COURT OF THE DISTRICT OF COLUMBIA FAMILY COURT Domestic Relations Branch IN RE: ________________________________________ PRINT CHILD(REN)’S NAME(S) ________________________________________ PRINT CHILD(REN)’S NAME(S) ________________________________________ PRINT CHILD(REN)’S NAME(S) DR _____________________ Related Cases: v. _________________________________ PRINT THE NON-CUSTODIAL PARENT’S NAME ________________________________________ STREET ADDRESS _____________________________ _____________________________ ________________________________________ CITY, STATE AND ZIP CODE RESPONDENT. PETITION FOR APPOINTMENT OF STANDBY GUARDIAN (By Parent or Legal Custodian) I, ____________________________, am the parent or legal custodian in this case and state that: 1. This Court has the authority to decide my petition for appointment of a guardian for minor children because [CHECK ONE] Home State. The District of Columbia is the child(ren)’s “home state” because the child(ren) currently live(s) in the District of Columbia AND has/have lived in the District of Columbia for at least six months immediately before filing this Petition. Home State. The child(ren) do not currently live in the District of Columbia, BUT the District of Columbia was the “home state” AND the child(ren) has/have been away from the District of Columbia for less than six months before the filing of this Complaint AND a parent or a person acting as a parent continues to live in the District of Columbia. DC Bar Pro Bono Program (revised 9-2011) Petition for Appointment of Standby Guardian (by parent or legal custodian) Page 1 of 9 American LegalNet, Inc. www.FormsWorkFlow.com Significant Connections. There is no “ho me state” or the “home state” has declined to exercise jurisdiction on the grounds that the District of Columbia is the more appropriate forum AND the child(ren) and at least one parent or person acting as a parent has a signif icant connection with the District of Columbia AND there is substantial evidence available in the District of Columbia concerning the child(ren)’s care, protection, training and personal relationships. More Appropriate Court. All courts with jurisdiction have declined to exerc ise their jurisdiction in favor of the District of Columbia because this is the more appropriate Court to determine standby guardianship of the child(ren). No Other Court. There is no other court with jurisdiction to determine standby guardianship of the child(ren). Temporary Emergency Jurisdiction. Th e District of Columbia is not the “home state” BUT the child(ren) is/are present in the District of Columbia AND the child(ren) has/have been abandoned OR it is necessary in an emergency to protect the ch ild(ren) because the child (ren), or a sibling or parent of the child(ren), is/are subjected to or threatened with mistreatment or abuse. 2. I state the following about myself: a. My name is __________________________________________________________. b. My address is ________________________________________________________. c. My date of birth is _____________________________________________________. d. My telephone number is ________________________________________________. 3. I am asking the court to appoint a standby guardian for my child(ren) because I suffer from a chronic disease, and might not recover. A medical diagnosis was made by _______________________________________________ on ___________________________. PRINT DOCTOR’S NAME PRINT DATE OF DIAGNOSIS 4. I am asking the court to appoint the following person to serve as Standby Guardian of my children: a. His/her name is _______________________________________________________. b. His/her address is _____________________________________________________. c. His/her date of birth is __________________________________________________. d. His/her telephone number is _____________________________________________. DC Bar Pro Bono Program (revised 9-2011) Petition for Appointment of Standby Guardian (by parent or legal custodian) Page 2 of 9 American LegalNet, Inc. www.FormsWorkFlow.com 5. The names and birthdate(s) of my child(ren) is/are: a. _____________________________________________________________________ PRINT CHILD’S NAME PRINT CHILD’S DATE OF BIRTH b. _____________________________________________________________________ PRINT CHILD’S NAME PRINT CHILD’S DATE OF BIRTH c. _____________________________________________________________________ PRINT CHILD’S NAME PRINT CHILD’S DATE OF BIRTH d. _____________________________________________________________________ PRINT CHILD’S NAME PRINT CHILD’S DATE OF BIRTH 6. The Standby Guardian’s authority for my child(ren) will not take effect unless one of these triggering events happen: a. My written acknowledgment of debilitation and consent to commencement of the standby guardianship; or b. A determination by an Attending Clinician that I am physically or mentally unable to care for my child(ren); or c. I die p rior to the commencement of a judicial proceeding to appoint a guardian of my child(ren). 