the elective share statute constitutes a transfer, subject to the transfer penalty provisions.

Child Under 21, Blind, or Disabled
The home can be transferred to a child of the institutionalized individual who is under the age of 21, or a child of any age who is blind or disabled. For example, a person about to enter a nursing home has a daughter who is blind. The potential Medicaid applicant can transfer the home to the blind daughter as an exempt transfer, and there will be no transfer penalty. In a second marriage situation, the question remains whether the institutionalized individual could transfer ownership of the home to a stepchild who met the criteria of caregiver.
Sibling
The home can be transferred to a brother or sister of the institutionalized individual who already had an equity interest in the home prior to the transfer and who was residing in the home for a period of at least one year immediately before the individual becomes an institutionalized individual. It may not be necessary for the sibling to be named on the deed to the property for a year prior to the transfer. The sibling may have an equity interest if he or she has paid taxes or other expenses and has actually lived in the home for a period of time. For example, a potential Medicaid applicant is not married and lives in his home with his brother. Each owns a portion of the house as tenants in common and they have been living together for more than one year. The potential Medicaid applicant would simply deed the property to the healthy sibling, and there would be no transfer penalty.
Caregiver Child
The home can be transferred to a caregiver child. A caregiver is defined as a son or daughter of the institutionalized individual who is residing in the individual's home for a period of at least two years immediately before the date the individual becomes an institutionalized individual, and who has provided care to such individual that permitted the individual to reside at home rather than in an institution or facility. The care provided by the son or daughter must have been essential to the safety of the individual and consisted of activities such as, but not limited to, supervision of medication, monitoring of nutritional status, and ensuring the safety of the individual.

There may be an issue as to when the transfer of the home to the caregiver child must take place. In a New Jersey case, the Burlington County Board of Social Services contended that a deed transferred 90 days after institutionalization did not qualify, and that such transfers need be made within 30 days of institutionalization. The Administrative Law Judge held and the Director affirmed that there is no time set forth in the regulation as to when the deed must be given. The only reference to time is that the home must be the home in which the individual resided immediately prior to entering the nursing home. Based on this case, it would appear that a deed could be given at any time prior to, or subsequent to, entering a nursing home. For example, a potential Medicaid recipient is about to enter a nursing home. His daughter has lived with him for two years and provided a level of care sufficient to keep him out of a nursing home. The deed to the house can simply be deeded to the daughter. There would be no transfer penalty, because this is an exempt transfer.
Special California Ruling
The California Department of Health Services has ruled that transfer of a home may be an exempt transfer. The letter states that the home is an exempt resource so long as the individual files a written notice of intent to return home. Exempt property can be retained without affecting Medicaid eligibility. Since the transfer is not made for purposes of establishing Medicaid eligibility it is an exempt transfer.
2. Non-Home Assets

Community Spouse
The transfer penalties do not apply to a transfer of assets to the community spouse. This is also an exempt transfer. The assets forming a part of the Community Spouse Resource Allowance (CSRA) must be transferred to the community spouse within 90 days of Medicaid eligibility; otherwise, they are no longer exempt as part of the CSRA.

For example, a husband is ready to enter a nursing home. The husband transfers all of his assets to his wife. All assets in the names of the husband and wife are also transferred to the wife. This protects the assets as a part of the wife's CSRA. If the wife dies prematurely, her will leaves the assets to a special needs trust for the benefit of the husband, and on the death of the husband to their children.

Exempt Children
Transfers from the institutionalized individual or the community spouse to the institutionalized individual's child, who is blind or permanently and totally disabled, are exempt. Therefore, there is no transfer penalty. For example, a potential Medicaid applicant is single and has $100,000 of assets. He could transfer the $100,000 to his blind daughter immediately prior to entering a nursing home. There would be no period of ineligibility due to the transfer.
Sibling
The home can be transferred to a brother or sister of the institutionalized individual who already had an equity interest in the home prior to the transfer and who was residing in the home for a period of at least one year immediately before the individual becomes an institutionalized individual. It may not be necessary for the sibling to be named on the deed to the property for a year prior to the transfer. The sibling may have an equity interest if he or she has paid taxes or other expenses and has actually lived in the home for a period of time. For example, a potential Medicaid applicant is not married and lives in his home with his brother. Each owns a portion of the house as tenants in common and they have been living together for more than one year. The potential Medicaid applicant would simply deed the property to the healthy sibling, and there would be no transfer penalty.
Taxation
In transferring a home to an exempt child, consideration must be given to the gift tax rules, carry over basis, and the capital gains tax exclusion from the sale of a principal residence.
Copyright 2009 by Begley & Bookbinder, P.C., an Elder & Disability Law Firm with offices in Moorestown, Stone Harbor and Lawrenceville, New Jersey and Oxford Valley, Pennsylvania and can be contacted at 800-533-7227. The firm services southern and central New Jersey and eastern Pennsylvania. Tom Begley Jr. is one of the speakers with Kenneth Vercammen at the NJ State Bar Association's Annual Nuts & Bolts of Elder Law and co-author with Kenneth Vercammen, martin Spigner and Kathleen Sheridan of the 400 plus page book on Elder Law.

The Firm provides services in connection with protecting assets from nursing home costs, Medicaid applications, Estate Planning and Estate Administration, Special Needs Planning and Guardianships. If you have a legal problem in one of these areas of law, contact Begley & Bookbinder at 800-533-722

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General Practice, Solo and Small Firm Division:
Elder Law Committee and the ESTATE PLANNING, PROBATE & TRUST COMMITTEE

Who We Are

The Elder Law Committee of the ABA General Practice Division is directed towards general practitioners and more experienced elder law attorneys. The committee consistently sponsors programs at the Annual Meeting, the focus of which is shifting to advanced topics for the more experienced elder lawyer.

This committee also focuses on improving estate planning skills, substantive law knowledge and office procedures for the attorney who practices estate planning, probate and trust law. This committee also serves as a network resource in educating attorneys regarding Elder Law situations.

To help your practice, we feature in this newsletter edition a few articles and tips on marketing and improving service to clients. But your Editor and chairs can't do it all. Please send articles, suggestions or ideas you wish to share with others.

Let us know if you are finding any useful information or anything you can share with the other members. You will receive written credit as the source and thus you can advise your clients and friends you were published in an ABA publication. We will try to meet you needs.

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Jay Foonberg, Co-Chair, Author of Best Sellers "How to Start and Build a Law Practice" and "How To Get and Keep Good Clients", Beverly Hills, CA JayFoonberg@aol.com

We will also provide tips on how to promote your law office, your practice and Personal Marketing Skills in general. It does not deal with government funded "legal services" for indigent, welfare cases.

Kenneth Vercammen, Esq. Chair
KENNETH VERCAMMEN & ASSOCIATES, PC
ATTORNEY AT LAW
2053 Woodbridge Ave.
Edison, NJ 08817
(Phone) 732-572-0500
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Mode JUDGMENT OF LEGAL INCAPACITY & APPOINTING A GUARDIAN

SUPERIOR COURT OF NEW JERSEY
CHANCERY DIVISION [insert county] COUNTY
PROBATE PART



In the Matter of [insert the incapacitated
person’s name], an Incapacitated Person

Docket No.

