IN THE MATTER OF
IN THE _______________________ COURT
BEFORE THE _________________________
, Director of Social Services of the
and Petitioner herein, respectfully shows
unto the court:
__________________________, North Carolina is a qualified applicant for or recipient of:
( ) Payee in Energy Assistance Case ( ) Payee in Work First Case ( ) S. A.
That the petitioner alleges that the following grounds are applicable to the
that _________ he fails to manage the assistance payment(s) to the extent that
deprivation or hazard to ________ self or others results.
WHEREFORE, pursuant to G.S. 108A-37, the petitioner hereby requests that
the Court appoint some suitable and competent person to act as personal representative
for _______________________________________________for the purpose of receiving and
managing the public assistance payment(s) for the said applicant, recipient, or payee.
Clerk of Court
Sworn to and subscribed before me
this the ____day of_____________, 19___.
DSS-1630 (Rev. 10-82)
Prepare in Duplicate
Original for Court Record