700-00070C 226 Petition to Appoint Custodial Guardian for a Minor (03/2019)Page 1 of 5 STATE OF VERMONT SUPERIOR COURT PROBATE DIVISION Unit Docket No .: In re Guardianship of : PETITION TO APPOINT CUSTODIAL GUARDIAN FOR A MINOR I ask the court to appoint a guardian for the minor child, In support of this request, I state under oath: 1.Reason for GuardianshipThe minor is a child in need of guardianship for the following reasons: (check all that apply)No parent objects and the transfer of custody is in the best interest of the minor and is not solelyfor the purpose of establishing a residence for school purposes.One or both parents are under guardianship.One or both parents are incompetent or unsuitable to have custody of the minor.The minor has no living parent authorized to act as guardian.The parent of the minor resides outside the state and has so resided for three years and has notcontributed to the minor222s support during that time, and the minor has resided in the state threeyears prior to the date of appointment.Describe the specific reasons why a guardianship is necessary: 2.Information about the Minor: (You must provide the Court with a copy of the child222s birth certificatewhen you file the petition.) Name of Minor DOB Age Grade Current Address where Minor resides Town State Zip Current Mailing Address if different Phone Number 3.During the last five (5) years the minor has resided at the following addresses: (Begin with theaddress listed above. List all household members .) Address Include Street, City/Town and State Dates From W hen to W hen Names of all persons residing in the household with the child American LegalNet, Inc. www.FormsWorkFlow.com 700-00070C 226 Petition to Appoint Custodial Guardian for a Minor (03/2019)Page 2 of 5 4.Is the child:A member of a federally recognized Indian tribe? Yes NoEligible for membership in a federally recognized Indian tribe and the biological child of a member ofan Indian tribe? Yes No 5.Is the child in school?Yes No If yes, indicate the name and location of the school:The child222s current grade level is: 6.Information about the parents of the minor (If either parent is deceased, you must provide a copy ofthe death certificate.) a. Name of Parent #1 DOB Deceased YesNo Age Mailing Address for Parent #1 Town State Zip Residential Address if different Town Phone Number b. Name of Parent #2 DOB Deceased YesNo Age Mailing Address for Parent #2 Town State Zip Residential Address if different Town Phone Number c.If you cannot provide a valid name and/or address for one or both parents, please describe in detailthe efforts that have been made to locate the parent or parents. If the identity of the father isunknown, provide all of the information you can about potential fathers and any prior paternityproceedings. d.Parents222 Position Regarding GuardianshipParent #1 is in agreement with guardianship for minor:Yes No Don222t KnowParent #2 is in agreement with guardianship for minor: Yes No Don222t Know 7.Status of Legal Custody of Minora.The following person or person(s) currently has/have parental rights and responsibilities (legalcustody) for the minor: Name(s) Relationship to Minor Mailing Address Legal custody was granted by a court? Y es N o Name and address of court b.There is a pending proceeding involving custody, parental rights and responsibilities or parent childcontact (visitation): Yes NoIf yes, provide the name and address of the court and the docket number of the case: American LegalNet, Inc. www.FormsWorkFlow.com 700-00070C 226 Petition to Appoint Custodial Guardian for a Minor (03/2019)Page 3 of 5 PLEASE PROVIDE COPIES OF ANY COURT ORDERS WITH YOUR FILING 8.Other legal proceedings involving the minor child, parent or proposed guardian (check all that apply.For each proceeding, check the person or persons involved in the proceeding)Juvenile delinquencyminorparentguardianCHINS (Child in Need of Care or Supervision)Abuse/Neglect or UnmanageableminorparentguardianDomestic Violence(relief from abuse or restraining order)minorparentguardianDivorceminorparentguardianPaternityminorparentguardianAdoptionminorparentguardianConviction for a crimeminorparentguardianOther Court proceedingminorparentguardianSpecify type of proceeding:9.Is DCF (Department for Children and Families) involved with this child?Yes NoIf yes, provide the name of the DCF social worker, if known: 10.Is there an existing child support order for this child? Yes NoIf the guardianship is approved, does the proposed guardian expect to receive child support or financialbenefits for the child? Yes No 11.Is the child a recipient of social security benefits?Yes NoIf yes, provide the name of the representative payee, if known: 12.Is there an existing parent child contact (visitation) order that affects the child? Yes NoIf yes, either attach a copy of the most recent court order or provide information about the orderincluding the schedule of contact, the name of the person entitled to contact and whether the contactcurrently takes place: 13.Is there any reason why the child should not have contact with the parents?Yes NoIf yes, describe the reasons in detail: American LegalNet, Inc. www.FormsWorkFlow.com 700-00070C 226 Petition to Appoint Custodial Guardian for a Minor (03/2019) Page 4 of 5 14. Information about Proposed Guardian and Co-Guardian, if any: Guardian Name of proposed guardian DOB Mailing Address Town Zip Phone Number Relationship between proposed guardian and minor child : Relative Friend/Neighbor Other If there is a proposed co - guardian, provide information below about that person Co-Guardian Name of proposed co - guardian DOB Mailing Address Town Zip Phone Number Relationship between proposed co - guardian and minor child Relative Friend/Neighbor Other 15. List all persons residing in the proposed guardian222s home and the relationship of those persons to the minor child: Name of Household Member Relationship to Child Add an additional page if necessary 16. Change of School Does the proposed guardian intend to change the child222s school? Yes No Don222t Know If yes, provide the name and address of the school the child will attend 17. Answer the following questions by checking the box if the statement is true. If your answer to any of the questions is yes, please explain your answer on an additional page. a. I have participated as a party, witness, or in some other way in a court case about the custody of this child either in Vermont or another state. Yes No b. I have information about a custody case concerning this child that is now pending in a Vermont court or a court in another state. Yes No c. I have knowledge about a person who is not a party to this case who has physical custody of this child or who claims to have custody or visitation rights to this child Yes No d. If you answered yes to any of the questions above, please explain: American LegalNet, Inc. www.FormsWorkFlow.com 700-00070C 226 Petition to Appoint Custodial Guardian for a Minor (03/2019) Page 5 of 5 THEREFORE, I/we request that the court appoint a guardian for the minor child. By signing this petition, I/we certify that I/we have read the petition and that to the best of my/our knowledge, information and belief, the facts set forth in the petition are true and that the petition is not filed for any improper purpose such as to harass or cause unnecessary delay or needless litigation. Date Signature of Petitioner Petitioner222s Mailing Address Petitioner222s Phone Number Subscribed and sworn before me on: D ate My commission expires on: Date of Expiration Signature of Notary Attachments Filing fee payable to the Vermont Superior Court, Probate Division List of Interested Persons (Form PG73) A copy of the birth certificate of the minor child* A consent to the guardianship signed by Parent #1 (Form PMG70p) A consent to the guardianship signed by Parent #2 (Form PMG70p) A consent to the guardianship signed by the proposed guardian (Form PMG70g) Copies of any court orders that currently affect the child If either parent is deceased, a copy of the death certificate* Guardian222s Consent to Background Check by DCF *Check with the probate court whe