CIVIL ACTION

JUDGMENT OF LEGAL INCAPACITY AND
APPOINTING A GUARDIAN OF THE PERSON
AND ESTATE


THIS MATTER being opened to the Court by [insert the plaintiff attorney’s name], attorney
for [insert the plaintiff’s name], in the presence of [insert the court appointed attorney’s name], attorney for
the then alleged incapacitated person, and [insert the incapacitated person’s name], the then alleged
incapacitated person, and no demand having been made for a jury trial, and the Court sitting
without a jury having found from the report of [insert the court appointed attorney’s name], Esq.,
together with the report of the examining physicians [insert the name of the physician] M.D. and
[insert the name of the physician] M.D. (alternate licensed practicing psychologist) and proofs given that
[insert the incapacitated person’s name] is an incapacitated person who lacks sufficient capacity to
govern himself/herself and manage his/her affairs, and it further appearing that [insert the
proposed guardian’s name] consents to serve as Guardian of the Person and Estate of [insert the
incapacitated person’s name] and for good cause shown:
IT IS on this ___ day of ____________, 20 ___ ORDERED AND ADJUDGED that:
1. [Insert the incapacitated person’s name] is an incapacitated person and is unfit and
unable to govern himself/herself and manage his/her affairs, except that [insert the incapacitated
person’s name] is fully able at this time to govern himself/herself and manage his/her own
affairs with respect to the following areas: [insert areas of decision making that the incapacitated person
retains, such as, living arrangements, marriage, advance directives, voting, gifting, manage finances, execute a will,
establish a trust, execute contracts, make judgments regarding daily activities et cetera].
2. [Insert the proposed guardian’s name] be and hereby is appointed Guardian of the
Person and Estate of [insert the incapacitated person’s name] and that Letters of Guardianship of the
Person and Estate be issued upon his/her (a) qualify according to law, (b) acknowledging to
Revised 03/2005, CN 10510-English page 1 of 5
the Surrogate of [insert county] County, upon receipt of a copy of the guardian’s manual and
annual report form, the receipt of the same and (c) entering into a surety bond unto the
Superior Court of New Jersey in the amount of $_____________, which bond shall contain
the conditions set forth N.J.S.A. 3B:15-7 and R. 1:13-3. The court shall approve the bond as
to form and sufficiency.
3. Upon qualifying, the Surrogate of [insert county] County shall issue Letters of
Guardianship of the Person and Estate to [insert the proposed guardian’s name] and thereupon [insert
the proposed guardian’s name] be and hereby is authorized to perform all the functions and duties
of a Guardian as allowed by law, except as limited herein or in areas where [insert the
incapacitated person’s name] retains decision making rights.
4. The Guardian of the Estate may not alienate, mortgage, transfer or otherwise
encumber or dispose of real property without court approval. Said limitation shall be stated
in the Letters of Guardianship.
5. The court having reviewed the affidavit or certification of services of [insert the
court appointed attorney’s name], Esq., previously filed with the court, [insert the proposed guardian’s
name] shall pay [insert the court appointed attorney’s name], court-appointed attorney for [insert the
incapacitated person’s name], a fee of $_______________ for professional services rendered and
$___________ for expenses incurred, which disbursements are hereby approved.
6. The court having reviewed the affidavit or certification of services of [insert the
plaintiff attorney’s name], Esq., previously filed with the court, [insert the proposed guardian’s name]
shall pay [insert the plaintiff attorney’s name], attorney for plaintiff, a fee of $_____________ for
professional services and $______________ for expenses incurred, which sum includes
reimbursement or payment of the cost of the physician affidavits or certifications, which
disbursements are hereby approved.
7. [Insert the proposed guardian’s name] is hereby directed to file annually a report of the
well-being of [insert the incapacitated person’s name]. The report must be filed each year on the
anniversary date of this Judgment with the Surrogate of [insert county] County.
[IF APPLICABLE]
A copy of the report must also be served upon [insert the court appointed attorney’s name or next-of-kin].
8. [Insert the proposed guardian’s name] is directed to file an annual informal accounting
Revised 03/2005, CN 10510-English page 2 of 5
on the anniversary date of this judgment, or any time as ordered by this court, with the
Surrogate of [insert county] County. Said annual informal account does not replace or satisfy
the duty to file and bring on for approval a formal accounting as required by law or as
ordered by the court.
[IF APPLICABLE]
A copy of the informal accountings must also be served upon [insert the court appointed attorney’s
name or next-of-kin]..
9. [Insert the proposed guardian’s name] is hereby directed to advise the Surrogate of
[insert county] County within ten (10) days of any changes in the address or telephone number
of himself or herself or the incapacitated person or within thirty (30) days of the incapacitated
person’s death or of any major change in status or health.
10. [Insert the proposed guardian’s name] shall cooperate fully with any Court staff or
volunteers until the guardianship is terminated by the death or return to competency of [insert
the incapacitated person’s name] or the Guardian’s death, removal or discharge.
11. [Insert the plaintiff attorney’s name], attorney for plaintiff, shall serve a copy of this
Judgment upon all interested parties and attorneys of record within seven (7) days from the
receipt hereof.
12. [Insert the proposed guardian of the estate’s name] shall file with the Court within 90
days, an inventory of all of the incapacitated person’s property and income. Within said
period a copy of the inventory shall be served on all next-of-kin and parties in interest.
13. [Insert the court appointed attorney’s name], court appointed attorney for [insert the
incapacitated person’s name], having reported to the court and advocated on behalf of the
incapacitated person, be and hereby is discharged from any further obligation to act as
attorney for [insert the incapacitated person’s name].
[USE IF APPLICABLE]
14. It appearing that the plaintiff and the attorney appointed to represent the alleged
incapacitated person have inquired about powers-of-attorney, health care directives and trusts
for the benefit of the incapacitated person that were executed by the incapacitated person and
proof of service having been made on the attorneys-in-fact, representative or trustee
designated in such document or documents, and good cause shown appearing that the
Revised 03/2005, CN 10510-English page 3 of 5
authority therein contained should be revoked [alternate language: modified]
It is ORDERED and ADJUDGED that the power and authority conferred by [insert an
appropriate description, such as, a power of attorney executed on (date) designating [insert the agent’s name] as
attorney-in-fact, health care representative or trustee] be and hereby is revoked [alternate language: modified
as follows (insert narrative of modification)].
[USE IF APPLICABLE]
Nothing herein shall affect or limit the [insert an appropriate description of any power of attorney, health
care directive or revocable trust that will not be revoked or modified, notwithstanding the principal’s incapacity and the
report by the attorney for the alleged incapacitated person].
[USE IF APPLICABLE]It further appearing that [insert the name] [insert appropriate
description, such as, attorney-in-fact or trustee] under a [insert date executed] [insert appropriate description,
such as, power of attorney or revocable trust] has power and control over the incapacitated person’s
real and personal property and doubt or concern, whether the [insert attorney in fact or trustee]
is acting within the powers delegated or is acting solely for the benefit of the
incapacitated person, having been raised.
It is hereby ORDERED and ADJUDGED that [insert name] [insert appropriate description, such
as, attorney-in-fact or trustee] under the herein revoked [alternate modified] [insert appropriate description,
such as, power of attorney or revocable trust] shall within sixty (60) days serve upon the guardian of
the incapacitated person’s estate an accounting that reports all corpus and income receipts
and disbursements under the said [insert appropriate description, such as, power of attorney or revocable
trust].
[USE IF APPLICABLE]
15. It appearing that the best interest of the incapacitated persons requires that the
attorney appointed for the incapacitated person should review and report on the [initial]
ability of the Guardian to perform and fulfill the duties required. [Insert the court appointed
attorney’s name], be and hereby is directed to continue to act on behalf of the court and [insert the
incapacitated person’s name] for a period of [insert the number of months, years or until the ward dies or is
returned to competency that the court determines is appropriate]. During said continuing period [insert the
court appointed attorney’s name] must review all reports, accountings and [here insert any special
functions, i.e., confirm the placement of the incapacitated person in a nursing home, confirm marshalling of assets,
Revised 03/2005, CN 10510-English page 4 of 5
confirm that the Guardian has created estate books and records et cetera] and shall communicate to the court
through the surrogate’s office any matters or issues that he or she perceives are necessary to
be identified and raised for the best interest of [insert the incapacitated person’s name]. While acting
pursuant to the terms of this order, [insert the court appointed attorney’s name] shall be vested with
such immunities or other defenses that an agent of the court is entitled to claim.
16. [Here insert any additional powers, limitations or conditions deemed necessary to protect the
incapacitated person and his/her estate.]
______________________________________
J.S.C
Revised 03/2005, CN 10510-English page 5 of 5

