IN THE COURT OF CHANCERY OF THE STATE OF DELAWARE Alleged disabled person/Minor: AFFIDAVIT OF PETITIONER’S HISTORY Petitioner’s Name: 1. Have you ever declared bankruptcy? Yes No If so, when? If so, what type? 2. Have you ever been convicted of a misdemeanor? Yes No If so, describe which misdemeanor, when and in what jurisdiction you were convicted (i.e., State, County and Police Department). 3. Have you ever been convicted of a felony? Yes No If so, describe which felony, when and in what jurisdiction you were convicted (i.e., State, County and Police Department). American LegalNet, Inc. www.FormsWorkFlow.com 4. Have you ever been found guilty of an offense by a court martial? Yes No If so, describe which offense and when you were found guilty. 5. Do you give the State of Delaware permission to conduct a criminal background check on you at any time during the consideration of your petition for guardianship and, if granted, at any time during the period you are a guardian? Yes No I solemnly swear and affirm under penalty of law that the statements and answers above are true to the best of my knowledge. Signature SWORN TO AND SUBSCRIBED before me on this date: Notary Public or Clerk of the Court American LegalNet, Inc. www.FormsWorkFlow.com