PP - 109 (Rev. 5/1/12 ) STATE OF MAINE County Probate Court Docket No . In Re: Affidavit in Support of Minor A ppointment of Guardian of Minor I , , Petitioner or Nominee in the a b ove docketed matter, hereby swear to the truth of this Affidavit in support of th e Petition for Appointment of Guardian of Minor and allege as follows : The Petition for Appointment of Guardian of Minor in the above - entitled matter recites that the minor is the child of: CHILD CUSTODY AFFIDAVIT 1 1 . or whereabouts is: 2 . During the last five years the child has lived at the following addresses with the following people: Name o f Custodian Address of Custodian When Child Was Present With This Custodian 3. The Custodians named in #2 currently live at the following address: Name of Custodian Current Address of Custodia n 1 See 19 - A M.R.S. 247 1753. American LegalNet, Inc. www.FormsWorkFlow.com PP - 109 Page 2 of 3 (Rev. 5/1/2012 ) 4. Has the Petitioner or Nominee participated , as a party or witness or in any other capacity , in any o ther proceeding concerning the custody of or visitation with t he ch ild ? If so, identify the c ourt, case number, and the date of the child custody determination, if any. Provide this Court with attested copies thereof. 5. Does the Petitioner or Nominee know of any proceeding that could affect the current proceeding, including proceedings for enforcement and proceedings relating to domestic violence, protective orders, termination of parental rights and adoptions ? If so, identify the c ourt, case number, and the nature of the proceeding. Provi de this Court with attested copies thereof. 6. Does the Petitioner or Nominee know the names and addresses of any person not a party to the proceeding who has p hysical custody of the child or claims rights of legal custody or physical cus tody of or visitation with the child. If so, identify the names and addresses of those persons. INTOLERABLE LIVING SITUATION 2 (Complete Questions 7, 8, and 9 only if you allege an intolerable living situation.) 7 . A living situation has been created that is at least temporarily intolerable for the minor , as follows: 8. Describe how t he proposed guardian will provide a living situation that is in the best interest of the minor . 9. Has any State Agency been notified? YES NO. If yes, please identify the department and case worker: 2 See 18 - A M.R.S. 247 5 - 204. American LegalNet, Inc. www.FormsWorkFlow.com PP - 109 Page 3 of 3 (Rev. 5/1/2012 ) DE FACTO GUARDIAN 3 (Complete Questions 10 - 12 only if you allege that you are a de facto guardian.) 10. The child is under three years of age and has resided with me for six months or more (the six months need not be consecutive) ; or The child is at least three years of age and has resided with me for twelve months or more (the twelve months ne ed not be consecutive). 11. A non - consenting parent has demonstrated a lack of consistent participation with the minor as follows (describe each non - : 12. As I file this affidavit wit h the Prob ate Court as the de facto guardian of this child, I also certify that, before filing this Affidavit, I have served a copy of this Affidavit on the parent(s) and any legal guardian(s) of the child. (Please list separately and state date and method of service to each parent and any legal guardian(s). Dated : Petitioner STATE OF MAINE COUNTY OF Dated: Then personally appeared the above - named , who, under penalty of perjury, affirmed under oath the truth of the facts in the foregoing affidavit. Before me, Notary Public/Attorney - at - Law Print Name: For Notary Public: Date Commission Expires 3 See 18 - A M.R.S. 247 5 - 101(1 - B). MARP American LegalNet, Inc. www.FormsWorkFlow.com