– Model Order for Scheduling Hearing for Guardianship
of Alleged Incapacitated Person


This Directive promulgates a model form of order for scheduling a hearing for the
guardianship of an alleged incapacitated person. The Judicial Council approved this
form order at its February 27, 2008 meeting.

The purpose of the order for hearing is to schedule and give notice of the
guardianship hearing to interested persons and to provide formal notice of the hearing
to the alleged incapacitated person (AIP). R. 4:86-4. Orders for hearing are required
because use of an order to show cause would be inconsistent with the underlying
allegations of a guardianship action, namely, that the alleged incapacitated person is
under a disability and is unable to manage his or her personal and business affairs. A
summary action order to show cause also is inconsistent with the alleged incapacitated
person’s right to a jury trial. R. 4:86-4; N.J.S.A. 3B:12-24.

This model order provides guidance in drafting acceptable orders for
guardianship hearings and is preformatted to comply with the Rules of Court. Use of
the model order is encouraged but not mandatory; however, any variations from the
model must nonetheless conform to the requirements of the Rules of Court and any
applicable Administrative Directives.

Attachment
cc: Chief Justice Stuart Rabner
Hon. Glenn A. Grant, Acting Admin. Director Designate
Christina P. Higgins, Acting Deputy Administrative Director
AOC Directors and Assistant Directors
Trial Court Administrators
Civil Division Managers
Kevin M. Wolfe, Chief
Steven D. Bonville, Special Assistant
Francis W. Hoeber, Special Assistant

[Questions or comments may
be directed to 609-292-8470.]
Directive # 10-08

1
 

SUPERIOR COURT OF NEW JERSEY
CHANCERY DIVISION _________ COUNTY
PROBATE PART



In the Matter of ___________________, an

Alleged Incapacitated Person


Docket No.:

CIVIL ACTION
ORDER FIXING GUARDIANSHIP
HEARING DATE AND APPOINTING
ATTORNEY FOR ALLEGED
INCAPACITATED PERSON


This matter having been opened to the Court by ________________________ , attorney for
the plaintiff, __________________________________________ for a judgment declaring
_________________________ an incapacitated person and appointing a guardian pursuant to
N.J.S.A. 3B:12-24.1 and Rules 4:86-1 to 8 and for such other relief as the Court may deem just, and
the Court having read and considered the verified complaint, the supporting certifications or
affidavits, and all other papers and pleadings filed in this matter, and for good cause shown:
IT IS on this ________ day of __________________, 20___, ORDERED that:
1. This matter be set down for hearing before this Court at the ______________ County
Court House, _______________________________, New Jersey, on the _________ day of
__________________, 20___ , at ________ o’clock in the ______ noon, or as soon thereafter as
plaintiff may be heard, to determine the issues of incapacity of _____________________________
and the appointment of a guardian.
2. A copy of the verified complaint, supporting affidavits or certifications and this Order,
shall be served on _____________________________, the alleged incapacitated person, by
personally serving the same at least 20 days prior to the date scheduled for the hearing.
3. A separate notice shall be personally served on the alleged incapacitated person stating
that if he/she desires to oppose the action he/she may appear either in person or by attorney and may
demand a trial by jury.
4. A copy of the verified complaint, supporting affidavits or certifications and this Order
shall also be served on all the next-of-kin and other parties-in-interest identified in the verified
Model Order for Scheduling Hearing for Guardianship
of Alleged Incapacitated Person (Rule 4:86-4) –
Promulgated by Directive #10-08

2
complaint by certified mail, return receipt requested at least 20 days prior to the date scheduled for
the hearing.
5. _________________, Esquire, whose address is: _____________________________ and
telephone number is: _______________________ be and hereby is appointed as attorney for the
alleged incapacitated person. Said attorney shall personally interview the alleged incapacitated
person, examine the medical records, make inquiry of persons having knowledge of the alleged
incapacitated person’s circumstances, his/her physical and mental state and his/her property, make
reasonable inquiries to locate any Will, powers of attorney or health care directives previously
executed by the alleged incapacitated person, or to discover any interests the alleged incapacitated
person may have as a beneficiary of a will or trust. Said attorney shall prepare a written report of
findings and recommendations and an affidavit of services to be filed with the Court and with the
plaintiff’s attorney and other parties who have filed a written response at least ____ days prior to the
hearing.
6. A copy of the verified complaint, supporting affidavits or certifications and this Order
shall be immediately served on the attorney for the alleged incapacitated person by personal service
or certified mail, return receipt requested.
7. The attorney above appointed to represent the alleged incapacitated person is hereby
regarded as a HIPAA (Health Insurance Portability and Accountability Act) representative for the
alleged incapacitated person and shall have the right and power to examine records, including
medical and psychiatric records, pertaining to the alleged incapacitated person and to visit and
confer with the alleged incapacitated person.
8. The plaintiff shall file with the Surrogate of _________ County a proof of service of the
pleadings required by this order to be served on the alleged incapacitated person and the parties in
interest no later than _____ (__) days before the date this matter is scheduled to be heard.
9. Any next-of-kin and other party-in-interest who wishes to be heard with respect to any of
the relief requested in the verified complaint shall file with the Surrogate of ______________
County at [insert address of Surrogate in the County where the action is being brought] together
with the applicable filing fee and serve upon the attorney for the plaintiff and the attorney for the
alleged incapacitated person at the address set forth above, a written answer, an answering affidavit ,

3
a motion returnable on the date this matter is scheduled to be heard or other written response _____
days before the date this matter is scheduled to be heard.


