STATE OF ILLINOIS IN THE CIRCUIT COURT OF THE 17TH JUDICIAL CIRCUIT COUNTY OF WINNEBAGO FILE STAMP In the Matter of Case No. ____________________ ______________________________ A Minor NOMINATION I, a minor 14 years of age or older, nominate ________________________________________ as my guardian of ____________________________. (estate, person, estate & person) __________________________________ Minor Signature Dated __________________________________ Under penalties 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, except as to matters therein stated to be on information and belief and as to such matters the undersigned certifies as aforesaid that they verily believe the same to be true. __________________________________ Minor Signature CC ­ 121 V1 American LegalNet, Inc. www.FormsWorkFlow.com