Form A IN THE CIRCUIT COURT OF THE STATE OFOREGON FOR THE COUNTY OF In the Matter of the Guardianship of: ) Case Number: ) ) PETITION FOR APPOINTMENT Minor Child(ren) ) OF GUARDIAN ) ) petitions for the appointment of guardian of the minor, , and respectfully represents to the Court as follows: 1. THAT the name, age/date of birth, residence address and current location of the minor is: Name: Age: Birthdate: Residence Address: Current Location: 2. THAT the minor is a resident of County, Oregon, and is also physically present in the State of Oregon. THAT no other court in the State of Oregon has acquired jurisdiction of this matter, no protective proceeding has been established in another state, and no guardian has been heretofore appointed for the minor. 3. THAT the name, age, address and interest of the Petitioner to the minor is: Name: Age: Residence Address: Interest: Page 1 of 5 - Petition to Appoint Guardian of a Minor - County ( 201) American LegalNet, Inc. www.FormsWorkFlow.com 4. THAT the name, age, address, and relationship of the proposed guardian to the minor are: Name: Age: Residence Address: Relationship to Minor: 5. THAT the proposed guardian is competent, willing, and able to serve as guardian. 6. Is the proposed guardian a public or private agency (or an employee of that agency) that provides services to the minor? yes no 7. THAT the proposed guardian has has not been convicted of a crime. THAT the proposed guardian has has not filed for or received protection under the bankruptcy laws. THAT the proposed guardian has has not had a professional or occupational license revoked or cancelled. If the proposed guardian has been convicted or a crime, filed for or received protection under the bankruptcy laws, or has had a professional or occupational license revoked or cancelled, please explain: 8. Does the proposed guardian intend on placing the child in a mental health treatment facility, nursing home, or other residential facility? yes no 9. Is the proposed guardian a professional that acts as a fiduciary for three or more persons unrelated to the fiduciary? yes no 10. The name and address of any other person providing care to the minor is: Page 2 of 5 - Petition to Appoint Guardian of a Minor - County ( 201) American LegalNet, Inc. www.FormsWorkFlow.com The name and address of any fiduciary appointed by the court for the minor is: The name and address of any trustee for a trust established for or by the minor is: The name and address of any appointed health care representative for the minor is: The name and address of any attorney-in-fact for the minor is: The minor has been living with the petitioner since and before that he/she was living with: 11. THAT it is necessary to establish a guardianship for the following reasons: 12. THAT the name and address of the natural parent(s) of the minor are: Date of Birth: Date of Birth: Address: Address: 13. consent (if the minor is over 14 years of age) is attached hereto marked is incorporated herein. 14. I understand that I must inform the court if I find out about another custody proceeding concerning this minor filed in this, or another state. Page 3 of 5 - Petition to Appoint Guardian of a Minor - County ( 201) American LegalNet, Inc. www.FormsWorkFlow.com I have have not been involved in any other court proceeding concerning custody of the minor (if so, list County, State, and case number). County: State: Case Number: DHS has has not given Petitioner a deadline to file for guardianship of Respondent in lieu of 15. I know do not know, of any person other than who has physical custody of the minor or claims to have custody or visitation rights with minor. (If so, list that person): THAT the minor has lived with the following person(s) for the past five years: NAME OF PERSON ADDRESS AT THAT TIME CURRENT ADDRESS (if different) 16. Does the minor have any Native American or Alaskan Native Ancestry, wherein the Indian Child Welfare Act (ICWA) may apply? yes no 17. THAT the amounts of the min: Savings Account: $Trust Fund: $ Real Property: $ Other: $ Is the minor receiving any AFS benefits through the Department of Human Services? yes no Is the minor receiving any Veterans benefits? yes no Will the proposed guardian exercise any control over the estate of the minor? yes no The monthly income of the minor is . The amount of moneys that the proposed guardian will be holding for the minor at the time of appointment is . Page 4 of 5 - Petition to Appoint Guardian of a Minor - County ( 201) American LegalNet, Inc. www.FormsWorkFlow.com Page 5 of 5 - Petition to Appoint Guardian of a Minor - County ( 201) 18. WHEREFORE, Petitioner prays for appointment of as guardian of the minor, . I hereby declare that the above statement is true to the best of my knowledge and belief, and that I understand it is made for use as evidence in court and is subject to penalty for perjury. DATED this day of , 20 . Signature of Petit ioner Print Name and Date of Birth Contact Address City/State/Zip Code Contact Telephone E - mail Signature of Co - Petitioner ( If applicable ) Print Name and Date of Birth Contact Address City/State/Zip Code Contact Telephone E - mail American LegalNet, Inc. www.FormsWorkFlow.com