__________________________________
J. S. C.

How to Become the Legal Guardian of a Person Receiving
Services From the Division of Developmental Disabilities
(Superior Court of New Jersey, Chancery Division, Probate Part)

http://www.judiciary.state.nj.us/prose/10558.pdf
DESCRIPTION OF GUARDIANSHIP ACTION:
Guardianship over an incapacitated person over the age of 18 who is receiving services from
the Division of Developmental Disabilities (DDD) can be obtained in one of two ways. The
first way is that the Commissioner of the Department of Human Services can initiate
proceedings when it is determined that an individual is in need of a guardian. The second
method is that a private citizen can petition the court to have a guardian named. This packet
contains instructions for a private citizen to follow to obtain the appointment of a legal guardian
over an incapacitated person receiving Division of Developmental Disabilities services.
NOTE: These materials have been prepared by the New Jersey Administrative Office of the
Courts for use by self-represented litigants. The guides, instructions, and forms will be
periodically updated as necessary to reflect current New Jersey statutes and court rules. The
most recent version of the forms will be available at the county courthouse or on the Judiciary’s
Internet site (www.judiciary.state.nj.us). However, you are ultimately responsible for the content
of your court papers.
Click Here for a List of Where to Send your Completed Forms:
2
THINGS TO THINK ABOUT BEFORE YOU REPRESENT YOURSELF IN COURT
TRY TO GET A LAWYER
The court system can be confusing and it is
a good idea to get a lawyer if you can. If
you cannot afford a lawyer, you may contact
the legal services program in your county to
see if you qualify for free legal services.
Their telephone number can be found in
your local yellow pages under “Legal Aid”
or “Legal Services.”
If you do not qualify for free legal services
and need help in locating an attorney, you
can contact the bar association in your
county. Their telephone number can also
be found in your local yellow pages. Most
county bar associations have a Lawyer
Referral Service. The county bar Lawyer
Referral Service can supply you with the
names of attorneys in your area willing to
handle your particular type of case and
sometimes consult with you at a reduced
fee.
There are also a variety of organizations of
minority lawyers throughout New Jersey,
and also organizations of lawyers who
handle specialized types of cases. Ask
your county court staff for a list of lawyer
referral services that include these
organizations.
WHAT YOU SHOULD EXPECT IF YOU
REPRESENT YOURSELF

While you have the right to represent
yourself in court, you should not expect any
special treatment, help, or attention from
the court. You must still comply with the
court rules, even if you are not familiar with
them. The following is a list of some things
the court staff can and cannot do for you.
Please read it carefully before asking the
court staff for help.
-We can explain and answer questions
about how the court works.
-We can tell you what the requirements are
to have your case considered by the court.
-We can give you some information from
your case file.
-We can provide you with samples of court
forms that are available.
-We can provide you with guidance on how
to fill out forms.
-We can usually answer questions about
court deadlines.
-We cannot give you legal advice. Only
your lawyer can give you legal advice.
-We cannot tell you whether or not you
should bring your case to court.
-We cannot give you an opinion about what
will happen if you bring your case to court.
-We cannot recommend a lawyer, but we
can provide you with the telephone number
of a local lawyer referral service.
-We cannot talk to the judge for you about
what will happen in your case.
-We cannot let you talk to the judge outside
of court.
-We cannot change an order issued by a
judge.
KEEP COPIES OF ALL PAPERS
Make and keep for yourself copies of all
completed forms and any canceled checks,
money orders, sales receipts, bills, contract
estimates, letters, leases, photographs,
and other important documents that relate
to your case.
3
DEFINITIONS OF WORDS THAT MAY BE USED IN THIS PACKET
Alleged Incapacitated
Person: The individual over whom the plaintiff is seeking a guardian.
Affidavit: An affidavit is a written statement of facts confirmed by an oath taken before a notary public
or other official authorized to administer oaths. See certification.
Certification: A certification is a written statement of facts confirmed by a certification that under
penalty of law all information contained is true to the best of your knowledge and belief. See affidavit.
County of
Settlement: The county of settlement is the county responsible for a share of the charge incurred for
services provided to persons unable to pay. Typically, this is the alleged incapacitated
person’s county of residence at the time of application for eligible DDD services. However, it
is possible for the county of residence and the county of settlement may be different. It
depends on the residential history of the alleged incapacitated person.
File: To file means to give the appropriate forms and fee to the court to begin the court’s
consideration of your request.
Judgment: A judgment is the official decision of a court in a case.
Order: An order is a signed paper from the judge telling someone they must do something.
Interested
Party: An interested party is a person or government agency that has an involvement with the
incapacitated person that is the subject of the court action. It includes the alleged
incapacitated person’s next-of-kin who are his closest relatives, the county of settlement (the
county adjuster) and the administrator of the Division of Developmental Disabilities program
providing services to the alleged incapacitated person.
Plaintiff: The plaintiff is the party who starts the lawsuit.
Proof of
Service: A proof of service is a sworn statement that tells the court who was given notice of the
complaint and supporting pleadings in your case. It also tells the court how those persons
received these documents.

