Physicians Affidavit - Guardianship

Physician's Affidavit - Guardianship UNITED STATES OF AMERICA STATE OF ILLINOIS COUNTY OF LASALLE IN THE CIRCUIT COURT OF THE THIRTEENTH JUDICIAL CIRCUIT IN THE MATTER OF THE ESTATE OF _______________________________ Disabled Person No.______________________ PHYSICIAN'S AFFIDAVIT - GUARDIANSHIP ___________________________________________, on oath states: 1. 2. 3. I am licensed to practice medicine in all its branches in Illinois. On _________________________, 20______, I examined __________________________ In my opinion he/she managing is _____________________________________________________ (physically) (and) (mentally) incapable of 4. his ___________________________________________________ (person) (estate) (person and estate) My opinion based on these facts: (Facts must correspond to Section 11a-9, Chapter 110 ½) Signed and Sworn to before me _______________________________, 20______ __________________________________________ Notary Public _______________________________________ M.D. _______________________________________ Address Name: __________________________________ _______________________________________ Attorney for: _____________________________ Address: _________________________________ City: ____________________________________ Telephone: _______________________________ City _______________________________________ Telephone LASALLE COUNTY CIRCUIT CLERK OTTAWA, ILLINOIS 61350 American LegalNet, Inc. www.FormsWorkFlow.com