COUNTY OF ----------------------------------------------------------------------------X Proceeding for the Appointment of a Guardian for File No. The 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-entitled proceeding is as follows: [Check appropriate interest] Parent of the above-named infant Other (Specify) hereby personally appears in this proceeding and (1) renounces all right to Letters of Guardianship of the person and property person property of infant. (2) waives the issuance and service of process in this matter, and (3) consents that be appointed the guardian of the a. Person of the above-named infant b. Property of the above-named infant c. Person and Property of the above-named infant and that such letters may be granted to said person or to any other person entitled thereto without notice to the undersigned. Date: STATE OF ) ss.: COUNTY OF ) On , , before me personally came known to me to be the individual described in and who executed the foregoing instrument, and to me such person duly acknowledged that executed the same. Notary Public Commission Expires: American LegalNet, Inc.