Return Date: Return date is the date the plaintiff and defendant are told to appear in court.
Service: Copies of your papers are personally delivered to the alleged incapacitated person and mailed
to the parties in interest and the attorney appointed to represent the alleged incapacitated
person.
Verified
Complaint: A verified complaint is a document in which you briefly tell the court the facts in your case and
the relief you want the court to grant. This is filed by the plaintiff.
4
IMPORTANT INFORMATION ON GUARDIANSHIP ACTIONS
EXAMINATION
The forms provided in this packet are for
guardianships being obtained for persons
receiving services from the Division of
Developmental Disabilities and is often
called a Title 30 guardianship.
TITLE 30 GUARDIANSHIPS
Title 30 requires that one medical
physician or psychologist examine or
evaluate the individual and submit a written
report under oath. A second report under
oath is submitted by the chief executive
officer, medical director or other Division of
Developmental Disabilities official having
administrative control over the functional
program or services. Typically the regional
DDD administrator supplies the report.
From now on this package calls the report
provider the “DDD official.” The DDD
official must agree that the individual is in
need of guardian based on the agency’s
knowledge of his/her functional level.
PLENARY AND LI MI TED
GUARDIANSHIPS
It is important to recognize that DDD
regulations require that a guardianship
recommendation must be founded upon a
sound clinic basis and every effort must be
made to seek a solution that is the least
restrictive and intrusive to the person’s life
and, thereby, preserve the
person’s autonomy to the maximum extent
possible. Therefore, limited guardianships
may be recommended by the DDD official
where the alleged incapacitated person
can express some, but not all, decisions. A
plenary (full) guardianship is appropriate
for those persons incapable of making or
expressing any decisions.
PROCEDURE
Once the verified complaint, physician or
psychologist and the Division of
Developmental Disabilities official’s
affidavits or certifications are filed with the
Surrogate, a hearing date is set to
determine the need for a legal guardian.
The court orders that the next of kin be
notified by certified and regular mail of the
hearing date and also appoints an attorney
for the alleged incapacitated person. The
court appointed attorney will conduct an
investigation including a meeting with the
alleged incapacitated person and the
proposed guardian. Based on his/her
findings, the court appointed attorney will
make a recommendation to the court.
Payment
for the attorney’s services may be paid out
of the incapacitated person’s Social
Security. Personal notice is also given to
the alleged incapacitated person stating
that the alleged incapacitated person and
the court appointed attorney may oppose
the request for guardianship.
If the court appointed attorney does not
dispute the need for a guardianship or the
fitness of the proposed guardian, the
appointed attorney may recommend to the
court that a hearing is not necessary. If a
hearing is required, the court appointed
attorney and the proposed guardian must
attend. The alleged incapacitated person
does not need to attend if the court
appointed attorney or the evaluating
physician or psychologist recommend that
it is not in the best interest of the alleged
incapacitated person to attend.
5
JUDGMENT AND LETTERS OF
GUARDIANSHIP
Once the court enters the judgment, the
guardian(s) will be requested to appear in
the Surrogate’s Court to qualify and sign
the necessary papers. Letters of
Guardianship will be issued by the
Surrogate and mailed to the guardian(s).
++++++
6
HOW TO FILE A GUARDIANSHIP ACTION WITH THE COUNTY SURROGATE
The numbered steps listed below tell you what
forms you will need to fill out, and what to do with
them.
Each form should be typed or clearly printed on 8
½” x 11" white paper only. Forms may not be filed
on a different size or color paper. The text must be
double spaced.
STEPS FOR FILING YOUR COMPLAINT FOR
GUARDIANSHIP.
STEP 1: Fill out the VERIFIED COMPLAINT TO
APPOINT GUARDIAN. (FORM A)
This complaint must be verified either by an
affidavit (oath before a notary public) or certification
(shown in Form A).
STEP 2: Have a physician or psychologist
complete a certification form. (FORM B or C)
If you choose to have a physician complete the
certification form use FORM B. If you want a
psychologist to complete a certification use FORM
C. The physician or psychologist who completes
these forms must be the person who examined the
alleged incapacitated person.
Note: The examination of the alleged
incapacitated person cannot be more than 30 days
prior to the filing of the Complaint.
STEP 3: Obtain a Certification from the New
Jersey DDD Official
The DDD official will complete a form verifying that
the individual is a current client of the Division of
Developmental Disabilities (DDD) and is receiving
services.
This form is not included in this packet.
Contact your county Surrogate for information on
how to contact the regional DDD office.
STEP 4: Fill out the ORDER FOR HEARING
(FORM D)
This form will allow the court to insert the date and
time of hearing and assign an attorney for the
alleged incapacitated person. A copy of this order
is served on the alleged incapacitated person, the
attorney appointed to represent the alleged
incapacitated person and the parties-in-interest
(next of kin, county adjuster and regional DDD
official).
STEP 5: Complete the top portion of the
Judgment Appointing Guardian. (FORM E)
If the judge grants your request, this is the document
that he or she will sign naming you as guardian.
STEP 6: Check your completed forms and Make
Copies.
Check your forms to make sure they are complete.
Remove all instruction sheets. Make sure you have
signed all the forms whenever necessary. Make at
least three copies. One set will be your records.
STEP 7: Pay the Filing Fee.
The filing fee to file these forms is $200, payable by
check or money order. Make the check payable to
the Surrogate of the county in which you are filing.
STEP 8: Deliver or Mail your completed forms
(FORMS A, [B or C] and D), along with the
Certification of the DDD Official, to the County
Surrogate.
DO NOT send in Forms F or G at this time. You
must wait until you get copies of the SIGNED
Order for Hearing (FORM D) from the court
before you complete these forms. You can
deliver your completed forms in person or you can
mail them. If you mail them, we recommend you mail
them certified, return receipt requested. This will
provide you with proof that you mailed your forms.
Your post office can tell you how to send out mail
certified, return receipt requested. The county you
mail your papers to is the county where the alleged
incapacitated person lives. When you deliver or mail
your completed forms to the Surrogate, you must
supply the court with a self-addressed stamped
envelope so that the court can send you certified
copies of the order.
STEP 9: Review copies of the Order for Hearing
returned from the court for instructions on how
to proceed.
The court will return copies of the Order for Hearing
to you. Once you receive these copies, you must
follow the court’s instructions in the Order for Hearing
to complete your paperwork properly.
7
STEP 10: Fill out the NOTICE OF PENDING
HEARING. (FORM F)
Once you get the signed Order for Hearing from
the court, complete the Notice of Pending Hearing.
This will inform the alleged incapacitated person of
the time, date and place of the hearing to
determine whether they are incapacitated. This
form MUST be personally delivered to the alleged
incapacitated person at least 20 days prior to the
date of the hearing.
STEP 11: Arrange to serve the Complaint
(FORM A), Physician’s or Psychologist’s
Certification (FORM B or C), DDD Official’s
affidavit or certification and the signed Order
for Hearing (FORM D) on the alleged
incapacitated person and on the other
interested parties.
Once you get back the Order for Hearing signed by
the judge, you must personally deliver a copy of the
complaint (Form A), physician’s or psychologist’s
certification (FORM B or C), regional director’s
affidavit or certification and the signed order (Form
D) to the alleged incapacitated person. You must
deliver copies of the same forms to all other parties
by certified mail, return receipt requested, and by
regular mail. You must also forward copies of the
complaint and order to the court appointed
attorney.
STEP 12: Complete the PROOF OF SERVICE
Form (FORM G) and the Judgment (FORM E).
After service on the parties-in-interest is
accomplished, complete the Proof of Service form
and the Judgment and mail or deliver both forms to
the Surrogate to show that the papers have been
properly served. This must be filed at least 5 days
prior to the hearing. This document lists all the
papers that were served personally on the alleged
incapacitated person and all papers that were
mailed (certified and regular mail) to the next of kin
and to the alleged incapacitated person’s attorney.
Attach photocopies of the return receipt cards
returned by the post office.
STEP 13: Call the Surrogate a few days prior
to the date set for the hearing to confirm the
hearing will be held.
If there has been no opposition to the guardianship
application, the judge may not require a hearing.
However, if a hearing is scheduled, you must attend
the hearing. Call to confirm whether a hearing will be
held.
STEP 14: Qualification. If the court declares the
alleged incapacitated person to be incapacitated
and appoints a guardian, then the appointed person
must appear in the Surrogate to qualify. This
involves signing acceptance documents and filing a
surety bond, if the court requires the same.
STEP 15: Legal Fee Payment. If the court
awards the attorney appointed to represent the
incapacitated person a fee, arrange to pay the same
from the incapacitated person’s assets or income.
DEADLINES YOU NEED TO MEET
Examinations by the physician or psychologist of the
alleged incapacitated person must be made no
more than 30 days prior to the filing of the complaint.
The alleged incapacitated person and all interested
parties listed in the complaint must have at least 20
days notice of the hearing date.
The Proof of Service (FORM F) must be filed with
the court at least 5 days prior to the date scheduled
for the hearing.
INTERPRETER OR ACCOMMODATION
If you need an interpreter or an accommodation for
a disability for the hearing, please contact the court
before the hearing date.
++++++
8
INSTRUCTIONS FOR COMPLETING THE ATTACHED FORMS
INSTRUCTIONS FOR FORM A - VERIFIED COMPLAINT TO APPOINT GUARDIAN
A. In paragraph #1 type or print the information about the person over whom you are seeking to be
appointed guardian.
B. In paragraph #2 type or print the name of the person over whom guardianship is sought and the
disability that he or she has been diagnosed with. Type or print the name of the physician or
psychologist who completed either a physician’s or psychologist’s certification (FORM B or C) (See
step #2 for more information on this.)
C. In paragraph # 3 type or print the name of the person over whom guardianship is sought and indicate
where he/she is receiving services from the New Jersey Division of Developmental Disabilities.
D. In paragraph # 4 type or print the names of the next of kin of the person over whom a guardian is
sought. Insert the name and address of the appropriate county adjuster for the county of settlement
and the name and address of the DDD service provider administrator.
E. In paragraph # 5 insert your personal information
F. In paragraph #6 indicate whether the person over whom guardianship is sought owns any real or
personal property and his or her monthly income, if any. Type or print any employer’s name and the
salary of any employment by the alleged incapacitated person.
G. In paragraph #7 type or print any courses of instructions or other training the alleged incapacitated
person attends.
H. In paragraph #9 type or print the name of the person over whom guardianship is sought. Use the first
paragraph #9A if a plenary (full) guardianship is requested; use the second paragraph #9B if a
limited guardianship is requested.
I. In the relief demanded use the first letter (A1,B1 and C1) paragraphs, if a plenary (full) guardianship
is requested. Use the second letter (A2,B2 and C2) paragraphs, if a limited guardianship is
requested.
J. Sign and date the form where it asks you to do so.
9
INSTRUCTIONS FOR FORM B -- PHYSICIAN CERTIFICATION
You must have a New Jersey licensed medical physician or psychologist complete a certification attesting
to the fact that the alleged incapacitated person is in fact incapacitated. The medical physician or
psychologist who completes this form must be the one to examine the alleged incapacitated person.

