-10- COUNTY OF ---------------------------------------------------------------------------- X Proceeding for the Appointment of a Standby Guardian for An Infant. ---------------------------------------------------------------------------- X AFFIDAVIT AND CONSENT File No. STATE OF NEW YORK ) ) ss.: COUNTY OF ) , being duly sworn, deposes and says: 1. I am a competent person over the age of eighteen years, and I submit this affidavit in support of the petition to have me appointed standby guardian of the person only, property only, or person and property of the above named infant. [Check one] 2. I have known the subject infant since by reason of the following [State relationship, if any]: 3. I reside at and the other resident members of my household are [Include all persons residing there and their respective ages]: SG-5 American LegalNet, Inc. www.FormsWorkFlow.com -11- 4. Except for minor traffic offenses and adjudications as a youthful offender or juvenile delinquent: (a) Have you ever been convicted of a crime yes no (b) Have you ever forfeited bail or other collateral yes no (c) Do you have criminal charges pending against you yes no (d) Do you have a physical impairment or mental or medical condition that would interfere with your ability to perform the duties of guardian of the infant yes no (e) Have you ever used controlled substances or narcotics or been addicted to alcohol yes no - (e), set forth details in space provided]. 5. I am willing and able to undertake the care, custody and control of the infant until the infant attains the age of eighteen or until the court determines otherwise. 6. , or incapacity or death, or upon written consent, I agree to file all necessary documentation with the court within 90 days of the receipt of the determination of the incapacity, or written consent. Signature of the Proposed Standby Guardian Sworn to before me this day of , 20 Notary Public Commission Expires: (Affix Notary Stamp or Seal) American LegalNet, Inc. www.FormsWorkFlow.com