Estate Planning

KENNETH VERCAMMEN & ASSOCIATES, PC

ATTORNEY AT LAW

2053 Woodbridge Ave

Edison, NJ  08817 

(Phone) 732-572-0500

(Fax)   732-572-0030

website: www.njlaws.com

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.  Please read our website article to help you understand how guardianships are handled

http://www.njlaws.com/guardianship_of_disabled_adults.html?id=460&a=

       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 11/30/13

2.   Current address and phone for incapacitated person whom Guardianship is sought:

____________________________________________________________

____________________________________________________________

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 “A” 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 “B (1)”   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: 

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________