Cover Page Individualized Education Program (IEP) {12014}

NOTICE: This is a not a public document. The information entered on this form will be kept confidential. You therefore must enter all requested information, including any requested personal identifying information, such as your Social Security number, driver's license number, or active bank or credit card accounts. Filing Attorney Information or Pro Se Litigant: Name NJ Attorney ID Number Law Firm/Agency Name Address Telephone Number In the Matter of, , Name of Alleged Incapacitated Person (AIP) Superior Court of New Jersey Chancery Division - Probate Part County Docket Number Civil Action an Alleged Incapacitated Person Cover Page Individualized Education Program (IEP) . Attached is a copy of the Individualized Education Program (IEP) for This IEP was prepared for the 20 /20 Academic Year. All medical and other reports included in this IEP are attached. I hereby certify and say that the foregoing statements made by me are true to the best of my knowledge, and that I will supplement this form as may be necessary should additional information become available. I am aware that if any of the foregoing statements made by me are willfully false, I am subject to punishment. Date Signature Print Name American LegalNet, Inc. www.FormsWorkFlow.com Published 02/2017, CN 12014 (Certification in Support of Guardianship - IEP) page 1 of 3 Filing Attorney Information or Pro Se Litigant: Name NJ Attorney ID Number Law Firm/Agency Name Address Telephone Number In the Matter of, , Name of Alleged Incapacitated Person (AIP) Superior Court of New Jersey Chancery Division - Probate Part County Docket Number Civil Action an Alleged Incapacitated Person I, Certification in Support of Guardianship , of full age, hereby certify as follows: I am (check one) the chief executive officer, medical director, or other officer having administrative control over the program from which is receiving functional or other services provided by the Division of Developmental Disabilities; OR a designee of the Division of Developmental Disabilities having personal knowledge of the functional capacity of ; OR a licensed physician or psychologist; OR a licensed care professional having personal knowledge of the functional capacity of . 1. This certification is made by me in support of an application for a declaration of incapacity for , an alleged incapacitated person. 2. I am personally familiar with the functional capacity of the alleged incapacitated person. My knowledge of his/her functional capacity is based upon: 3. In my opinion, the alleged incapacitated person is: unfit and unable to govern herself/himself and to manage her/his affairs in all areas. OR unfit and unable to govern herself/himself and to manage her/his affairs in some areas but does have capacity in the areas listed below (select all that apply): medical decision making residential decision making other (please describe) legal decision making educational decision making financial decision making vocational decision making 4. My opinion is based upon: Published 02/2017, CN 12014 (Certification in Support of Guardianship) American LegalNet, Inc. www.FormsWorkFlow.com page 2 of 3 5. It is my opinion that the alleged incapacitated person (check one) is is not capable of attending the court hearing in this matter. If the alleged incapacitated person is not capable of attending the court hearing the following are the reasons for the individual's inability: 6. I am not related either through blood or marriage, to the alleged incapacitated person, nor to a proprietor, director or chief executive officer of any institution for the care and treatment of the mentally ill in which the alleged incapacitated person is living or in which it is proposed to place her/him; nor am I professionally employed by the management thereof as a resident physician or psychologist; nor am I financially interested therein. I hereby certify and say that the foregoing statements made by me are true to the best of my knowledge, and that I will supplement this form as may be necessary should additional information become available. I am aware that if any of the foregoing statements made by me are willfully false, I am subject to punishment. Date Signature Print Name Published 02/2017, CN 12014 (Certification in Support of Guardianship) American LegalNet, Inc. www.FormsWorkFlow.com page 3 of 3