This form is for medical physicians only. If a medical physician is the one who has conducted the evaluation
of the alleged incapacitated person, then this form should be used. Inform him/her that you are seeking to
be appointed guardian over the alleged incapacitated person and that you need him/her to complete this
form.
INSTRUCTIONS FOR FORM C -- PSYCHOLOGIST CERTIFICATION
You must have a New Jersey licensed medical physician or psychologist complete a certification attesting
to the fact that the alleged incapacitated person is in fact incapacitated. The medical physician or
psychologist who completes this form must be the one to examine the alleged incapacitated person. The
examination must take place no more than 30 days before you file this guardianship action.
This form is for psychologists only. If a psychologist is the one who has conducted the evaluation of the
alleged incapacitated person, then this form should be used. Inform him/her that you are seeking to be
appointed guardian over the alleged incapacitated person and that you need him/her to complete this form.
INSTRUCTION FOR FORM D - ORDER FOR HEARING
(This form is self explanatory. Fill in only the top portion.)
Note: The Public Defender, if available, may be appointed if only guardianship of the person is sought. If
you seek guardianship of the person and the estate or the public defender is not available, then the court
will appoint a private attorney.
INSTRUCTIONS FOR FORM E - JUDGMENT APPOINTING GUARDIAN
Where indicated, type or print your name, the name of the attorney appointed for the alleged incapacitated
person, the name of the physician or psychologist and the name of the Division of Developmental Disabilities
official who has completed the certification.
10
INSTRUCTIONS FOR FORM F - NOTICE OF PENDING HEARING
(Portions that are not self explanatory)
A. Where shown, enter the docket number in this case. You will get this number when the court returns
the signed order to you. (FORM D)
B. Where it says “TO” type or print the name of the alleged incapacitated person.
C. Fill out the date, time, and place of the hearing. You will get this information when the court sends
back the signed order for hearing with all of this information on it.
D. Type or print the name of the proposed guardian in the last paragraph.
INSTRUCTIONS FOR FORM G - PROOF OF SERVICE
(Portions that are not self explanatory.)
A. In paragraph #1 type or print the name of the person who handled service of the pleadings.
B. In paragraph #2 type or print the date you personally mailed or delivered copies of FORMS A, [B or
C] & D to the alleged incapacitated person.
C. In paragraph # 4 type or print the date you mailed a copy of FORMS A, [B or C] & D to the next of kin
of the alleged incapacitated person and other interested parties.
D. Sign and date the form where it asks you to do so.
11
FORM A -- VERIFIED COMPLAINT TO APPOINT GUARDIAN
Plaintiff(s) Type your name(s)
Address:
Telephone Number:
SUPERIOR COURT OF NEW JERSEY
CHANCERY DIVISION
COUNTY
PROBATE PART
In The Matter of

TYPE INCAPACITATED PERSON’S NAME
an Alleged Incapacitated Person
Docket No.
CIVIL ACTION
VERIFIED COMPLAINT TO APPOINT
GUARDIAN FOR PERSON RECEIVING
DIVISION OF DEVELOPMENTAL
DISABILITIES SERVICES
I/ We, the Plaintiff(s), and
, residing at
, City /Township /Borough
of , County of and State of
New Jersey, by way of verified complaint says:
1. The name, age, present resident address, length of time at residence,
permanent residence (domicile) and marital status of the alleged incapacitated person are:
A. Name:
B. Age:
C:
Present residence:
since .
D.
Permanent residence:
since .
E. Marital status: (Check one) __Married __Never Married__Divorced
F. Children: (Check one) __No Children __Children as listed in
Paragraph 4
12
2. has been diagnosed as suffering from
as shown by the attached affidavit or certification
of (Medical Physician or Psychologist). Because
of this condition, lacks sufficient capacity to
govern himself/herself and manage his/her affairs.
3. has been receiving services from the
New Jersey Division of Developmental Disabilities at
since . He/She
continues to need such services, as shown by the attached affidavit or certification of
, Division of Developmental Disabilities official.
4. The names, residence addresses, and relationships of the spouse, next-of-kin
most closely related to the alleged incapacitated person (parents, siblings et cetera) and other
persons interested in the status of the alleged incapacitated person (custodian, county
adjuster, DDD program administrator) are as follows:
Name Address Relationship Age
13
5. The name, address, age, telephone number and relationship to the alleged
incapacitated person of the proposed guardian(s) are as follows:
Name:
Address:
Age:
Telephone number
Relationship
6. The character and approximate value of the real and personal property and income
of the alleged incapacitated person are as follows:
A. Personal property:
(i) bank accounts $
(ii) stocks, bonds and mutual funds $
(iii) other personal property (specify) $ _________________
Total personal property value $
B. Real property (describe)
$
$
C. Periodic compensation and income from:
i. real property $ / month
ii personal property $ / month
iii pensions $ / month
iv public assistance benefits $ / month
v social security benefits $ / month
vi trust distributions: $ / month
vii other income sources (specify) $ / month
viii
wages (employer:) $ _________________/ month
Total monthly income $ / month
14
7. (If applicable) , the alleged incapacitated
person, attends classes at .
8. The alleged incapacitated person does not have an attorney. It is requested that the
court appoint an attorney to serve as legal counsel for the alleged incapacitated person.
9A.
Because of ’s condition, he/she is
without the necessary cognitive capacity to understand personal, financial, health and medical
matters that affect his/her well-being and, therefore, he/she lacks the capacity to
govern himself /herself in all of his/her financial and personal affairs.
OR
9B.
Because of ’s condition, he/she is without the
necessary cognitive capacity to understand some of the personal, financial, health and medical
matters that affect his/her well-being and, therefore, he/she lacks the capacity to
govern himself/herself in the following financial and personal affair areas:
.
In all other respects, he/she is fully able at this time to govern himself/herself and
govern and manage his/her affairs.
WHEREFORE, the plaintiff(s) demand(s) judgment pursuant to N.J.S.A. 30:4-165.7:
A1. declaring to be suffering from a chronic
functional impairment and as a result is incapable and unable to govern himself/herself and
manage his/her affairs;
OR
A2. declaring to be suffering from a chronic
functional impairment and as a result is incapable and unable to govern himself/herself and
manage his/her affairs with respect to :
;
15
B1.
Appointing the plaintiff(s) the guardian of his/her PERSON and issuing
Letters of Guardianship upon qualifying according to law;
OR
B2.
Appointing the plaintiff(s) the limited guardian of his /her PERSON and issuing
Letters of Limited Guardianship upon qualifying according to law;
C1.
Appointing the plaintiff(s) the guardian of his/ her ESTATE and issuing Letters
of Guardianship upon qualifying according to law.
OR
C2.
Appointing the plaintiff(s) the limited guardian of his/her ESTATE and issuing
Letters of Limited Guardianship upon qualifying according to law.
Date:

___________________________________
SIGNATURE OF PLAINTIFF

TYPE NAME
Date:

