-11- SU COUNTY OF ----------------------------------------------------------------------------X Proceeding for the Appointment of a Guardian for an Infant. ----------------------------------------------------------------------------X AFFIDAVIT OF PARENT File No. STATE OF NEW YORK ) COUNTY OF ) ss.: The undersigned, , being duly sworn, deposes and says: 1. I am a competent person over the age of eighteen (18) years and I am the natural/adoptive parent of (Mother/Father) (Infant) and I reside at 2. As the natural/adoptive parent of the above-named infant, I have determined that it would be in the best interests of the child if was/were appointed guardian (s) of the (Proposed Guardian(s)) was/were appointed guardian (s) of the infant for the following reasons: 3. No guardian has ever been appointed for the infant herein nor has custody thereof been surrendered by me nor otherwise judicially awarded to any other person or agency except as listed below: 4. I understand that I am relinquishing all rights to care, custody and control of my i nfant (Son/Daughter) in favor of , the proposed guardian (s) of the person of said infant. 5. I understand that I am relin quishing all rights to care, custody and control of my infant shall remain in (Proposed Guardian) as guardian of the person until the infant shall attain the age of eighteen (18) years, and that the proposed guardian (s) is/are capable of assuming such care, custody, and control over the infant. Signature of Parent Notary Public Commission Expires (Affix Notary Stamp or Seal) G-4 (9/00) American LegalNet, Inc. www.FormsWorkFlow.com