Guardianship Interview Form |
KENNETH VERCAMMEN & ASSOCIATES, PC ATTORNEY AT LAW 2053 Woodbridge Ave Edison, NJ 08817 (Phone) 732-572-0500 (Fax) 732-572-0030 "GUARDIANSHIP INTERVIEW FORM" Please fill out completely and fax or mail back. This form is extremely important. Your accuracy and completeness in responding will help us best represent you. ALL THE PAGES AND SECTIONS OF THIS FORM MUST BE COMPLETED PRIOR TO SEEING THE ATTORNEY. WRITE YOUR SPECIFIC QUESTIONS AT THE END OF THE LAST PAGE. PLEASE HELP YOURSELF TO THE FREE INFORMATION BROCHURES IN THE RECEPTION AREA. PLEASE PRINT CLEARLY Your Full Name: [Person Filling out Form] ______________________________________________________ First Last Street Address: ________________________________________ City ____________________ State ____ Zip Code _____________ Telephone Numbers: Cell: __________________________________ Day: ____________________ Night: ________________________ E-mail address: __________________________________________ Referred By: ___________________________________________ If referred by a person, is this a client or attorney? If you heard about this law office by the internet, which search engine? What search terms did you use? Today's Date ___________________________________________ 1. Name of person for whom you seek Guardianship: ________________ [Guardianship Questionnaire rev non PI 6/18/08 G3] ____________________________________________________________ ____________________________________________________________ 3. Your relationship to person: _________________________________ 4. Incapacitated person is of the age of ________________., DOB _______ 5. The other kin of Incapacitated person are: ___________________, relationship _______________, residing at: ___________________, ___________________, relationship _______________, residing at: _________________, ___________________, relationship ______________, residing at: ____________________ 6. Name, address and fax number of Doctor 1 who will sign Affidavit that person is incapacitated: ____________________________________________________________ ____________________________________________________________ 7. Name, address and fax number of Doctor 2 who will sign Affidavit that person is incapacitated: ____________________________________________________________ ____________________________________________________________ 8. Is there a Will? _____ Did you bring a photocopy? ____ B. Is there a Power of Attorney? _____ Did you bring a copy? ____ C. Do You Have a Copy of the Deed? ________ ASSETS The court rules require details of assets be set forth in a Guardianship case. SCHEDULE ñAî REAL PROPERTY If none, write none 1. Street and Number _____________________________________ Town: ____________________ Lot: ___ Block: ____ County: ____________________ Title/Owner of Record: _______________ Tax Assessor Assessed Value: $____________________ Full Market Value of Property: $____________________ Mortgage Balance: $______________________ Any other Real Estate: $______________________ SCHEDULE ñB (1)î BANK ACCOUNTS, STOCK, CD, OTHER ASSETS All Other Personal Property Owned Individually or Jointly; Market Value, Indicate the Manner of Registration at Date of Death. If none, write none for each line Bank Accounts/ Brokerage Accounts - Name of Bank, Acct. # ___________________________________________ $_________ __________________________________________ $_________ ___________________________________________ $_________ __________________________________________ $_________ Stock - Name of Stock Co., Acct. # ________________ $_________ ___________________________________________ $_________ Investment Bonds., Acct. # $_________ ___________________________________________ $_________ Cars _______________________________________ $_________ Other assets over $10,000 ______________________ $_________ ___________________________________________ $_________ ___________________________________________ $_________ ___________________________________________ $_________ Liabilities More Than $2,000: If none, write none ____________________________________________________________ ____________________________________________________________ Estimated Gross Estate: $__________________________________ Set forth several specific acts of incompetency by the alleged incapacitated person: ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ PLEASE USE THIS PAGE TO WRITE YOUR SPECIFIC QUESTIONS FOR THE ATTORNEY: ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________
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Tuesday, September 27, 2011
Guardianship Interview Form
