SURROGATE'S COURT OF THE STATE OF NEW YORKCOUNTY OF BROOME-----------------------------------------------------------------------------X PETITION G TO TERMINATE AGUARDIANSHIP ACCOUNTIN THE MATTER OF THE GUARDIANSHIP OFPURSUANT TO SCPA 2471727 AND/ORG FOR THE REVOCATION OF LETTERS,OF GUARDIANSHIP OF THEPROPERTY AND/OR G FOR THE MODIFICATION OF LETTERS(an infant) or (an Intellectually Disabled) (or DevelopmentallyDisabled) Person FILE NO: -----------------------------------------------------------------------------XTO THE SURROGATE'S COURT, BROOME COUNTYIt is respectfully alleged:1.The name, domicile (or, in the case of a bank or trust company, its principal office) and interest in thisproceeding of the petitioner(s) are as follows:Name: InterestDomicile or Principal Office: (Street and Number)(City, Village or Town)StateZip CodeMailing Address: (If different from domicile)Name: Interest Domicile or Principal Office: (Street and Number)(City, Village or Town)StateZip CodeMailing Address: (If different from domicile)2.Name of infant/ward:Permanent Address: Date of birth: 3.Date Letters of Guardianship were issued: Type of Letters [Check one]:[ ]Person and Property[ ]Property only[CHOOSE EITHER 4(a) or 4(b), AS APPLICABLE].G4.(a)NO GUARDIANSHIP FUNDS HAVE EVER BEEN COLLECTED OR ADMINISTERED FORBENEFIT OF THE WARD.- OR -G4.(b)The name and address of the financial institution(s) in which funds of the ward are/were on deposit:[List all, attach additional sheet if needed]Name: Address: Amount on deposit at date of this petition $ Name: Address: Amount on deposit at date of this petition $ American LegalNet, Inc. www.FormsWorkFlow.com TOTAL CURRENTLY ON DEPOSIT AT ALL FINANCIAL INSTITUTIONS: $[COMPLETE NUMBER 5 IF GUARDIANSHIP FUNDS WHICH, IN THE AGGREGATE, DO NOT EXCEED$10,000.00 REMAIN ON DEPOSIT IN AN ACCOUNT ESTABLISHED FOR THE WARD]5.The source of the funds comprising the current deposit(s) is/are as follows:6. All annual accounts have been filed as required by law. If guardianship funds remain on deposit forbenefit of the ward, a final account must accompany the petition to include a bank statement(s).7.The only persons interested in this proceeding entitled to notice thereof are the following:8.There are no other persons than those mentioned interested in this application or proceeding.9.No previous application has been made for the relief now sought.[CHOOSE ONE FORM OF RELIEF BELOW].[WHERE NO GUARDIANSHIP FUNDS EVER COLLECTED/ADMINISTERED FOR WARD]GWHEREFORE, petitioner(s) respectfully request(s) that an order be granted revoking the Letters ofGuardianship of the [Check one] [ ] Person and Property [ ] Property only. [Check if applicable] [ ] And that an Amended Decree granting Amended Letters of Guardianship be issuedappointing petitioner Guardian of the Person Only. - OR - [WHERE GUARDIANSHIP FUNDS NOT EXCEEDING $10,000.00 REMAIN ON DEPOSIT FOR BENEFITOF THE WARD].GWHEREFORE, petitioner(s) respectfully request(s) that an order be granted authorizing termination of guardianship account number(s) at[Name of Financial Institution(s)]and to pay the balance of the account(s) which do not exceed Ten Thousand and 00/100 Dollars ($10,000.00) to as (choose one) G parent of the ward or G a competent adultwith whom such person resides or G a person who has some interest in such person222s welfare for the use and benefitof such person AND (choose one) G that the Letters of Guardianship of the Property shall remain in full force and theproperty guardian(s) will continue to account to the court annually as required by law even if the account reports a zero American LegalNet, Inc. www.FormsWorkFlow.com balance OR G that the Letters of Guardianship of the Property only be revoked. [Check if applicable] [ ] And thatan Amended Decree granting Amended Letters of Guardianship be issued appointing petitioner Guardian of the PersonOnly. Date: PETITIONER Date: PETITIONERSTATE OF NEW YORK )COUNTY OF BROOME ) ss:I, , the petitioner named in the foregoing Petition, being dulysworn, says:I have read the foregoing Petition subscribed by me and know the contents thereof, and the same is true of myown knowledge, except as to those matters therein stated to be alleged on information and belief, and as to those matters,I believe it to be true.Sworn to before me this PETITIONERday of , 2NOTARY PUBLICCommission Expires: (Affix Notary Stamp or Seal)STATE OF NEW YORK )COUNTY OF BROOME ) ss:I, , the petitioner named in the foregoing Petition, being dulysworn, says:I have read the foregoing Petition subscribed by me and know the contents thereof, and the same is true of myown knowledge, except as to those matters therein stated to be alleged on information and belief, and as to those matters,I believe it to be true.Sworn to before me this PETITIONERday of , 2NOTARY PUBLICCommission Expires: (Affix Notary Stamp or Seal) American LegalNet, Inc. www.FormsWorkFlow.com SURROGATE222S COURT OF THE STATE OF NEW YORKCOUNTY OF BROOME---------------------------------------------------------------------------XIn the Matter of the Application of toWAIVER AND CONSENT terminate a guardianship account established for, File No.: Pursuant to SCPA 2471727 and/or for the revocationof Letters of Guardianship of the Property and/or forthe Modification of Letters of Guardianship of thePerson and Property.XThe undersigned , whose permanentaddress is and who is a competent person over the age of eighteen (18) years and whose interest in the above-named proceedingis as follows:[Check appropriate interest.]GProperty Guardian of the wardGParent of the ward (not court appointed guardian)GCompetent adult other than guardian or parent with whom ward residesGPerson with interest in ward222s welfare other than guardian or parenthereby personally appears in this proceeding and1.Waives the issuance and service of process in this matter, and2.Acknowledges receipt of a copy of the petition and exhibits thereto and consents to the relief requested therein. Date: (Signature) (Print Name) STATE OF NEW YORK) ) ss:COUNTY OF BROOME)On , , before me personallycametome known to be the person described in and who executed the foregoing instrument. Such person duly swore to suchinstrument before me and duly acknowledged that he/she executed the same.Notary PublicCommission Expires:(Affix Notary Stamp or Seal) American LegalNet, Inc. www.FormsWorkFlow.com