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. Pilot Form 6 –05/24/02 1 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:__________________________________________________________________ ________________________________________________________________________________________________________ Pilot Form 6 –05/24/02 2 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) 3