SURROGATE222S COURT OF THE STATE OF NEW YORKCOUNTY OF --------------------------------------------------------------------XProceeding for the Appointment of a Guardian forWAIVER OF PROCESS RENUNCIATION AND CONSENTTO APPOINTMENT OF A GUARDIANFile No. Pursuant to SCPA Article 17-A--------------------------------------------------------------------XThe undersigned , whose permanent address is(Street and Number)(City, Village, Town)(State)(Zip Code)and who is a competent person over the age of eighteen (18) years and whose interest in the above-named proceeding is asfollows:[Check appropriate interest][ ]Parent of the above-named alleged [ ] intellectually disabled person [ ] developmentally disabled person.[ ]Spouse of the above-named alleged [ ] intellectually disabled person [ ] developmentally disabled person.[ ]An adult child of the above-named alleged [ ] intellectually disabled person [ ] developmentally disabledperson.[ ]An adult brother/sister of the above-named alleged[ ] intellectually disabled person[ ] developmentally disabled person[ ] Other [Specify] hereby personally appears in this proceeding and1.renounces all right to apply as a guardian under Article 17-A of the SCPA2.waives the issuance and service of process in this matter, and3.consents that be named the Guardian(s) of the[ ] person[ ] property[ ] person and property[ ] limited guardianship of the propertyand that be named the StandbyGuardian of the[ ] person[ ] property[ ] person and property[ ] limited guardianship of the property GMD-3 -1- American LegalNet, Inc. www.FormsWorkFlow.com and that be named the First AlternateStandby Guardian of the[ ] person[ ] property[ ] person and property[ ] limited guardianship of the propertyand that be named the Second AlternateStandby Guardian of the[ ] person[ ] property[ ] person and property[ ] limited guardianship of the propertyand that such letters may be granted to said person(s) or to any other person(s) entitled thereto without notice to theundersigned.(Signature)Date: (Print Name)STATE OF ) ss.:COUNTY OF)On , , before me personally cametome 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) American LegalNet, Inc. www.FormsWorkFlow.com