Free Affidavit of Physician - West Virginia

AFFIDAVIT OF PHYSICIAN
[West Virginia Code: § 44A-2-9(c)]

STATE OF _________________________________, COUNTY OF ______________________________, to-wit: This day, personally appeared before me the undersigned physician who, having been first duly sworn, says, represents and certifies as follows: I, ______________________________, a licensed physician in the State of ____________________________, hereby certify that I have examined and/or evaluated the condition of [insert name of alleged protected person here] _______________________________________________________, and that in my expert opinion, this individual cannot attend the hearing into whether a guardian or conservator should be appointed for this individual for the following reasons [check applicable reasons and provide supporting facts in spaces provided and attach additional pages, if necessary]:
__________ The presence of the individual is not possible due to a physical inability. The basis for this opinion is as follows:_________________________________________________________________________ _________________________________________________________________________________. Requiring the presence of this individual would significantly impair the individual's health. Explain: _________________________________________________________________________________ ________________________________________________________________________________.

__________

_________

Other Reason(s):____________________________________________________________ __________________________________________________________________________ _________________________________________________________________________.

Given under my hand this ________ day of ______________________, 20 _______. ______________________________________ SIGNATURE OF PHYSICIAN The foregoing affidavit was taken, subscribed and sworn to before me by the said ____________________, in my said County and State on this, the ________ day of __________________________, 20 _________. Given under my hand and NOTARIAL SEAL. [AFFIX NOTARIAL SEAL] ___________________________________________ NOTARY PUBLIC My Commission Expires: ____________________________
SCA-CG 902A / 6-94