SURROGATE222S COURT OF THE STATE OF NEW YORKCOUNTY OF ----------------------------------------------------------------------------XProceeding for the Appointment of aGuardian forAFFIDAVIT OF PROPOSEDGUARDIAN OF THE[ ] PERSON[ ] PROPERTY[ ] PERSON AND PROPERTY[ ] LIMITED GUARDIAN OF THE PROPERTYPursuant to SCPA Article 17-A----------------------------------------------------------------------------XFile No. STATE OF NEW YORK)COUNTY OF) ss.:To the Surrogate222s Court, County of The undersigned , being duly sworn, deposes and says:1.I am a competent person over the age of eighteen (18) years, and I submit this affidavit in support of my petition tobe appointed guardian of [ ] an intellectually disabled person [ ] a developmentally disabled person.2.I have known the subject Respondent since by reason of thefollowing: [State relationship if any.]3.I reside at , and theother resident members of the household are: [Include all persons residing there and their dates of birth.]4.My educational background is as follows:5.Not including minor traffic offenses and adjudications as a youthful offender or juvenile delinquent,(a)I have never been convicted of an offense against the law, except (b)I have never forfeited bail or other collateral, except GMD-1A -1- American LegalNet, Inc. www.FormsWorkFlow.com (c)I do not have any criminal charges pending against me, except 6.I have no physical or mental impairment, or medical condition, which would interfere with my ability to perform theduties of guardian of the [ ] intellectually disabled person [ ] developmentally disabled person, except7.I am not addicted to narcotics or to alcohol.8.I am willing and able to undertake care, custody and control of the Respondent until the court determines otherwise.9.I believe that my appointment as guardian would be in the best interests of the Respondent for the following reasons:(Signature of Proposed Guardian)(Print Name)Sworn to before me this day of , Notary PublicCommission Expires:(Affix Notary Stamp or Seal)-2- American LegalNet, Inc. www.FormsWorkFlow.com