-1- `` COUNTY OF ----------------------------------------------------------------------------X Proceeding for the Appointment of a Guardian for an Infant. ----------------------------------------------------------------------------XFiling Fee Paid $ Certs $ Certs $ $ Bond, $ Receipt No: No: PETITION FOR APPOINTMENT OF GUARDIAN OF PERSON AND PROPERTY PROPERTY ONLY File No. TO THE SURROGAT It is respectfully alleged: 1. infant are as follows: Name: Telephone Number: Permanent Address: (Street and Number) Mailing address: (If different from permanent address) Date of Birth: Relationship to Infant: Name: Telephone Number: Permanent Address: Mailing address: (If different from permanent address) Date of Birth: Relationship to Infant: 2. The name, permanent address, date of birth and marital status of the infant of this proceeding is as follows: Name: ress: (Street and Number) (City, Village, Town) (State) (Zip Code) Mailing address: (If different from permanent address) Date of Birth: Marital Status: [Attach certified copy of birth certificate] 3. Father: Date of Birth: Date of Death: Permanent Address: (Street and Number) (City, Village, Town) (State) (Zip Code) Mailing Address: (If different from permanent address) G-2-B (9/00) American LegalNet, Inc. www.FormsWorkFlow.com -2- Name of Mother: Date of Birth: Date of Death: Permanent Address: (Street and Number) (City, Village, Town) (State) (Zip Code) Mailing Address: (If different from permanent address) Name of Spouse: Date of Birth: Date of Death: Permanent Address: (Street and Number) (City, Village, Town) (State) (Zip Code) Mailing Address: (If different from permanent address) 4. The names and addresses of the adult persons with whom the infant resides if other than parents are: Name: Permanent Address: (Street and Number) (City, Village, Town) (State) (Zip Code) Mailing Address: (If different from permanent address) Relationship to infant: 5. If father and mother are deceased, list the names and addresses of the nearest distributees of full age who live within the state. [If not applicable, so state] Name: Permanent Address Relationship: 6. [If not applicable, so state and if deceased, add date of death] Name Permanent Address Maternal Grandmother Maternal Grandfather Paternal Grandmother Paternal Grandfather 7. ship of (a) capable of providing care, custody and control of the infant during minority and is motivated solely by the best interests of the child in requesting this appointment. American LegalNet, Inc. www.FormsWorkFlow.com -3- (b) value of all REAL and PERSONAL property to which the infant is entitled is: $ [Answer question 8 only if requesting guardianship of the property] 8. (a) PERSONAL PROPERTY [State exact title of all bank accounts with account number and balance, and/or list insurance policies by company, policy number, amount insured, and name of insured and relationship to infant and/or list the name, number of shares and value of all stocks, bonds, and any other personal property. (b) REAL PROPERTY [State whether real property is mortgaged or under a lien and the amount thereof. Indicate whether property is to be occupied as a residence by the infant. If not, indicate rental income or whether a sale of the property is contemplated.] Location of Property Gross Value Annual Income Amount Mortgaged or Under a Lien (c) ANNUAL INCOME OF INFANT FROM ALL SOURCES: (1) Compensation or pension to be received from: $ (2) Income from Trust $ (3) Other Income $ (d) STATE SOURCE OF ALL PROPERTY listed above. [If any property is derived from an estate or as a result of the death of any person, name the decedent, his or her date of death and relationship to the infant, whether a fiduciary has been appointed, court name, file number, and type of letters. Provide a copy of any will or decree directing payment. List names and addresses of all banks, insurance companies and persons from whom payment is expected]. 9. (a) The infant has never had, at any time, a guardian appointed for him/her, and, (b) Custody of the infant has never been surrendered by any person lawfully charged therewith nor has custody been the subject of any court order, except as hereinafter listed: [Attach copies of all surrenders, court orders, or divorce decrees]. 10. That if the infant is a non-domiciliary married person and the petition relates to property only, that the property is American LegalNet, Inc. www.FormsWorkFlow.com -4- 11. Petitioner has ] does not have knowledge that a person nominated to be a guardian, or any individual eighteen years of age or over who resides in the home of the proposed guardian: a. Is the subject of a reported filed with the Statewide Central Register of Child Abuse and Maltreatment pursuant to the rules of Child Protective Services, following an investigation which determines that some credible evidence of alleged abuse or maltreatment exists, and/or b. 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 subject infant is an abused or neglected child. [If petitioner has such knowledge, attach an affidavit explaining in detail]. 12. Petitioner has completed and annexed the Request For Information Guardianship Form (OCFS 3909) required to be submitted to the New York State Central Register of Child Abuse and Maltreatment. 13. The infant is is not a Native American child under the Indian Child Welfare Act of 1978. (25 U.S.C. Sections 1901-1963) 14. There are no other persons interested in this proceeding upon whom process is required to be served other than those listed above. 15. No prior application has been made to any Court for the relief requested herein. WHEREFORE, your petitioner respectfully prays that: [Check and complete all relief requested] (a) Letters of Guardianship of the Person and Property Property be granted to or such other person or corporation as may be entitled thereto and that process issue to all interested persons who have not waived issuance of same requiring them to show cause why such relief should not be granted. (b) The guardian of the property be directed to collect and receive all moneys and other property of the infant jointly with a clerk of the Surrogatesame in the name of guardian, subject to order of the court with either: 1. Name of Bank/Depository Branch Address 2. Name of Bank/Depository Branch Address (c) The bond of the guardian be dispensed with. Dated: (Signature of Petitioner) (Signature of Petitioner) (Print Name) (Print Name) American LegalNet, Inc. www.FormsWorkFlow.com -5- STATE OF ) COUNTY OF ) ss.: , being duly sworn deposes and says that I am the petitioner above named. I have read the foregoing petition and the same is true of my own knowledge except as to matters therein stated to be alleged upon information and belief and as to those matters I believe them to be true. Sworn to before me this day of , (Signature of Petitioner) Notary Public (Print Name) Commission Expires: (Affix Notary Stamp or Seal (Signature of Petitioner) (Print Name) COMBINED OATH & DESIGNATION STATE OF ) COUNTY OF ) ss.: being duly sworn, deposes and says: 1. OATH OF GUARDIAN: I am over eighteen (18) years of age, and I will well, faithfully and honestly dischargethe duties of such guardian: That I amacquainted with estate of said infant and have read the statement contained in the foregoing petition as to the estimated value of same, and believe same to be correct, and that I am not ineligible to receive letters. 2. DESIGNATION OF CLERK FOR SERVICE O of County, and his/her successor in office, as a person on whom service of any process ffect as if it were served personally upon me, whenever I cannot be found within the state of New York after due diligence used. My permanent address is : (Street Address) (City/Town/Village) (State) (Zip) (Signature of Proposed Guardian) (Signature of Proposed Guardian) (Print Name) (Print Name) On , , before me personally came to me known to be the person described in and who executed the foregoing instrument. Such person duly sworn to such instrument before me and duly acknowledged that he/she executed the sam