7. During the last five years, or since birth for child(ren) under five years old, each child has lived at the following address(es) with the following person(s): Child’s Name Previous Address DC Bar Pro Bono Program (revised 9-2011) During What Dates Child Lived With (names) Petition for Appointment of Standby Guardian (by parent or legal custodian) Page 3 of 9 American LegalNet, Inc. www.FormsWorkFlow.com 8. I state the following about the child(ren)’s mother: [CHECK ONE] The mother is the custodial parent [GO TO STATEMENT 12] The mother is a non-custodial parent AND: a. The mother’s name is __________________________________________________. b. The mother’s address or whereabouts: [CHECK ONE] the mother stays at _______________________________________________. the mother’s whereabouts are unknown; her last contact with us was _________________________________________________________________. DESCRIBE THE DATE AND CIRCUMSTANCES OF THE LAST CONTACT c. The non-custodial mother: [CHECK ONE] consents to my appointment as the child(ren)’s guardian. DC Bar Pro Bono Program (revised 9-2011) Petition for Appointment of Standby Guardian (by parent or legal custodian) Page 4 of 9 American LegalNet, Inc. www.FormsWorkFlow.com is deceased, and I have attached the death certificate to this Petition. has had her parental rights terminated by a judge. does not consent. has no known address. is unknown. 9. I state the following about the child(ren)’s father: [CHECK ONE] The father is a custodial parent [GO TO STATEMENT 13) The father is a non-custodial parent AND: a. The father’s name is __________________________________________________. b. The father’s address or whereabouts: [CHECK ONE] the father stays at _______________________________________________. the father’s whereabouts are unknown; his last contact with us was _________________________________________________________________. DESCRIBE THE DATE AND CIRCUMSTANCES OF THE LAST CONTACT c. The non-custodial father: [CHECK ONE] consents to my appointment as the child(ren)’s guardian. is deceased, and I have attached the death certificate to this Petition. has had his parental rights terminated by a judge. does not consent. has no known address. is unknown. 10. I state the following about other cases involving the child(ren): [CHECK ONE] There are no other cases concerning custody of or visitation with the child(ren), and there are no other cases that could affect this proceeding. The following cases concern custody of or visitation with the child(ren), or involve one or both of the parties: [CHECK ALL THAT APPLY] custody ________________________________________________________________________________________________ NAME & LOCATION OF COURT CASE NUMBER DATE OF ORDER, IF ANY abuse/neglect ________________________________________________________________________________________________ CASE NUMBER NATURE OF PROCEEDING NAME & LOCATION OF COURT DC Bar Pro Bono Program (revised 9-2011) Petition for Appointment of Standby Guardian (by parent or legal custodian) Page 5 of 9 American LegalNet, Inc. www.FormsWorkFlow.com access to children (visitation) ________________________________________________________________________________________________ NAME & LOCATION OF COURT CASE NUMBER NATURE OF PROCEEDING adoption ________________________________________________________________________________________________ CASE NUMBER NATURE OF PROCEEDING NAME & LOCATION OF COURT child support ________________________________________________________________________________________________ NAME & LOCATION OF COURT CASE NUMBER NATURE OF PROCEEDING divorce ________________________________________________________________________________________________ CASE NUMBER NATURE OF PROCEEDING NAME & LOCATION OF COURT domestic violence (civil) ________________________________________________________________________________________________ NAME & LOCATION OF COURT CASE NUMBER NATURE OF PROCEEDING domestic violence (criminal) ________________________________________________________________________________________________ CASE NUMBER NATURE OF PROCEEDING NAME & LOCATION OF COURT juvenile delinquency ________________________________________________________________________________________________ NAME & LOCATION OF COURT CASE NUMBER NATURE OF PROCEEDING mental health/retardation ________________________________________________________________________________________________ CASE NUMBER NATURE OF PROCEEDING NAME & LOCATION OF COURT paternity ________________________________________________________________________________________________ CASE NUMBER NATURE OF PROCEEDING NAME & LOCATION OF COURT termination of parental