THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) Guardianship of PETITION FOR GUARDIANSHIP OF MINOR The petitioner states the following: 1. 2. Petition is made for guardianship over the minor's: Person and Estate Person Only Petitioner name Mailing address Petitioner name Mailing address 3. Attorney name Mailing address 4. The minor is: under Minor's legal name Mailing address Alternate names Alternate addresses 5. Name of minor's birth or adoptive parents. If both parents are deceased, attach a list of the names and addresses of the minor's grandparents, adult siblings, aunts and uncles. (Attach copy of death certificate of deceased parent(s), if applicable.) Estate Only Relationship to minor Telephone Relationship to minor Telephone Telephone Bar ID# OR over the age of fourteen. (Attach certified copy of birth certificate.) Date of birth Telephone Father name Mailing address Residence address (if different from above) Mother name Mailing address Residence address (if different from above) 6. Date of birth Telephone Date of birth Telephone List the names and addresses of any persons having the principal care and custody of the minor during the 60 days preceding the filing of this petition. Name Relationship to minor Address Telephone NHJB-2162-P (01/02/2014) Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Guardianship of Case Number: PETITION FOR GUARDIANSHIP OF MINOR 7. Proposed guardian name Relationship to minor Mailing address Proposed guardian name Relationship to minor Mailing address Date of birth Occupation Telephone Date of birth Occupation Telephone 8. List names and addresses of any person(s) nominated as guardian(s) of the person and/or the estate of the minor in the will of a deceased parent. Name Relationship to minor Address Telephone 9. List names and addresses of any adults, other than the proposed guardian, who will be living in the same home as the minor. Those persons must provide the court with a completed Criminal Record Release Authorization form and a DHHS Record Release Authorization form. Are there any pending adoption, juvenile, domestic violence, marriage dissolution, domestic relations, paternity, legitimation, custody or other proceedings affecting minor or parents of this minor? Yes No If yes, attach a separate sheet identifying and explaining each. Is an adoption of the minor by the proposed guardian(s) contemplated? Is the minor entitled to receive local, state or federal benefits and/or entitlements? Is there an existing child support order for this child? If yes, is support collected by the Division of Child Support Services? If no, are you seeking a child support order as part of this guardianship? Is there an existing court visitation order for this child? If yes, attach a copy of that order to this petition. Is there any reason that this child should not visit with his/her parents? If yes, state clearly and specifically any reason(s). Attach pages if needed. Yes Yes Yes Yes Yes Yes Yes No No No No No No No 10. 11. 12. 13. 14. 15. 16. 17. Is this guardianship being sought by the Department of Health and Human Services as part of a Yes No permanency plan pursuant to the Adoption and Safe Families Act of 1997? Is the child an American Indian child as defined by the Indian Child Welfare Act? Yes No If yes, the name and address of the tribe are: Is the tribe recognized by the federal government as eligible for federal services or certain Yes Alaskan native corporations as defined in 43 U.S.C. §1602(c)? NHJB-2162-P (01/02/2014) Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com No Case Name: Guardianship of Case Number: PETITION FOR GUARDIANSHIP OF MINOR 18. Is this petition filed in conjunction with a settlement of minor's action, per RSA 464-A:42? Yes No If yes, attach a copy of the petition or proposed petition seeking approval and all supplemental documentation to be filed with the Superior or District Division. If applying for guardianship over the minor's estate, provide the probable value and general character of the estate below: DESCRIPTION Real Estate $ Personal Property Income (include local, state and federal benefits) Debts $ $ $ 19. 20. State specific facts which are claimed to demonstrate that the appointment of a guardian is in the best interests of the minor. (Attach additional pages as needed. Make each allegation a separate paragraph and number each paragraph.) REQUEST FOR TEMPORARY ORDERS and/or PERMANENT ORDERS The petitioner(s) request(s) that the following relief be granted in the best interests of the minor, after a hearing on the merits. (State clearly, and number separately, your requests to the court.) 22. FOR EX PARTE RELIEF ONLY. State additional facts or attach an affidavit (statement under oath) alleging facts involving the circumstances of the minor which establish that unless the ex parte relief is granted, the minor will, or is likely to, suffer immediate or irreparable harm or injury. NHJB-2162-P (01/02/2014) Page 3 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Guardianship of Case Number: PETITION FOR GUARDIANSHIP OF MINOR REQUEST FOR EX PARTE ORDERS The petitioner(s) request(s) that the following ex parte (emergency) relief be granted. (State clearly, and number separately, your requests to the court.) Date Date Petitioner Signature Petitioner Signature State of This instrument was acknowledged before me on My Commission Expires Affix Seal, if any , County of by Signature of Notarial Officer / Title FOR COURT USE ONLY. The following consents, if required, will be obtained by the judge at the time of the hearing. We hereby voluntarily and knowingly give consent to the appointment of as guardian(s). Date Date Date Date Date Parent Signature Parent Signature Minor Signature Guardian Signature Guardian Signature ORDER Upon consideration of this petition, it is decreed that the petition be granted and letters of guardianship be issued. Prior to the issuance of said letters, the guardian is ordered to file with the court, within days of this order, a fiduciary bond in the amount of $ , without sureties with corporate sureties. Date Signature of Judge Printed Name of Judge NHJB-2162-P (01/02/2014) Page 4 of 4 American LegalNet, Inc. www.FormsWorkFlow.com