Docket No.: _____________ State of New Jersey Camden County Surrogates Court In the matter of the appointment of a Standby Guardian for: APPLICATION FOR _____________________________________________, a Minor } APPOINTMENT OF A STANDBY AKA: _______________________________________ GUARDIAN OF A MINOR Applicant, seeking judicial appointment of a Standby Guardian pursuant to N.J.S. 3B 12 72 says: 1. Applicant: ____________________________ Resides at: ______________________________________________________________ 2. Applicant is a: Parent of the following minors: Minor Name Age of Minors Parent and/or Custodian Parent and/or Custodian Residence Name 3. A designation of Standby Guardian for this minor was executed by _________________ on __________, a copy of that document is attached. 4. In the event the Court grants the request for judicial appointment of a Standby Guardian, the authority of the appointed Standby Guardian shall become effective upon the occurrence of the following trigger event or events: 4.1. The attending physician concludes that the designating parent is mntally incapacitated, and thus e unable to care for the child(ren). 4.2. The attending physician concludes that the designating parent is physically debilitated, and thus unable to care for my child(ren), and the designating parent consents in writing before two witnesses to the designated Standby Guardians authority taking effect. 4.3. Upon the death of designating parent. S2.DOC Page 1 of 2 >>>> 2 Docket No.: _____________ 5. There is a significant risk that the parent or legal custodian will die, become incapacitated, or become debilitated as a result of a progressive chronic condition or fatal illness. 6. The name of the proposed Standby Guardian is________________________. 7. The contact information of the proposed Standby Guardian is _____________________, _____________________, _____________________, ________, ______________,______________. 8. The qualifications of the proposed Standby Guardian are _______________ 9. Petitioner also asks the Court to appoint an Alternate Standby Guardian to act if the appointed Guardian dies, becomes incapacitated or otherwise refuses or is unable to assume the duties of the Standby Guardian, after the death, incapacity or debilitation of the parent or legal custodian of the minor child(ren). 10. The name of the proposed Alternate Standby Guardian is ___________________. 11. The contact information of the proposed Alternate Standby Guardian is ________________________, __________________, ___________________, ___________, _____________, _____________________. 12. The qualifications of the proposed Alternate Standby Guardian are __________________________ Wherefore, applicant requests judgement appointing a Standby Guardian __________________________________________________________________________________________ Applicants Signature __________________________________________________________________________________________ Date The allegations in this application are true to the best of my knowledge and belief. __________________________________________________________________________________________ Applicants Signature Sworn and Subscribed to before me the Day __________ of ______________ (Notary) S2.DOC Page 2 of 2