SURROGATE222S COURT OF THE STATE OF NEW YORKCOUNTY OF ----------------------------------------------------------------------------XIn the Matter of the Application of forAppointment/Confirmation as Standby Guardian ofPursuant to SCPA Article 17-A----------------------------------------------------------------------------XFile No. TO THE SURROGATE222S COURT OF THE COUNTY OFIt is respectfully alleged that:1.The name, date of birth, permanent address and telephone number of the petitioning [ ] guardian [ ] standby[Attach certified copy of birth certificate if not already filed with the court.]2(b). [ ] The Respondent is notFiling Fee Paid $ Certs $ Certs $ $ Bond, Fee $Receipt No: No: PETITION FOR APPOINTMENT/CONFIRMATIONOF STANDBY GUARDIAN [SCPA 1757] OF[ ] PERSONAmerican LegalNet, Inc. www.FormsWorkFlow.com 3. The Petitioner was appointed [ ] guardian [ ] standby guardian [ ] alternate standby guardian [ ] secondalternate standby guardian [ ] third alternate standby guardian in the above-titled matter by decree on, and letters issued appointing as guardian of theabove-named Respondent. Within said decree the Petitioner was appointed as [ ] standby guardian [ ] alternatestandby guardian [ ] second alternate standby guardian [ ] third alternate standby guardian(s) subject toconfirmation.4.The guardian(s) is/are no longer able to act due to the following:[ ] death [attach a certified copy of the death certificate(s)][ ] incapacity [attach proof of incapacity][ ] adjudication of incompetency [attach proof][ ] renunciation [attach proof of renunciation][Please note: Paragraph 5 to be completed only if new or different standby guardian(s) is/are to be designatedin this proceeding.]5.The names, permanent addresses, dates of birth and relationship of the guardian(s) is/are:(a) Name of the Standby Guardian: Permanent Address: (Street and Number)(City, Village, Town)(State)(Zip Code)Date of Birth: Interest/Relationship to Respondent: Education: Qualifications: to be appointed Standby Guardian of the[ ] person[ ] property[ ] person and property[ ] limited guardian of the property (b) Name of the Alternate Standby Guardian: Permanent Address: (Street and Number)(City, Village, Town)(State)(Zip Code)Date of Birth: Interest/Relationship to Respondent: Education: Qualifications: to be appointed Alternate Standby Guardian of the[ ] person[ ] property[ ] person and property[ ] limited guardian of the property (c) Name of the Second Alternate Standby Guardian: Permanent Address: (Street and Number)(City, Village, Town)(State)(Zip Code)Date of Birth: Interest/Relationship to Respondent: Education: Qualifications: to be appointed Second Alternate Standby Guardian of the[ ] person[ ] property[ ] person and property[ ] limited guardian of the property -2- American LegalNet, Inc. www.FormsWorkFlow.com (d) Name of the Third Alternate Standby Guardian: Permanent Address: (Street and Number)(City, Village, Town)(State)(Zip Code)Date of Birth: Interest/Relationship to Respondent: Education: Qualifications: to be appointed Third Alternate Standby Guardian of the[ ] person[ ] property[ ] person and property[ ] limited guardian of the property [Please note: Paragraph 6 and 7 to be completed if seeking confirmation of standby guardian or alternate standbyguardian.]6.Petitioner has assumed the duties of the standby guardian in accordance with the decree dated , and pursuant to the provisions of SCPA 1757 and has been so acting as such standby guardian since , and that one hundred eighty (180) days have not elapsed since the assumption of such duties.7.Petitioner is requesting confirmation as standby guardian of the Respondent222s [ ] person [ ] property[ ] person and property [ ] limited guardian of the property.8.Petitioner [ ] has [ ] does not have knowledge that the person nominated herein to be a guardian or any individualeighteen years of age or over who resides in the home of the proposed guardian:a.Is the subject of a report filed with the Statewide Central Register of Child Abuse and Maltreatment pursuantto the rules of Child Protective Services, following an investigation which determines that some credibleevidence of alleged abuse or maltreatment exists, and/orb.Has been the subject of or the Respondent in a Child Protective Proceeding commenced pursuant to law,which proceeding resulted in an order finding that the child is an abused or neglected child.[If Petitioner has such knowledge, attach an affidavit explaining in detail.]9.Petitioner has completed and submitted to the court the Request For Information Guardianship Form (OCFS 3909)required to be submitted to the New York State Central Register of Child Abuse and Maltreatment.10.[Answer if required by court.]The names and addresses of persons interested (i.e.: parents, spouse, adult children and/or adult siblings) in thisproceeding upon whom service of process is required or concerning whom the court is required to have informationare: [Set forth names, addresses and relationship to the intellectually disabled or developmentally disabled personand whether any person is under a disability along with details required by SCPA 304(3).] 11.There are no other persons than those mentioned interested in this application or proceeding.-3- American LegalNet, Inc. www.FormsWorkFlow.com WHEREFORE, your Petitioner(s) respectfully request(s) that: [Check and complete all relief requested](a)Petitioner be confirmed as guardian, and appropriate letters be issuedto , as the standby guardian of the [ ] person[ ] property[ ] person and property[ ] limited guardianship of the propertyof the Respondent(b)Appointment of as Standby Guardian of the[ ] person[ ] property[ ] person and property[ ] limited guardianship of the propertyof the Respondent(c)Appointment of as Alternate Standby Guardian of the[ ] person[ ] property[ ] person and property[ ] limited guardianship of the propertyof the Respondent(d)Appointment of as Second Alternate Standby Guardian of the[ ] person[ ] property[ ] person and property[ ] limited guardianship of the propertyof the Respondent(e)Appointment of as Third Alternate Standby Guardian of the[ ] person[ ] property[ ] person and property[ ] limited guardianship of the propertyof the Respondentbe granted, or to such other person or corporation as may be entitled thereto and that process issue to all interestedpersons who have not waived the issuance of same requiring them to show cause why such relief should not begranted.(f)A hearing [ ] be held [ ] not be held.(g)The appearance of the Respondent [ ] be required [ ] not be required at any hearings directed by the Court.(h)The guardian of the person be authorized and empowered to make all decisions with respect to the medical and dentalneeds of the Respondent and to render consent to any medical procedures which are necessary to the health andwelfare of the Respondent unless the court directs otherwise. A health care decision may include a decision to withholdor withdraw life-sustaining treatment as defined in subdivision (j) of 81.03 of the Mental Hygiene Law.(I)The guardian of the property be directed to continue to collect and receive all moneys and other property of theRespondent jointly with a clerk of the Surrogate222s Court, or depository subject to the provisions of SCPA 1708, and shalldeposit same in the name of the guardian, subject to order of the court with either:[Designate a sufficient number of banks/depositories, located in this county, so that the deposit does notexceed the maximum amount insured by the federal deposit insurance corporation or the national credit unionshare insurance fund ($250,000.00).]1. Name of Bank/DepositoryBranch Address2. Name of Bank/DepositoryBranch Address-4- American LegalNet, Inc. www.FormsWorkFlow.com (j)The bond of the guardian be dispensed with.(k)Additional relief requested Dated: 1.2.(Signature of Petitioner)(Name of Corporate Petitioner) (Print Name)(Signature of Officer) (Print Name and Title of Officer)STATE OF NEW YORK )COUNTY OF ) ss.:, being duly sworn deposes and says that I am thePetitioner(s) above named. I/we have read the foregoing petition and the same is true of my own knowledge except as