State of Minnesota County Judicial District: Court File Number: Case Type: District Court Probate In the Matter of the Guardianship/ Conservatorship of: Affidavit Regarding Background Study Ward/Protected Person , states as follows: 1. A Petition has been filed in this matter requesting my appointment Guardian/Conservator for the above named Ward/Protected Person as 2. I have been the subject of a background study within the past two years pursuant to Minn. Stat. §524.5-118. A true and correct copy of the background study is attached to this affidavit. I have not been arrested, charged with any crime, convicted of any crime, the subject of any criminal investigation, or the subject of any investigation regarding maltreatment of vulnerable adults or maltreatment of minors since date of the background study, except as follows: 3. 4. I declare under penalty of perjury that everything I have stated in this document is true and correct. Minn. Stat. § 358.116. Date: County and State where signed: Affiant's Signature Address: City/State/Zip: Telephone: ( E-mail address: ) American LegalNet, Inc. www.FormsWorkFlow.com GAC102 State ENG Rev 7/15 www.mncourts.gov/forms Page 1 of 1