SURROGATE222S COURT OF THE STATE OF NEW YORKCOUNTY OF ---------------------------------------------------------------------------XIn the Matter of the Application of forCONSENT, OATH ANDAppointment/Confirmation as Standby Guardian of DESIGNATION Pursuant to SCPA Article 17-AFile No. ----------------------------------------------------------------------------XSTATE OF NEW YORK)COUNTY OF ) ss.:, being duly sworn, deposes and says: I am an adult competentperson and I do hereby consent to the relief requested in the petition and my appointment as [ ] standby guardian [ ] alternate standby guardian [ ] second alternate standby guardian [ ] third alternate standby guardianof the[ ] person[ ] property[ ] person and property[ ] limited guardianship of the propertyof the above-named Respondent and I waive the issuance and service of process upon me herein. I will make an applicationfor confirmation in accordance with SCPA 2471757 and will be subject to a formal hearing if the Respondent is eighteen yearsof age or over. I agree that upon the death, incapacity, renunciation or adjudication of incompetency of the last guardian whohas been designated to serve prior to me, I will immediately assume the duties of guardianof the[ ] person[ ] property[ ] person and property[ ] limited guardianship of the property and will seek to have this Court confirm my appointment within (180) days of my assumption of duties.1.OATH OF [ ] STANDBY GUARDIAN [ ] ALTERNATE STANDBY GUARDIAN [ ] SECOND ALTERNATESTANDBY GUARDIAN [ ] THIRD ALTERNATE STANDBY GUARDIAN: I am over eighteen (18) years of age andthat I will well, faithfully and honestly discharge the duties of [ ] standby guardian [ ] alternate standbyguardian [ ] second alternate standby guardian [ ] third alternate standby guardian of the[ ] person[ ] property[ ] person and property[ ] limited guardianship of the propertyof the above named Respondent, that I am acquainted with the estate of the Respondent; and that I am not ineligible to receiveletters.2.DESIGNATION OF CLERK FOR SERVICE OF PROCESS: I do hereby designate the Clerk of the Surrogate222s Courtof County, and his/her successor in office, as a person on whom service of any process issuing fromsuch Surrogate222s Court may be made, in like manner and with like effect as if it were served personally upon me wheneverI cannot be found and served within the State of New York after due diligence used. CSMD-6 (/201) -1- American LegalNet, Inc. www.FormsWorkFlow.com My permanent address is : (Street Address)(City/Town/Village)(State)(Zip)(Signature of Proposed Guardian)(Print Name)On , , before me personally cameto me 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)-2- American LegalNet, Inc. www.FormsWorkFlow.com