Docket No.: ___________ State of New Jersey Camden County Surrogates Court In the matter of the appointment of a Standby Guardian for: DESIGNATION OF ______________________________________________, a Minor } STANDBY GUARDIAN AKA: ________________________________________ I, _________________________, pursuant to N.J.S. 3B 12 74 hereby name ________________________ as Standby Guardian for my child(ren) whose names follow: Minor Name Age of Minors Residence The name, home address and telephone number of the Standby Guardian are as follows; __________________, _____________________, ________________, _________, _______________, ______________________. By this consent and designation, I am providing that the Standby Guardians authority shall take effect if and when the following event or events occur (choose as follows): my attending physician concludes that I am mlly incapacitated, and thusenta unable to care for my child(ren); or my attending physician concludes that I am physically debilitated, and thus unable to care for my child(ren), and I consent in writing before two witnesses to the designated Standby Guardians authority taking effect; or upon my death S1.DOC Page 1 of 2 >>>> 2 Docket No.: ___________ In the event that the person designated above is unable or unwilling to act as Guardian of my child(ren) I hereby name _________________________ as Alternate Standby Guardian. The name, home address and telephone number of the Alternate Standby Guardian are as follows; __________________, __________________, _____________________, _________, ___________, ____________________. I understand that this designation will expire in six months from the date of this designation, and that the authority of the Designated Standby Guardian, if any, will cease, unless byat date either I or the Designated th Standby Guardian petition the Court for appointmas Standby Guardian, pursuant to N.J.S. 3B: 12 72. ent I hereby authorize that the person designated Standby Guardian herein shall be provided with a copy of the attending physicians statement. I the event that I am incapacitated odebilitated and a designated Standby Gur ardianship is activated pursuant to this designation, I declare that it is my intention to retain full parental rights to the extent consistent with my condition and, further, that I retain the authority to revoke the designated or alternate designated Standby Guardianship consistent with my rights herein at any time. __________________________________________________________________________________________ Designators Signature, Address, Telephone Number, Date __________________________________________________________________________________________ Witness Signature, Address, Telephone Number, Date __________________________________________________________________________________________ Witness Signature, Address, Telephone Number, Date S1.DOC Page 2 of 2