rights ________________________________________________________________________________________________ NAME & LOCATION OF COURT CASE NUMBER NATURE OF PROCEEDING 11. I state the following about other persons not named as parties to this case: [CHECK ONE] I do not know of any other person not already named as a party to this case who is physically caring for the child(ren) or who claims a right to legal custody of, physical custody of, or visitation with the child(ren). DC Bar Pro Bono Program (revised 9-2011) Petition for Appointment of Standby Guardian (by parent or legal custodian) Page 6 of 9 American LegalNet, Inc. www.FormsWorkFlow.com The following person(s) not already named as a par ty to this case is/are p hysically caring for the child(ren), or claim a right to legal custody of, physical custody of, or visitation with the child(ren): Name Current Address 12. The standby guardian I have named is a fit and proper person to be named as standby guardian of the minor child(ren) AND I believe it is in the best interest of the minor child(ren) that this standby guardian be appointed. Attachments 13. I have included the following attachment(s), as required by law: A copy of the Designation. The birth certificate(s) of the child(ren). Proof that I am giving notice of this Petition and Hearing to the Defendants. A consent to the appointment of the standby guardian signed by the other parent or a statement of any known reason explaining why that parent is not or should not be assuming responsibility for the child(ren). Request for Relief I RESPECTFULLY REQUEST that the Court appoint the person named in this petition as the Standby Guardian of my child(ren) named in this petition. I ALSO REQUEST that the Court award any other relief it considers fair and proper. DC Bar Pro Bono Program (revised 9-2011) Petition for Appointment of Standby Guardian (by parent or legal custodian) Page 7 of 9 American LegalNet, Inc. www.FormsWorkFlow.com [CHECK ONE] I do not know of any proceedings in the District of Columbia or in any state or territory involving the same claim or subject matter as this case. I do know of proceedings in the District of Columbia or in any state or territory involving the same claim or subject matter as this case, as listed on the first page of this Petition (“Related Cases”). Respectfully Submitted, ____________________________________ SIGN YOUR NAME ___________________________________________ STREET ADDRESS ___________________________________________ CITY, STATE AND ZIP CODE ___________________________________________ TELEPHONE NUMBER SUBSTITUTE ADDRESS: CHECK BOX IF YOU HAVE WRITTEN SOMEONE ELSE’S ADDRESS BECAUSE YOU FEAR HARASSMENT OR HARM. I, _________________________________, solemnly swear or affirm under criminal penalties for the making of a false statement that I have read the foregoing Petition for Appointment of a Standby Guardian and that the factual statements made in it are true to the best of my personal knowledge, information and belief. ___________________________________ SIGN YOUR NAME ______________________________ DATE ___________________________________ PRINT YOUR NAME DC Bar Pro Bono Program (revised 9-2011) Petition for Appointment of Standby Guardian (by parent or legal custodian) Page 8 of 9 American LegalNet, Inc. www.FormsWorkFlow.com RULE 4 CERTIFICATE OF SERVICE WHEN YOU FILE YOUR PETITION FOR APPOINTMENT OF STANDBY GUARDIAN, THE FAMILY COURT CENTRAL INTAKE CENTER WILL GIVE YOU A SUMMONS THAT YOU MUST SERVE ON THE OTHER PARTY WITH A COPY OF YOUR PETITION. YOU MUST SERVE THE OTHER PARTY BEFORE THE SUMMONS EXPIRES IN 60 DAYS. IF YOU ARE UNABLE TO SERVE THE OTHER PARTY WITHIN THE 60 DAYS, YOU CAN ASK THE FAMILY COURT CENTRAL INTAKE CENTER TO GIVE YOU ANOTHER SUMMONS. T HE SECOND SUMMONS IS CALLED AN “ALIAS SUMMONS.” Y OU MUST ASK FOR THE ALIAS SUMMONS BEFORE THE FIRST SUMMONS EXPIRES. HERE ARE THE WAYS YOU CAN SERVE YOUR PETITION AND THE SUMMONS: by having someone else, who is over 18 years old and not a party to the case (NOT you), hand it to the other party; or by having someone else, who is over 18 years old and not a party to the case (NOT you), leave a copy at the other party’s home with a person of suitable age and discretion who lives there; or by mailing it to the other party by certified mail, return receipt requested. IF THE RETURN RECEIPT (“GREEN CARD”) COMES BACK TO YOU, FILE IT WITH THE FAMILY COURT CENTRAL INTAKE CENTER BY ATTACHING IT TO AN “AFFIDAVIT OF RETURN OF SERVICE BY CERTIFIED MAIL.” AFTER YOU SERVE THE OTHER PARTY, YOU MUST COMPLETE THE CERTIFICATE OF SERVICE PORTION FOUND AT THE BOTTOM OF THE SUMMONS AND FILE IT WITH THE FAMILY COURT CENTRAL INTAKE CENTER. DC Bar Pro Bono Program (revised 9-2011) Petition for Appointment of Standby Guardian (by parent or legal custodian) Page 9 of 9 American LegalNet, Inc. www.FormsWorkFlow.com