IN THE CIRCUIT COURT OF THE NINETEENTH JUDICIAL CIRCUIT LAKE COUNTY, ILLINOIS ESTATE OF ___________________________________ ) ) ) ) _____________________________________________ ) a minor ) Return Date: ____________________ Case No. ________________________ AFFIDAVIT OF PETITIONING GUARDIAN OF THE PERSON FOR A MINOR CHILD I, __________________________________________________, petitioner for guardianship of the person for (Name of Petitioner) _________________________________________________, a minor child, do hereby state under oath and subject to (Name of Minor) penalties of perjury, as follows: 1. That I have: Never been known by any other name OR Used the following name(s): _________________________________________________________________ 2. That I am ____________ years old; I am male female; 3. My date of birth is ___________________; (MM/DD/YYYY) 4. That I currently reside at ______________________________________________________________________ 5. In addition to my current residences, I have also lived at the following addresses in the last five years: _________ __________________________________________________________________________________________ 6. That I am of sound mind and have not been adjudicated as disabled by any court of law; a. That I have not been convicted of a felony OR b. That I have been convicted of a felony, the specific circumstances of which are as follows: 1. ____________________________________________________________________________________ ____________________________________________________________________________________ 2. ____________________________________________________________________________________ ____________________________________________________________________________________ 7. That I do hereby consent and submit to a criminal background check and review of the Department of Children and Family Services Register. CERTIFICATION Under penalties of perjury as provided by law pursuant to Section 1-109 of the Code of Civil Procedure, the undersigned certifies that the statements set forth in this instrument are true and correct. Date: __________________________, 20_____. Prepared by: Name: ____________________________________________ Attorney's Name: ____________________________________ Address: __________________________________________ City: ______________________________ State: __________ Phone: ______________________Zip Code: _____________ Fax: ______________________________________________ ARDC #: __________________________________________ _____________________________________ Signature of Petitioner DCFS Check: Negative Results attached Signature: Date: American LegalNet, Inc. www.FormsWorkFlow.com 171P-385 (12/11)