Northum. Cnty. Pa 14.6
The petition to adjudicate incapacity and/or the appointment of a guardian referred to in Rule NOC-14.4A shall be in substantially the following form:
In the matter of (Respondent) an alleged incapacitated person | : | IN THE COURT OF COMMON PLEAS OF NORTHUMBERLAND COUNTY, PA. |
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: | ORPHANS' COURT DIVISION | |
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: | O.C. NO. |
PETITION TO ADJUDICATE INCAPACITY TO 20 P.S. 5511 AND FOR THE APPOINTMENT OF A GUARDIAN OF THE PERSON AND/OR OF THE ESTATE
TO: THE HONORABLE JUDGES OF THE NORTHUMBERLAND COUNTY COURT
The petition of (name of petitioner) respectfully states:
1. Name and current address of petitioner.
2. Petitioner's relationship to and interest in the alleged incapacitated person's welfare.
3. Name, age, residence and post office address of the alleged incapacitated person.
4. Name and address of person or institution providing residential services to the alleged incapacitated person.
5. Names and addresses of spouse, parents and all persons who are sui juris and would be entitled to share in the estate of the alleged incapacitated person if that person died intestate.
6. Names and addresses of medical, social, residential, and other service providers.
7. State whether respondent has or has not been a member of the United States Armed Services and whether he is or is not receiving any benefits from the United States Veterans Administration.
8. State whether any court has ever assumed jurisdiction in any proceeding to determine the competency or capacity of the respondent, and whether any guardian of the person and/or estate has ever been appointed.
9. The name and address of respondent's attorney, if known, or the attorney known to represent the respondent on other legal matters.
10. The reason why guardianship is sought.
11. A description of the functional limitations and physical and mental conditions of the alleged incapacitated person.
12. Allegations of fact regarding the services being utilized to meet essential requirements for the alleged incapacitated person's physical health and safety, to manage the person's financial resources or to develop or regain the person's abilities.
13. Allegations of fact regarding the type of assistance required by the person and as to why no less restrictive alternative would be appropriate.
14. Allegations of fact regarding the probability that the extent of the person's incapacities may significantly lessen or change.
15. For each type of guardian being requested, the name and address of the person or entity whom petitioner asks to be appointed guardian.
16. An averment that the proposed guardian has no interest adverse to the alleged incapacitated person.
17. Qualifications of proposed guardian.
18. The specific areas of incapacity over which it is requested that the guardian be assigned powers.
19. If guardian of the estate is being sought, the petition shall also include the gross value of the estate and the net income from all sources to the extent known.
WHEREFORE, petitioner prays this Honorable Court to grant the following relief:
A.
B.
etc.
By:
______________
Northum. Cnty. Pa 14.6