SUPERIOR 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) _______DRB ___________ RELATED CASES: __________________________ _______________________________ ________________________________________ PRINT CHILD(REN)'S NAME(S) 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: PRINT YOUR NAME 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 Center (revised 10/2016) Petition for Appointment of Standby Guardian (by parent or legal custodian) Page 1 of 8 American LegalNet, Inc. www.FormsWorkFlow.com  Significant Connections. There is no "home 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 significant 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 exercise 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. The 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 child(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 Center (revised 10/2016) Petition for Appointment of Standby Guardian (by parent or legal custodian) Page 2 of 8 American LegalNet, Inc. www.FormsWorkFlow.com 5. I state the following about the child(ren) in this case: Child's Full Name 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 prior 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 During What Dates Child Lived With (names) DC Bar Pro Bono Center (revised 10/2016) Petition for Appointment of Standby Guardian (by parent or legal custodian) Page 3 of 8 American LegalNet, Inc. www.FormsWorkFlow.com Child's Name Previous Address During What Dates Child Lived With (names) 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. 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. DC Bar Pro Bono Center (revised 10/2016) Petition for Appointment of Standby Guardian (by parent or legal custodian) Page 4 of 8 American LegalNet, Inc. www.FormsWorkFlow.com 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 f