In the General Court of Justice
Superior Court Division
Before the Clerk
STATE OF NORTH CAROLINA
______________________________ County
File No.: _________________________
IN THE MATTER OF:
MOTION IN THE CAUSE FOR
APPOINTMENT OF LIMITED GUARDIAN
Name and Address of Respondent
G.S. 35A-1105, 35A-1201, 35A-1207, 35A-1210
County of Residence of Respondent
Age
Name and Address of Moving Party
County of Residence of Moving Party
Name and Address of Moving Party
Ph.# of Moving Party
Phone No. of Attorney for Moving Party
State Bar No.
Moving Party’s Relationship to Respondent or Interest in Proceeding
Respondent Indigent
Jury Trial Requested
Name and Address of Treatment Facility if Respondent is an Inpatient in This County
The undersigned, being duly sworn, requests that the Court, after notice and hearing, review the guardianship of the respondent named
above to determine whether a limited guardianship or restoration to competency may be appropriate in this case.
In support of this Motion, the undersigned states:
1.
The respondent is  a resident of this county  domiciled in this county  an inpatient in the facility named above or
 present in this county, it being impossible to determine his/her county of residence or domicile.
2.
The respondent was previously declared incompetent in North Carolina
Date of Adjudication: ___________________________________________________
County:
___________________________________________________
File or other ID No.: ___________________________________________________
The respondent was adjudicated incompetent in another state in the proceeding identified below
Date of Adjudication: ___________________________________________________
State and County:
___________________________________________________
File or other ID No.: ___________________________________________________
3. The respondent retains or has recovered capacity in some life domains and can have his/her guardianship limited accordingly.
The life domains where respondent retains capacity are listed in question #6 below.
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4. The respondent’s next of kin, if any, and other persons known to have an interest in this proceeding are:
Name and Address
Name and Address
County of Residence
Telephone No.
County of Residence
Telephone No.
Relationship to Respondent or Interest in Proceeding
Relationship to Respondent or Interest in Proceeding
Name and Address
Name and Address
County of Residence
Telephone No.
County of Residence
Relationship to Respondent or Interest in Proceeding
Telephone No.
Relationship to Respondent or Interest in Proceeding
5. General statement of respondent’s assets and liabilities, including any income and receivables to which he/she is entitled:
Assets
Liabilities
Income and Receivables
Real Property
$____________ Mortgage Loans
$____________ Wages & Salaries
$____________
Tangible Personal Property $____________ Other Secured Loans $____________ Rents
$____________
Other Personal Property
$____________
Unsecured Loans
$____________
Pensions
$____________
There is a representative payee for governmental benefits Yes
No
Insurance & Compensations $____________
There a Power of Attorney in place.
Yes
No
Other (including SSI/SSDI) $___________
There is a special needs or other trust in place.
Yes
No
6. Capacity Assessment:
Nature of Impairment _________________________________________Nature of Residence ________________________________
Personal Capacity
I. Language (understands/participates in conversations, can read and write, understand signs such as "keep out," "men," "women")
 has capacity  lacks capacity Comment:__________________________________________________________________
________________________________________________________________________________________________________
II. Nutrition (makes independent decisions re: eating, prepares food, purchases food items)
 has capacity  lacks capacity Comment:__________________________________________________________________
________________________________________________________________________________________________________
III. Personal Hygiene (bathes, brushes teeth, uses proper hygiene when using the restroom, control toilet functions during day)
 has capacity  lacks capacity Comment:__________________________________________________________________
________________________________________________________________________________________________________
IV. Personal Safety: (recognizes danger and seeks assistance as needed, protects self from exploitation / personal harm)
 has capacity  lacks capacity Comment:__________________________________________________________________
________________________________________________________________________________________________________
V. Health Care (makes and communicates choices re medical treatment, notifies others of illness, follows medication instructions)
 has capacity  lacks capacity Comment:__________________________________________________________________
________________________________________________________________________________________________________
VI. Residential (makes and communicates decisions re residence / roommates, maintains safe shelter)
 has capacity  lacks capacity Comment:__________________________________________________________________
________________________________________________________________________________________________________
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VII. Employment (makes and communicates decisions re employment, demonstrates vocational skills such as neatness and
punctuality, writes or dictates application form)
 has capacity  lacks capacity Comment:_________________________________________________________________
________ _____________________________________________________________________________________________
VIII. Independent Living (follows a daily schedule, conducts housekeeping chores, uses community resources such as bank, store,
post office)
 has capacity  lacks capacity Comment:__________________________________________________________________
________________________________________________________________________________________________________
IX. Civil (knows to contact advocate if being exploited, understands consequences of committing a crime, registers to vote)
 has capacity  lacks capacity Comment:__________________________________________________________________
________________________________________________________________________________________________________
X. Financial Capacity (Estate)
A. Makes and communicates decisions re: paying bills and spending discretionary money, makes change for $1, $5, and $10,
maintains a personal bank account, spends discretionary money
 has capacity  lacks capacity Comment:__________________________________________________________________
________________________________________________________________________________________________________
B. Makes and communicates decisions regarding management of savings, investments, real estate, and other substantial assets,
 has capacity  lacks capacity Comment:__________________________________________________________________
________________________________________________________________________________________________________
C. Can resist attempts at financial exploitation by others.
 has capacity  lacks capacity Comment:__________________________________________________________________
_______________________________________________________________________________________________________
7. The movant requests that the current guardianship be modified and limited as follows:
Name and Address of Proposed Guardian if different than current guardian
Name and Address of Proposed Guardian if different than current guardian
 Of the Estate
 Of the Estate
 Of the Person
 General Guardian
 Of the Person
 General Guardian
VERIFICATION (Optional)
I, the undersigned movant, have read this Motion and state that its contents are true to my own knowledge except those matters stated
on information and belief, which I believe are true.
Date
SWORN AND SUBSCRIBED TO BEFORE ME
Date
Signature of Person Authorized to Administer Oath
Title
Pilot Form 6 –05/24/02
Signature of Moving Party
Date Commission Expires
Name of Petitioner (Type or Print)
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