Rev. 0 4/2018 IN THE COURT OF CHANCERY OF THE STATE OF DELAWARE A p erson with an alleged disability /Minor: AFFIDAVIT OF HISTORY Please Note: I f there is more than one proposed guardian, each person will need to complete a separate form. 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 ( e.g . State, County and Police De partment). 3. Have you ever been convicted of a felony? Yes No If so, describe which felony, when and in what jurisdiction you were convicted ( e. g. State, County and Police D epart ment). 4. I give the State of Delaware permission to conduct a criminal background check on me at any time during the consideration of my petition for guardianship and, if granted, at any time during the period I a m guardian . I solemnly swear and affirm under penalty of law that the statements and answers above are true to the best of my knowledge. STATE OF : COUNTY OF : This instrument was acknowledged before me on this day of , 20 by [Name of affiant] . Notary Public/ Chancery Court Clerk Proposed guardian s signature American LegalNet, Inc. www.FormsWorkFlow.com