Petitioners Name: Mailing Address: City, State, Zip Code: Contact Phone: IN THE SUPERIOR COURT OF ARIZONA FOR MARICOPA COUNTY In the Matter of the Guardianship/ ) No. Conservatorship of: ) ) AFFIDAVIT OF PROPOSED ) APPOINTEE PURSUANT TO ) A.R.S. 14-5106 an Adult/A Minor ) ____________________________) STATE OF ARIZONA ) ) ss. COUNTY OF MARICOPA ) I, , the proposed appointee, declare under penalty of perjury that each of the following statements is true, except for those marked "F" (false) and explained in an exhibit attached to and incorporated into this statement. YOU MUST CIRCLE EITHER T (TRUE) OR F (FALSE) BEFORE EACH STATEMENT, EXCEPT FOR STATEMENTS 8(A) AND 8(B) WHERE YOU MUST FILL IN THE BLANKS PROVIDED. AS TO EACH STATEMENT FOR WHICH YOU CIRCLE F, YOU MUST ATTACH AN EXHI BIT GIVING COMPLETE DETAILS. SEE ADDENDUM FOR THE INFORMATION REQUIRED. T F 1. I have not been convicted of a felony in any jurisdiction. T F 2. I have not acted as a guardian or conservator for another person within three years of the filing of the petition in this matter. T F 3. I have a working knowledge of the powers and duties imposed on a guardian and conservator. T F 4. I have not acted in a fiduciary capacity pursuant to a power of attorney for anyone within three years of the filing of the petition in this matter. T F 5 (a) I am not, to the best of my knowledge, listed in the Elder Abuse Registry at the Office of the Arizona Attorney General. T F 5 (b) To the best of my knowledge, no enterprise in which I have an interest is listed in the Elder Abuse Registry at the Office of the Arizona Attorney General. Page 1 of 2 Form #703 LRD 12/04/2003 ALL RIGHTS RESERVED Clerk of Superior Court of Arizona in Maricopa County >>>> 2 T F 6. Within three years of the filing of the petition in this case, I have not failed to file any report of guardian or conservatorship accounting for more than three months following receipt of notice that such report or accounting was delinquent. T F 7. I have never been removed as a guardian or conservator. 8(a) The nature of my relationship to the proposed ward or protected person is: 8(b) I met the proposed ward under the following circumstances: T F 9(a) I have never received anything of value exceeding a total of one hundred dollars in any one year by gift, devise, or bequest froman 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. T F 9(b) No enterprise in which I have an interest has ever received anything of value exceeding a total of one hundred dollars in any one year by gift, devise , or bequest 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. T F 10(a) To the best of my knowledge, I am not named as a personal representative, trustee, devisee 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. T F 10(b) To the best of my knowledge, no enterprise in which I have an interest is named as personal representative, trustee, devisee, 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. T F 11. I have no interest in any enterprise providing housing, health care, or comfort care services to any individual. _____________________________________ Signature of Proposed Appointee SIGNED AND SWORN TO before me this ____ day of __________________, 20___, by __________________________________. ______________________________________ Deputy Clerk/ Notary Public Page 2 of 2 Form #703 LRD 12/04/2003 ALL RIGHTS RESERVED Clerk of Superior Court of Arizona in Maricopa County >>>> 3 INSTRUCTIONS/ADDENDUM TO AFFIDAVIT OF PROPOSED APPOINTEE (A.R.S. 14-5106) The following information must be provided in an Exhibit attached to your affidavit for any statement which you marked F (false): 1. For 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 of this petition, list: a. The number of individuals for whom you are currently serving. b. The number of individuals for whom your appointment has been terminated within the three year period. 3. If you do not have the required information, please explain how you intend to obtain this information. 4. Give the number of persons for whom you have so acted. If you have acted in such capacity for the proposed ward/protected person list: a. The date of the execution of the power of attorney. b. The place where it was executed. c. The actions you have taken pursuant to the power of attorney. d. Whether the power of attrney is currently in effect. o 5(a). Give the reason for such listing. 5(b). Give the name(s) of the enterprise(s) and the reason for each such listing. 6. List the name and location of the court and tnamhe e and case number of the files in which you were delinquent. 7. List the name and location of the court, the nam and case nume ber of each file, and the circumstances of your removal. 8. Give the number of occasions on which you have received such gifts. 9. Give the number of occasions on which the enterprise has received such gifts. 10(a) Give the number of occasions on which you have been so named. 10(b) Give the number of occasions on which the enterprise has been so named. 11. List the name and address of each such enterprise and the extent and nature of your interest. DO NOT FILE THIS ADDENDUM WITH YOUR AFFIDAVIT Page 1 of 1 Form #703 LRD 12/04/2003 ALL RIGHTS RESERVED Clerk of Superior Court of Arizona in Maricopa County