Stipulation For Introduction Of Deposition

STATE OF MISSOURI CITY OF ST. LOUIS } SS } MISSOURI CIRCUIT COURT, TWENTY-SECOND JUDICIAL CIRCUIT PROBATE DIVISION, CITY OF ST. LOUIS IN THE MATTER OF No. STIPULATION FOR INTRODUCTION OF DEPOSITION It is hereby stipulated and agreed, that the deposition of be taken by a Notary Public on the interrogatories set forth herein and when signed by the Deponent and certified to by the Notary Public, may be read in evidence at the hearing of the above entitled matter, all notice and cross interrogatories being waived. __________________________ Attorney for Applicant __________________________ Attorney for Respondent American LegalNet, Inc. www.FormsWorkflow.com MISSOURI CIRCUIT COURT, TWENTY-SECOND JUDICIAL CIRCUIT PROBATE DIVISION, CITYOF ST. LOUIS In the Matter of No. Respondent DEPOSITION OF __________________________________________________________ ,a On this ________ day of _________________, _______, before me, Notary Public within and for the State of Missouri, personally appeared ___________________________, M.D., who, after being first duly sworn, testified as follows: INTERROGATORIES 1. Q. State your name, age and residence. A. 2. Q. What is your occupation, business or profession? A. 3. Q. Are you licensed to practice medicine in the State of Missouri? A. 4. Q. If your answer to Interrogatory number 3 above is affirmative, is your license subject to any restrictions imposed by the Board of Healing Arts of the State of Missouri? A. 5. Q. If in your practice you specialize in some particular field, please specify same. A. 6. Q. Are you self-employed? ________. If not, where are you employed and in what capacity? A. 7. Q. Are your duties as a physician such as will prevent your attendance in court as a witness in this cause? A. 8. Q. Are you acquainted with ________________________________________________________? A. 9. Q. Have you had occasion to examine, observe and treat _________________________________? A. American LegalNet, Inc. www.FormsWorkflow.com 10. Q. What was the date of such examination, or between what dates has _______________________ been under your observation? A. 11. Q. Give the symptomatology which you observed and both the neurological and mental diagnoses which you have made, based upon your examination and observation of . PLEASE STATE FULLY THE FACTS UPON WHICH YOUR DIAGNOSTIC CONCLUSIONS ARE BASED ­ NOT ACCEPTABLE AS EVIDENCE OTHERWISE. A. IF APPLICATION IS FOR APPOINTMENT OF A GUARDIAN OF THE PERSON: 12. to be "incapacitated," that is, unable Q. Do you consider by reason of any physical or mental condition to receive and evaluate information or to communicate decisions to such an extent that he/she lacks ability to meet his/her essential requirements for food, clothing, shelter, safety, or medical care such that serious physical injury, illness, or disease is likely to occur were a guardian not appointed for him/her? A. 13. Q. Please describe the physical and/or mental conditions upon which your answer to Interrogatory 12 is based. A. American LegalNet, Inc. www.FormsWorkflow.com IF APPLICATION IS FOR APPOINTMENT OF A CONSERVATOR OF THE ESTATE: 14. to be "disabled," that is, unable Q. Do you consider by reason of any physical or mental condition to receive and evaluate information or to communicate decisions to such an extent that he/she lacks ability to manage his/her financial affairs? A. 15. Q. Please describe the physical and/or mental conditions upon which your answer to Interrogatory 14 is based. A. 16. Q. Do you consider it for appointment of a guardian to protect his/her person? `s best interest to bring about the A. 17. `s best interest to bring about the Q. Do you consider it for appointment of a conservator to manage his/her resources? A. 18. Q. Do you consider mind? to be "incompetent," i.e., of unsound A. 19. Q. State anything further you may have to say regarding the alleged disability, incapacity, or . incompetence of A. American LegalNet, Inc. www.FormsWorkflow.com ___________________________________ DEPONENT _____________________________________ WITNESS KNOW ALL MEN BY THESE PRESENTS, that I, the undersigned Notary Public, hereby certify that the above-named deponent was first duly sworn by me to make true answers to the foregoing interrogatories, that said interrogatories were read by me to deponent, that the answers thereto are correctly recorded as hereinabove set forth, that this deposition was subscribed to by the deponent and witness in my presence. ___________________________________ NOTARY PUBLIC My Commission Expires: _________________ American LegalNet, Inc. www.FormsWorkflow.com