CC - 101 V1 - For Petitions involving MINORS - PROPOSED 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 minor(s): Full name and dates of birth of all household members: 1. Have you ever been convicted of a felony? [ ] Yes, or [ ] No 2. Have yo u, or any household members, 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 adjudged a person with a disability? [ ] Yes, or [ ] No 4. Have you, or any household members, ever been convicted of a felony involving harm or threat to a child, including any felony sexual offense? [ ] Yes, or [ ] No Date: Proposed Guardian FILE STAMP American LegalNet, Inc. www.FormsWorkFlow.com