FOR CLERK’S USE ONLY Name of Person Filing: ____________________________________________ Mailing Address: ____________________________________________ City, State, Zip Code: ____________________________________________ Day/Evening Telephone: ____________________________________________ ATLAS Number (if applicable) ____________________________________________ Attorney Bar Number (if applicable) _________________________________________ Representing: Self Petitioner Respondent In the Matter of the Guardianship and/or Conservatorship of ____________________________ Case Number: GC-____________________________ AFFIDAVIT OF PERSON TO BE APPOINTED GUARDIAN AND/OR CONSERVATOR An Adult 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 the following items. This document must be filed with the Petition for Appointment of Guardian and/or Conservator. 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. I am not, to the best of my knowledge, listed in the Elder Abuse Registry at the Office of the Arizona Attorney General. 6. True or False. 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. 7. True or False. 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. 8. True or False. I have never been removed by the court as a guardian or conservator. 9. True or False. The nature of my relationship to the proposed ward or protected person is: _________________________________________________ 10. True or False. I met the proposed ward under the following circumstances: _________________________________________________ 10/04/06 Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com Case No.______________________________ 11. True or False. 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. 12. True or False. 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. 13. True or False. 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. 14. True or False. 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. 15. 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. OATH OF THE PERSON SEEKING TO BE APPOINTED AS GUARDIAN AND CONSERVATOR: STATE OF ARIZONA MOHAVE COUNTY ) ) ss. 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 ________________ day of _______________, 20_________. by:____________________________________________ My Commission Expires: __________________________ ________________________________________ Notary Public / Deputy Clerk 10/04/06 Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com