*THIS DOCUMENT IS TO BE IMPOUNDED BY THE COURT* IN THE CIRCUIT COURT OF THE TWELFTH JUDICIAL CIRCUIT WILL COUNTY, ILLINOIS - IN PROBATE IN RE THE ESTATE OF _____________________________________________ Name of disabled adult CASE NO: _________________________ Respondent, A Disabled Adult VERIFIED STATEMENT IN SUPPORT OF PETITION FOR APPOINTMENT OF GUARDIAN FOR DISABLED ADULT _____________________________________________, states as follows: Name of guardian 1. That I have been named as a proposed guardian for _________________________________________ Name of disabled adult ________________________, a disabled adult. 2. That my driver's license and State in which it was issued is: __________________________________________ __________________________________ Driver's License Number State who issued driver's license 3. That my Social Security Number is: ____________________________________________ 4. My employment information is as follows: Name of Employer: __________________________________________________________________ Address of Employment: ______________________________________________________________ Phone Number of Employer: ___________________________________________________________ 5. That the names and contact information for three persons residing in the State of Illinois that I am consistently in contact with and who know how to reach me are: · Name: _______________________________________________________________________ Address: _____________________________________________________________________ Telephone: ___________________________________________________________________ · Name: _______________________________________________________________________ Address: _____________________________________________________________________ Telephone: ___________________________________________________________________ · Name: _______________________________________________________________________ Address: _____________________________________________________________________ Telephone: ___________________________________________________________________ ____________________________________________________ (Signature of Petitioner) CERTIFICATION I affirm under penalty of perjury that I have read the foregoing statement, that I know the contents thereof, and that the same are true and correct to the best of my knowledge and belief. ____________________________________________________ (Signature of Petitioner) Person/Attorney Who Prepared Form: Name: __________________________________________________ Address: ________________________________________________ City and Zip: ____________________________________________ Phone: _________________________________________________ ARDC #: _______________________________________________ ANDREA LYNN CHASTEEN, CLERK OF THE CIRCUIT COURT OF WILL COUNTY American LegalNet, Inc. www.FormsWorkFlow.com 135 (Revised 12 /16)