JV-079 (Rev. 03/21/2013) AUTHORIZATION FOR COURT ACTIVITYRECORD INFORMATION CHECK (CARI) DOCKET NUMBER Trial Court of MassachusettsJuvenile Court Department Guardianship of Minor DIVISIONI hereby authorize the Juvenile Court to conduct a court activity record information check todetermine whether I have a criminal record. I understand the court activity record informationcheck is intended for use by the Court in conjunction with my petition for guardianship of theabove named minor. I further understand that the Court will not consider a petition for aguardianship without conducting a court activity record information check of the guardian and theco-guardian, if applicable. Therefore, the information below is willingly supplied by me, and mysignature indicates my permission for this record check to be completed. Proposed Guardian's Name: Current Address: Social Security No: Gender: Male Female Date of Birth: Place of Birth: Maiden Name (if applicable): Other Names or Aliases used: Mother's Name: Father's Name: DATE SIGNATURE OF PROPOSED GUARDIAN NOTARIZATIONThe above signed made oath before me on that thisauthorization is his/her free act and deed.Notary Public:Print Name:My Commission Expires: FOR COURT USE ONLYResults of CARI: CARI Check Conducted on: Record (attached) No Record Sealed Record DATE SIGNATURE American LegalNet, Inc. www.FormsWorkFlow.com