SURROGATE222S COURT OF THE STATE OF NEW YORKCOUNTY OF ---------------------------------------------------------------------------XIn the Matter of the Application of forAppointment/Confirmation as Standby Guardian ofWAIVER OF PROCESS RENUNCIATION AND CONSENT TOAPPOINTMENT OF A STANDBY GUARDIANPursuant to SCPA Article 17-AFile No. --------------------------------------------------------------------------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 [ ] intellectually disabled [ ] developmentally disabled person.[ ] Spouse of the above-named [ ] intellectually disabled [ ] developmentally disabled person.[ ] An adult child of the above-named [ ] intellectually disabled [ ] developmentally disabled person.[ ] An adult brother/sister of the above-named [ ] intellectually disabled [ ] developmentally disabled person.[ ] Other [Specify] hereby personally appears in this proceeding and1.renounces my right to act as a guardian under decree dated , and2.waives the issuance and service of process in this matter, and3.consents that be appointed the Guardian of the[ ] person[ ] property[ ] person and property[ ] limited guardianship of the propertyand that be appointed the Alternate StandbyGuardian of the[ ] person[ ] property[ ] person and property[ ] limited guardianship of the property CSMD-2 (/201) -1- American LegalNet, Inc. www.FormsWorkFlow.com and that be appointed the Second AlternateStandby Guardian of the[ ] person[ ] property[ ] person and property[ ] limited guardianship of the propertyand that be appointed the Third Alternate StandbyGuardian 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