PP-101 (Rev. 5/1/12) STATE OF MAINE County Probate Court Docket No. In Re: Petition for Appointment Minor of Guardian of Minor 1. Name, address and telephone number of petitioner: 2. Name, address and telephone number of person to be nominated as guardian (if same as item 1, enter : 3. Birth date of person to be nominated as guardian: 4. Relationship of nominated guardian to the minor: 5. Name and legal residence address of minor: 1 6. Current location of minor (If same as item 5: 7. Birth date of minor: 8. These are facts that support the need for a guardian: 9. Is there any person who may disagree with your opinion of the facts? YES NO If yes, explain: 10. Has the person to be nominated/petitioner attached a child custody affidavit as required by 19-A M.R.S. 247 1753? YES NO American LegalNet, Inc. www.FormsWorkFlow.com PP-101 Rev. 5/1/12) Page 2 of 3 11. Does the petitioner believe a limited guardianship is sufficient in this case? YES NO . If yes, explain in detail proposed powers of the guardian and the parental rights and responsibilities retained parent(s): 2 12. Names and addresses and telephone numbers of all persons who must be notified and relationship of each such person to the minor. 3 (Indicate if waivers of notice have been or are to be filed). The following must be notified: the minor if 14 or over who has not otherwise consented or waived notice; the person who has had principal care and custody of the minor during 60 days immediately preceding date of petition; any living parent of minor; and any other interested party as directed by the Judge of Probate. NAME ADDRESS AND TELEPHONE NUMBER RELATIONSHIP WAIVERS 13. Which of these statements are true?: (a) Each parent with parental rights or legal custodian consent(s) to the guardianship and the guardianship is in the best interest of the child. 4 (b) A court has terminated or suspended all parental rights. (A certified copy of that Order is attached) 5 (c) All parental rights of custody have been terminated or suspended by circumstances: Explain. 6 (d) A court or other legal authority has determined that one or both surviving parents are incapacitated. Explain. 7 (e) The minor is faced with an intolerable living situation. Explain. 8 (f) Both parents have died without appointing a guardian for the child. Attach copies of death certificates. (g) There is a de facto guardian whose name and address is: . 9 American LegalNet, Inc. www.FormsWorkFlow.com PP-101 Rev. 5/1/12) Page 3 of 3 15. NOMINATION AND CONSENT OF MINOR. I, , being 14 years of age or older do hereby nominate to be my guardian and consent to his/her appointment as such without the necessity of hearing. 10 Dated: (signature of minor) The petitioner believes that the appointment of a guardian for the above-named minor is necessary and desirable and is in the . Petitioner requests the Court to: determine that appointment of a guardian for this minor is proper; make the requested appointment; and issue letters of appointment to the guardian. Dated: Petitioner or Attorney shall be signed by at least one attorney of record in Name, address, telephone and Maine Bar Registration Attorneys appearing for other parties Number of attorney of petitioner, if any: Name of Attorney Name of Party MARP 1 The address listed here or in item 6 must be in this county to establish venue. See 18-A MRSA 247 5-205. 2 See 18-A M.R.S. 247 5-105 3 See M.R.S. 2475-207 - The following must be notified: (a) The minor if 14 or over who has not otherwise consented or waived notice; (b) The person who has had principal care and custody of the minor during 60 days immediately preceding date of petition; (c) Any living parent of minor; (d) Any other interested party as directed by the Judge of Probate. 4 See 18-A M.R.S. 247 5-204(b) 5 See 18-A M.R.S. 247 5-204(a) 6 See 18-A M.R.S. 247 5-204(a) 7 See 18-A M.R.S. 247 5-202 8 See 18-A M.R.S. 247 5-204(c) 9 See 18-A M.R.S. 247 5-204(d), 247 5-101(1-B) and 2475-101 (1-C). 10 See 18-A M.R.S. 247 5-206. American LegalNet, Inc. www.FormsWorkFlow.com