___________________________________
SIGNATURE OF PLAINTIFF

TYPE NAME
VERIFICATION
I/We, and , hereby certify and say:
1.
I/ We are the plaintiff(s).
2. The contents of the complaint are true to my (our) personal knowledge and belief.
I (We) hereby certify that the statements made by me are true. I am aware that if any
are wilfully false, I am (We are) subject to punishment.
Date: Date:
______________________________________________________ ________________________________________________
Signature of Plaintiff Signature of Plaintiff
Type Name Type Name
16
FORM B -- PHYSICIAN’S CERTIFICATION
Plaintiff(s) TYPE YOUR NAME(s)
Address:
Telephone Number:
SUPERIOR COURT OF NEW JERSEY
CHANCERY DIVISION
COUNTY
PROBATE PART
IN THE MATTER OF
TYPE INCAPACITATED PERSON’S NAME
AN ALLEGED INCAPACITATED
PERSON
Docket No.
CIVIL ACTION
CERTIFICATION OF MEDICAL
PHYSICIAN
TYPE PHYSICIAN’S NAME
I, , M.D., with offices at
,
being of full age, do hereby certify and say as follows:
1. I am a permanent resident of the State of New Jersey and a physician licensed
to practice medicine in the State of New Jersey.
2. I am not a relative, either through blood or marriage, to
or of the proprietor, director
or chief executive of any private institution for the care and treatment of the mentally ill at which
he/she is living or at which it is proposed to place him/her, nor am I professionally employed
by the management thereof as a resident physician, nor do I have any financial interest therein.
3. I have reviewed the clinical data and history regarding
and personally examined
him/her on , 20 .
1
Note. Complete this paragraph if it is your opinion that the alleged
incapacitated person has sufficient capacity in certain areas that he or she should retain
decision making rights. This paragraph will set out the basis for the same for the court’s
consideration. Otherwise cross this paragraph out before signing.
17
4. My opinion as to ’s capacity to govern
himself/herself and manage his/her affairs is based upon the following:
5. Based upon my personal examination and the aforementioned clinical data and
history, it is my conclusion that suffers from a significant
chronic functional impairment and lacks the cognitive capacity to make decisions for
himself/herself or to communicate, in any way, decisions to others. His/Her
significant chronic functional impairment includes, but is not limited to, a lack of
comprehension of concepts related to personal care, health care or medical treatment and
is, therefore, incapable of governing himself/herself or managing his/her
personal or financial affairs.
6.1 It is also my opinion that does have
sufficient capacity to make limited decisions in the areas of :

The reasons for my opinion that he/she has the ability to make the aforementioned
limited decisions are:
7. Based upon my personal examination and aforementioned clinic data and
history, it is my conclusion that he/she is (check one) ___capable ___incapable of
attending the hearing in this matter. If incapable, state reasons:
I certify that the foregoing statements made by me are true. I am aware that if
any of the foregoing statements made by me are willfully false, I am subject to punishment.
Date: _______________________________ M.D.
type name
18
FORM C -- PSYCHOLOGIST’S CERTIFICATION
Plaintiff(s) TYPE YOUR NAME(s)
Address:
Telephone Number:
SUPERIOR COURT OF NEW JERSEY
CHANCERY DIVISION
COUNTY
PROBATE PART
In the Matter of
TYPE INCAPACITATED PERSON’S NAME
An Alleged Incapacitated Person
Docket No.
CIVIL ACTION
CERTIFICATION OF PSYCHOLOGIST
TYPE PSYCHOLOGIST’S NAME
I, , with offices at
, being of full age,
do hereby certify and say as follows:
1. I am a permanent resident of the State of New Jersey and a psychologist
licensed pursuant to N.J.S.A. 45:14B-1 et seq. to practice in the State of New Jersey.
2. I am not a relative, either through blood or marriage, to
or of the proprietor, director
or chief executive of any private institution for the care and treatment of the mentally ill at which
is living or at which it is proposed to place
him/her, nor am I professionally employed by the management thereof as a resident
physician, nor do I have any financial interest therein.
3. I have reviewed the clinical data and history regarding
and personally examined
him/her on the , 20 .
1
Note. Complete this paragraph if it is your opinion that the alleged
incapacitated person has sufficient capacity in certain areas that he or she should retain
decision making rights. This paragraph will set out the basis for the same for the court’s
consideration. Otherwise cross this paragraph out before signing.
19
4. My opinion as to ’s capacity to govern
himself/herself and manage his/her affairs is based upon the following:
5. Based upon my personal examination and the aforementioned clinic data and
history, it is my conclusion that suffers from a significant
chronic functional impairment and lacks the cognitive capacity to make decisions for
himself/herself or to communicate, in any way, decisions to others.
His/Her significant chronic functional impairment includes, but is not limited to,
a lack of comprehension of concepts related to personal care, health care or medical
treatment and is, therefore, incapable to governing himself/herself or managing
his/her personal or financial affairs.
6.1 It is also my opinion that does have
sufficient capacity to make limited decisions in the areas of :

The reasons for my opinion that he/she has the ability to make the aforementioned
limited decisions are:
7. Based upon my personal examination and aforementioned facts and history,
it is my conclusion that he/she is (check one) capable incapable
of attending the hearing in this matter. If incapable, state reasons:
I certify that the foregoing statements made by me are true. I am aware that if any of
the foregoing statements made by me are willfully false, I am subject to punishment.
Date:
_______________________________
TYPE PSYCHOLOGIST’S NAME
20
FORM D -- ORDER FOR HEARING
Plaintiff(s) TYPE YOUR NAME(S)
Address:

Telephone Number:
SUPERIOR COURT OF NEW JERSEY
CHANCERY DIVISION
COUNTY
PROBATE PART
In the Matter of
PRINT INCAPACITATED PERSON’S NAME
an Alleged Incapacitated Person
Docket No.
CIVIL ACTION
ORDER FIXING HEARING DATE AND
APPOINTING ATTORNEY FOR
ALLEGED INCAPACITATED PERSON
RECEIVING DIVISION OF
DEVELOPMENTAL DISABILITIES
SERVICES
This matter having been opened to the court on complaint of the plaintiff(s) for an order
seeking the appointment of a guardian for under R.4:86-10
and for such other relief as the court may deem just, and the court having read and considered
the verified complaint, the supporting affidavits or certifications and all other papers and
pleadings presented with this application, and for good cause shown:
(Do not write below this line - for court use only - except for the appropriate spaces where the name of the person over
whom guardianship is sought should be inserted.)
IT IS on this day of , 20___, ORDERED that:
1. This matter be set down for hearing before this court at the
County Court House, , New Jersey, before the Hon.
on the day of , 20 , at o’clock in the a.m. p.m.
or as soon thereafter as plaintiff(s) may be heard, to determine the issue of the legal
incapacity of and for the determination of the appointment of a
guardian; and
2. A copy of the complaint and supporting affidavits along with this order, shall be
served on , the alleged incapacitated person, by personal
service at least 20 days prior to the date scheduled for the hearing.
21
3. A separate notice advising the alleged incapacitated person of his
her right to a jury trial and to personally, or through legal counsel, appear and oppose the
application shall be personally served on the alleged incapacitated person at least 20 days
prior to the date scheduled for the hearing.
4. A copy of the complaint and supporting documents, along with this order, shall
be served on all the next of kin and other interested parties set out in the complaint by regular
and certified mail, return receipt requested, at least 20 days prior to the date scheduled for
the hearing.
5. , Esquire, whose address is
____________________________________and telephone is _____________________,
be and hereby is appointed as counsel for the alleged incapacitated person. Said attorney
shall be immediately served with copies of the complaint and supporting documents along
with this order. Said attorney shall personally interview the client, examine the medical
records, make inquiries of persons having knowledge of the alleged incapacitated person’s
circumstances, make reasonable inquiries to locate any will, powers of attorney or health care
directive previously executed by the alleged incapacitated person and prepare a written report
of findings and recommendations to be filed in court and with the plaintiff(s) pursuant to R.
4:86-10 at least ____ days prior to the hearing.
6. This court may summarily appoint a guardian of the person and estate without
a hearing if the attorney appointed for reports that
he/she on behalf of the alleged incapacitated person does not dispute either the need for
the guardianship or the fitness of the proposed guardian and the alleged
incapacitated person does not request a plenary hearing.

