-1- For Office Use Only Filing Fee Paid $ ) (Receipt No: No: ) COUNTY OF ---------------------------------------------------------------------------x PETITION FOR Proceeding for the Appointment STANDBY GUARDIANSHIP of a Standby Guardian for (SCPA 1726 (3) File No. An Infant. ---------------------------------------------------------------------------x , It is respectfully alleged: 1. The name, relationship, domicile, and telephone number of the petitioner are as follows: [Petitioner must be a parent or legal guardian of the infant. If legal guardian submit a copy of the order of Mother Fath er Domicile: (Street Address) (City/Town/Village) (County) (State) (Zip) (Telephone Number) Mailing address: (If different from domicile) 2. The name, domicile, date of birth and marital status of the infant are as follows: [Birth Certificate must be filed with this petition] Name: (Date of Birth) Domicile: (Street Address) (City/Town/Village) (County) (State) (Zip) Mailing address: (If different from domicile) 3. The names and addresses of the adult persons with whom the infant resides are : [If same as above so state] Name: Domicile: (Street Address) (City/Town/Village) (County) (State) (Zip) Mailing address: (If different from domicile) (if different from domicile) SG-1 American LegalNet, Inc. www.FormsWorkFlow.com -2- 4. The name and domicile of the proposed standby guardian are as follows: Name: (Relationship, if any, to infant) Domicile: (Street Address) (City/Town/Village) (County) (State) (Zip) Mailing address: (If different from domicile) 5. The naspouse, or if the other parent is deceased and there is no spouse, the grandparents residing within the county, are as follows: Father/Mother: Domicile: Spouse: (Date of Birth) Domicile: Maternal Grandparents: Domicile: Paternal Grandparents: Domicile: The foregoing persons are adult and competent, except: [If any of the above is an infant attach a Schedule containing the name of the infant, with whom he or she resides, whether he or she has a court-appointed guardian, and if so, provide the name and address of the guardian. If disability is other than infancy, fill out and attach Schedule A.] 6. No other persons or agencies are interested in this proceeding other than those mentioned above, except: 7a. No guardian or standby guardian ever has been appointed for the infant except as follows: [See SCPA Section 1704 (3)] 7b. Custody of the infant never has been surrendered by a person lawfully charged therewith, nor has custody of the infant been the subject of any court order, except as hereinafter listed: [So specify and attach copies of all surrenders, court orders, or divorce decrees] American LegalNet, Inc. www.FormsWorkFlow.com -3- 8. [If you seek the appointment of a Standby Guardian of the person only, DO NOT complete this resources are as follows: a. PERSONAL PROPERTY [State exact title of all bank accounts with account number and balance. List insurance policies by Company, policy number, amount insured, name of insured The personal property of the infant is not subja jurisdiction other than New York. [If property is so subject, so state] b. REAL PROPERTY [State whether the real property is encumbered and the amount of the encumbrance.Indicate whether property is to be occupied as a residence by the infant. Indicate rental income in (c.) (3) below. If a sale of the property is contemplated so state.] Location of Property Gross Value $ c. ANNUAL INCOME OF INFANT FROM ALL SOURCES: (1) Compensation or pension to be received from: $ (2) Income from Trusts $ (3) Income from Real Property $ (4) Other Income $ 9. The authority of the standby guardian is to become effective ubox] a. incapacity only b. death only c. incapacity or death 10. Petitioner suffers from a: progressively chronic illness fatal illness [ State the basis for the above statement, such as the date and source of the medical diagnosis. You need not identify the illness.] 11. The infant (is) (is not) a Native American Child subject to the Indian Child Welfare Act of 1978 (25 USC Section 1901-1963). American LegalNet, Inc. www.FormsWorkFlow.com -4- 12. Petitioner (has) (does not have) knowledge that the person nominated to be Standby Guardian has ever been named as a subject of an indicated report filed pursuant to Title 6 of Article 6 of the Social Services Law, or has been the subject of or the respondent in a child protective proceeding commenced under Article 10 of the Family Court Act, which proceeding resulted in an order finding that the child is an abused or neglected child. [If the petitioner has such knowledge, attach an affidavit explaining in detail]. 13. Completed and annexed hereto is the Request for Information Guardianship Form required to be submitted to the New York Central Register of Child Abuse and Maltreatment. 14. [Check appropriate box]: a. Petitioner is able to attend any hearing to be schedule by the court. b. The petitioner is medically unable to appear and asks that the court dispense with his/her appearance.] 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 Standby Guardianship of the Person and Property Person only Property only be granted to (death or incapacity) [ Delete if inapplicable] and that process issue to all interested persons who have not waived the issuance of same requiring them to show cause why such relief should not be granted. (b) The standby guardian of the property be prohibited from collecting or receiving any money or property of the infant until he or she qualifies and complies with the provisions of SCPA 1708. Dated: (Signature of Petitioner) (Print Name) American LegalNet, Inc. www.FormsWorkFlow.com -5- STATE OF NEW YORK ) ) ss.: COUNTY OF ) , 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. (Signature of Petitioner) Notary Public (Print Name) Commission Expires: (Affix Notary Stamp or Seal) Sworn to before me this day of , 20 Signature of Attorney: Pri nt Name: Firm Name: Tel.No.: Address of Attorney: American LegalNet, Inc. www.FormsWorkFlow.com -6- File # COUNTY OF ---------------------------------------------------------------------------x Proceeding for the Appointment SCHEDULE A of a Standby Guardian for PERSONS UNDER DISABILITY OTHER THAN INFANTS An Infant. ---------------------------------------------------------------------------x [use additional sheets if more than one] 1. Name: Relationship: Residence: With whom does this person reside? If this person is in prison, name of prison: Does this person have a court- appointed fiduciary? Yes No If yes, give name, title and address: If no, describe nature of disability: If no, give name and address of relative or friend interested in his or her welfare: American LegalNet, Inc. www.FormsWorkFlow.com