CC - 102 V1 - For Petitions involving ADULTS WITH DISABILITIES - P ROPOSED GUARDIAN INFORMATION SHEET *TO BE FILED UNDER SEAL* Pursuant to 735 ILCS 5/1 - 109 of the Illinois Code of Civil Procedure, I certify and verify that all information set forth below is true and correct under penalty of perjury. In Re: Case No. Current address: Phone: Email: Date of birth: Last four digits of Social Security Number: xx - xxx - Relationship to the adult with an alleged disability: Residence of alleged person with a disability (if different from proposed guardian): 1. Have yo u ever been convicted of a felony? [ ] Yes, or [ ] No 2. Have you ever been the respondent of an adjudicated finding of abuse or neglect by the Illinois Department of Family Services (DCFS) or similar agency? [ ] Yes, or [ ] No 3. Have you ever been adju dged a person with a disability? [ ] Yes, or [ ] No 4. Have you ever been convicted of a felony involving harm or threat to a minor or an elderly person, including any felony sexual offense? [ ] Yes, or [ ] No 5. Have you ever been convicted of any crime involving the neglect or exploitation of an elderly person? [ ] Yes, or [ ] No 6. D oes the alleged person with a disability have a Power of Attorney, Health Care Power of Attorney, Living Will, or similar advance directives for their care or management o f their estate? [ ] Yes, or [ ] No know. Date: Proposed Guardian FILE STAMP American LegalNet, Inc. www.FormsWorkFlow.com