Name of Person Filing Document: Your Address: Your City, State, Zip Code: Your Telephone Number: Attorney Bar Number (if applicable): Self (Without a Lawyer) OR Representing Attorney for: FOR CLERK’S USE ONLY SUPERIOR COURT OF ARIZONA MARICOPA COUNTY In the Matter of the Guardianship and/or Conservatorship of Case Number: PB ____________________________ an Adult or a Minor AFFIDAVIT OF PERSON TO BE APPOINTED GUARDIAN AND/OR CONSERVATOR INSTRUCTIONS: The person who wants to be appointed the guardian and/or conservator must answer each statement as TRUE or FALSE. Each answer that is false must be explained in writing in an attachment to this affidavit. STATEMENTS MADE UNDER OATH TO THE COURT: Arizona law A.R.S. §14-5106 requires the person seeking appointment to answer items 1-15. Additionally, the Superior Court in Maricopa County requires the person to complete the information requested in item 16. This document must be filed with the Petition for Appointment of Guardian and/or Conservator. 1. 2. 3. 4. 5. 6. 7. True or True or False. False. I have not been convicted of a felony in any jurisdiction. I have not acted as a guardian or conservator for another person for at least three years before I filed this Petition. I know and understand the powers and duties I would have as a guardian and/or conservator. I have not had a power of attorney for anyone for at least three years before I filed this Petition. I am not, to the best of my knowledge, listed in the Elder Abuse Registry at the Office of the Arizona Attorney General. To the best of my knowledge, no business in which I have an interest is listed in the Elder Abuse Registry at the Office of the Arizona Attorney General. Arizona law requires that a guardian/conservator file an annual report/accounting with the court. 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. I have never been removed by the court as a guardian or conservator. The nature of my relationship to the proposed ward or protected person is: True or False. True or False. True or False. True or False. True or False. 8. 9. True or True or False. False. ©Superior Court of Arizona in Maricopa County January 23, 2009 ALL RIGHTS RESERVED Page 1 of 3 PBGC11f Use only most current version American LegalNet, Inc. www.FormsWorkflow.com AFF Case No. 10. 11. True or True or False. False. I met the proposed ward under the following circumstances: I have never 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. No 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 am not related by blood or marriage and for whom I served at any time as guardian, conservator, trustee, or attorney-in-fact. To the best of my knowledge, I am not named as a personal representative, trustee, beneficiary, 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. To the best of my knowledge, no business in which I have an interest is named as a personal representative, trustee, beneficiary, 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. 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. 12. True or False. 13. True or False. 14. True or False. 15. True or False. 16. Additional identifying information about the person seeking this appointment: Gender: Weight: Color of Hair: Height: Color of eyes: Date of birth: OATH OR AFFIRMATION OF THE PERSON SEEKING TO BE APPOINTED GUARDIAN AND/OR CONSERVATOR: I have read, understood, and completed the above statements and the attached document. Everything I have said is true and correct to the best of my knowledge, information, and belief. SIGNATURE: Subscribed and sworn to before me this date: My Commission Expires: by Deputy Clerk or Notary Public ©Superior Court of Arizona in Maricopa County January 23, 2009 ALL RIGHTS RESERVED Page 2 of 3 PBGC11f Use only most current version American LegalNet, Inc. www.FormsWorkflow.com AFF Case No. EXPLANATIONS THAT MUST BE ADDED TO THE AFFIDAVIT OF PERSON WHO WANTS TO BE APPOINTED (Required by Arizona Law: A.R.S. § 14-5106) You must explain the following as an attachment to your Affidavit for any statement which you marked "F" (false). FILE THE EXPLANATIONS WITH THE AFFIDAVIT, BUT DO NOT FILE THIS INSTRUCTION SHEET. All the information in the explanations is also under oath to the court. 1. As to each felony for which you have been convicted, list: a. The nature of the offense. b. The name and address of the sentencing court. c. The case number. d. The date of conviction. e. The terms of the sentence. f. The name and telephone number of any current probation or parole officer. g. The reasons why the conviction should not disqualify you from appointment. 2. If you have acted as guardian or conservator within three years before filing this petition, list: a. The names of individuals for whom you are currently serving, and court case numbers. b. The names of individuals for whom your appointment has been terminated within the three-year period, and the court case number. If you do not have the required information, please explain how you intend to obtain this information. State the total number of persons for whom you have done this. If you have acted under a power of attorney for the proposed ward/protected person, explain: a. The date the power of attorney was signed. b. The place where it was signed. c. The actions you have taken pursuant to the power of attorney. d. Whether the power of attorney is currently in effect. State the reason for such listing. List the name(s) of the business(s) and the reason for each such listing. List the name and location of the court and the name and case number of the files in which you were delinquent in filing the required report. List the name and location of the court, the name and case number of each file, and the circumstances of your removal. State the number of occasions on which you received such gifts, list the gifts, the dates they were received, describe the gifts and list the value of each. State the number of occasions on which the business received such gifts, list the gifts, the dates they were received, describe the gifts and list the value of each. State the number of occasions on which you have been so named. State the number of occasions on which the business was named. List the name and address of each business and the extent and nature of your interest. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. ©Superior Court of Arizona in Maricopa County January 23, 2009 ALL RIGHTS RESERVED Page 3 of 3 PBGC11f Use only most current version American LegalNet, Inc. www.FormsWorkflow.com AFF