Fill out a separate Affidavit for each proposed guardian and/or conservator. Person Filing: Mailing Address: City, State, Zip Code: Phone Number: Representing Self COCONINO COUNTY SUPERIOR COURT In the Matter of the Guardianship and/or Conservatorship of: Ward 1: Ward 2: Ward 3: [ ] An Adult [ ] A Minor Case Number: AFFIDAVIT OF PERSON TO BE APPOINTED GUARDIAN AND/OR CONSERVATOR A.R.S. §14-5106 INSTRUCTIONS: As required by Arizona law A.R.S. §14-5106, indicate whether statements 1-11 below are true or false, and provide the information requested to complete "12" and "13". Explain any "false" statements on separate page(s) and attach to his document before filing. Sign the document in the presence of a Clerk of Court or a Notary Public, and file along with the Petition for Appointment of Guardian and/or Conservator. UNDER PENALTY OF PERJURY, I SWEAR OR AFFIRM: 1. True or False. I have not been convicted of a felony in any jurisdiction. 2. True or False. I have not acted as a guardian or conservator for another person for at least three years before I filed this Petition. 3. True or False. I know and understand the powers and duties I would have as a guardian and/or conservator. 4. True or False. I have not had a power of attorney for anyone for at least three years before I filed this Petition. 5. True or False. To the best of my knowledge, neither I nor any business in which I have an interest is listed in the Elder Abuse Registry at the Office of the Arizona Attorney General. 6. True or False. If I have been a guardian/conservator before, I either filed the required documents on time, or within 3 months of receiving a notice from the court that the report/accounting was due. 7. True or False. I have never been removed by the court as a guardian or conservator. Page 1 of 2 Revised September 2016 American LegalNet, Inc. www.FormsWorkFlow.com © 2016 Coconino County Law Library 8. True or False. Neither I nor any business in which I have an interest has ever received anything of value greater than a total of one hundred dollars in any one year by gift, or will, or inheritance from an individual or the estate of an individual to whom I was not related by blood or marriage and for whom I served at any time as guardian, conservator, trustee, or attorney-in-fact. 9. True or False. To the best of my knowledge, neither I nor any business in which I have an interest is named as a personal representative, trustee, devisee (beneficiary of a will), or other type of beneficiary for any individual to whom I am not related by blood or marriage and for whom I have ever served as guardian, conservator, trustee, or attorney-in-fact. 10. True or False. I have no interest in any business that provides housing, health care, nursing care, residential care, assisted living, home health services, or comfort care services to any individual. (Explain every "false" above on separate pages(s) and attach to this document before filing.) My relationship to the proposed person in need of protection is: (Examples: parent/grandparent/sister/caregiver/friend) I met the proposed ward under the following circumstances: OATH OR AFFIRMATION OF THE PERSON TO BE APPOINTED GUARDIAN AND/OR CONSERVATOR: I swear or affirm that I have read and understand the contents of this document, and that the information I have provided is true and correct to the best of my knowledge and belief. Signature: State of Arizona County of Subscribed and sworn before me this date: Seal: ) ) ) by: Notary Public: Notary Expiration Date: IF YOU ANSWERED "FALSE" TO ANY QUESTION ABOVE: YOU MUST ATTACH AN EXPLANATION AS ISTRUCTED ON THE NEXT PAGE. The page following is an instruction page only. Do NOT file it with the Court. Page 2 of 2 Revised September 2016 © 2016 Coconino County Law Library American LegalNet, Inc. www.FormsWorkFlow.com