______________________________________
, J.S.C.
22
FORM E -- JUDGMENT APPOINTING GUARDIAN

Plaintiff(s) TYPE YOUR NAME(S)
Address:
Telephone Number:
SUPERIOR COURT OF NEW JERSEY
CHANCERY DIVISION
COUNTY
PROBATE PART
In the Matter of

TYPE INCAPACITATED PERSON’S NAME
An Incapacitated Person
Docket No.
CIVIL ACTION
JUDGMENT OF LEGAL INCAPACITY
AND APPOINTING A GUARDIAN OF THE
PERSON AND ESTATE FOR PERSON
RECEIVING DIVISION OF
DEVELOPMENTAL DISABILITIES
SERVICES
This matter having been opened to the court on the complaint of the plaintiff(s)
, and the court having
appointed as attorney for
and the court having reviewed the pleadings and the affidavits or certifications of
, M.D., (or licensed
psychologist) and , Division of Developmental Disabilities official,
and the report of , Esq., and it appearing that
suffers from a chronic functional impairment and that
he/she lacks cognitive capacity and as a result is incapable of governing himself/herself
and managing his/her affairs.
It is on this day of , 20__ ORDERED and ADJUDGED that:
1. is an incapacitated person and is unfit
and unable to govern himself/herself and manage his /her affairs because of a significant
chronic functional impairment, except, but subject to the right of the guardian(s) herein
appointed to seek to have this portion of the judgment vacated or modified for good cause,
is able at this time to govern himself /herself
and manage his/her own affairs with respect to the following areas:
_______________________________________________________________________
______________________________________________________________________
_____________________________________________________________________.
23
2: be and hereby is/are appointed
[Limited] Guardian(s) of the Person and Estate of
and that Letters of [Limited] Guardianship of the Person and Estate shall be issued upon
him/her /them (a) qualifying according to law, (b) acknowledging to the Surrogate of
________________ County, upon receipt of a copy of the guardian’s manual, the receipt
of the same and (c) entering into a surety bond unto the Superior Court of New Jersey
in the amount of $ , which bond shall contain the conditions set forth in N.J.S.A.
3B:15-7 and R. 1:13-3. The court shall approve the bond as to form and sufficiency.
3. The guardian(s) shall have authority to make any and all medical decisions
regarding including, but not limited to, the authority to consent or withhold
consent to surgical procedures and such other procedures reasonably attendant thereto, and
all decisions concerning withdrawal or denial of life support shall be exercised in full
compliance with existing statutory and case law.
4. Upon qualifying, the Surrogate of ________________ County shall issue
Letters of Guardianship of the Person and Estate to
thereupon he/she/they shall then be authorized to perform all the functions and duties of
a guardian as allowed by law, except as limited herein or in areas herein above set forth
where retains decision making rights.
5. The Guardian(s) of the Estate may not alienate, mortgage, transfer or otherwise
encumber or dispose of real property without court approval. Said limitation shall be stated
in the Letters of Guardianship.
6. The court having reviewed the affidavit or certification of services of
, Esq., previously filed with the
court, ____________________________ shall pay ______________________________,
court-appointed attorney for _________________________, a fee of $ for
professional services rendered and $ for expenses incurred, which
disbursements are hereby approved.
7. is hereby directed to advise the Surrogate of
_______________ County within ten (10) days of any changes in the address or telephone
number of himself or herself and/or the incapacitated person or of the death of the
incapacitated person.
8. shall cooperate fully with any court staff
or volunteers until the guardianship is terminated by the death or return to competency of
or the guardian’s death, removal or discharge.
9. The plaintiff shall serve a copy of this Judgment upon all interested parties and
attorneys of record within seven (7) days from the receipt hereof.

________________________________________
, J.S.C.
24
FORM F NOTICE OF PENDING HEARING
Plaintiff(s) TYPE YOUR NAME(s)
Address:
Telephone Number:
SUPERIOR COURT OF NEW JERSEY
CHANCERY DIVISION
COUNTY
PROBATE PART
In the Matter of
TYPE INCAPACITATED PERSON’S NAME
An Alleged Incapacitated Person
Docket No.
CIVIL ACTION
NOTICE OF PENDING HEARING, RIGHT
TO APPEAR AND RIGHT TO REQUEST
A JURY TRIAL
TO:
Be advised that a verified complaint has been filed with the New Jersey Superior
Court, Chancery Division, Probate Part seeking to have you declared to be an
incapacitated person and have a guardian appointed. If a guardian is appointed, you
could lose your individual rights.
The matter has been set down for a hearing on
at a.m./p.m. in the County Court House,
, New Jersey.
You have the right to be present in court. You have the right to be represented by
an attorney of your own choosing. You may appear in person or through legal counsel to
oppose the relief sought. You have the right to demand a trial by jury.
If either you or the attorney appointed for you do not dispute the need for a
guardianship or the fitness of the proposed guardian, and if you do not request a plenary
hearing, the court may summarily appoint
as guardian(s) without the necessity of a hearing.
Date: Date:
________________________________________ ____________________________________________
Signature of Plaintiff Signature of Plaintiff
Type Name Type Name

25
FORM G PROOF OF SERVICE
Pro Se Plaintiff(s) TYPE YOUR NAME(s)
Address:

Telephone Number:
SUPERIOR COURT OF NEW JERSEY
CHANCERY DIVISION
COUNTY
PROBATE PART
In the Matter of
TYPE INCAPACITATED PERSON’S NAME
an Alleged Incapacitated Person
Docket No.
CIVIL ACTION
PROOF OF SERVICE
1. I, , of full age, hereby certify and say:
2. On , I personally served
, the alleged incapacitated person, at
with copies of the following
documents regarding the above captioned matter:
A. Verified Complaint
B. Division of Development Disabilities Official’s Certification
C. (Check one) Physician’s Certification or Psychologist’s
Certification
D. Order for Hearing
E. Notice of Pending Hearing, Right to Appear and Right to Request a
Jury Trial.
3. The alleged incapacitated person has been afforded the opportunity to
appear personally or through an attorney in this matter, and he/she has been given or
afforded assistance to communicate with friends, relatives or attorneys concerning this
matter.
26
4. On , I served a copy of the Verified Complaint,
DDD official’s Certification, (check one) Physician’s Certification or
Psychologist’s Certification and Order for Hearing by certified mailed, return receipt
requested, and regular mail on:
Name Address Date Served
5. Copies of all return receipt cards for certified mail are attached.
I hereby certify that the statements made by me are true. I am aware that if
any are wilfully false, I am subject to punishment.
Date: ____________________________________
signature
type name
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