STATE OF VERMONT SUPERIOR COURT Unit In re Guardianship of : PROBATE DIVISION Docket No.: 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 Guardianship The 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 solely for 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 not contributed to the minor's support during that time, and the minor has resided in the state three years 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 child's birth certificate when 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 the address listed above. List all household members .) Address Include Street, City/Town and State Dates From When to When Names of all persons residing in the household with the child 4. Is the child: A member of a federally recognized Indian tribe? Yes No Eligible for membership in a federally recognized Indian tribe and the biological child of a member of an Indian tribe? Yes No PMG70C ­ Petition to Appoint Custodial Guardian for a Minor (08/2014) American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 5 5. Is the child in school? If yes, indicate the name and location of the school: The child's current grade level is: Yes No 6. Information about the parents of the minor (If either parent is deceased, you must provide a copy of the death certificate.) DOB Deceased Age a. Name of Parent #1 Yes No Mailing Address for Parent #1 Town State Zip Residential Address if different Town Phone Number b. Name of Parent #2 DOB Deceased Age Yes No 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 detail the efforts that have been made to locate the parent or parents. If the identity of the father is unknown, provide all of the information you can about potential fathers and any prior paternity proceedings. d. Parents' Position Regarding Guardianship Parent #1 is in agreement with guardianship for minor: Parent #2 is in agreement with guardianship for minor: Yes Yes No Don't Know No Don't Know 7. Status of Legal Custody of Minor a. The following person or person(s) currently has/have parental rights and responsibilities (legal custody) for the minor: Name(s) Mailing Address Relationship to Minor Legal custody was granted by a court? Name and address of court Yes No b. There is a pending proceeding involving custody, parental rights and responsibilities or parent child contact (visitation): Yes No If yes, provide the name and address of the court and the docket number of the case: PMG70C ­ Petition to Appoint Custodial Guardian for a Minor (08/2014) American LegalNet, Inc. www.FormsWorkFlow.com Page 2 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 delinquency minor parent guardian CHINS (Child in Need of Care or Supervision) guardian Abuse/Neglect or Unmanageable minor parent Domestic Violence (relief from abuse or restraining order) minor parent guardian Divorce minor parent guardian Paternity minor parent guardian Adoption minor parent guardian Conviction for a crime minor parent guardian minor parent guardian Other Court proceeding Specify type of proceeding: 9. Is DCF (Department for Children and Families) involved with this child? Yes No If yes, provide the name of the DCF social worker, if known: 10. Is there an existing child support order for this child? Yes No If the guardianship is approved, does the proposed guardian expect to receive child support or financial benefits for the child? Yes No 11. Is the child a recipient of social security benefits? If yes, provide the name of the representative payee, if known: Yes No 12. Is there an existing parent child contact (visitation) order that affects the child? Yes No If yes, either attach a copy of the most recent court order or provide information about the order including the schedule of contact, the name of the person entitled to contact and whether the contact currently takes place: 13. Is there any reason why the child should not have contact with the parents? Yes No If yes, describe the reasons in detail: PMG70C ­ Petition to Appoint Custodial Guardian for a Minor (08/2014) American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 5 14. Information about Proposed Guardian and Co-Guardian, if any: Name of proposed guardian DOB Mailing Address Town Zip Guardian 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 Name of proposed co-guardian DOB Mailing Address Town Zip Co-Guardian Phone Number Relationship between proposed co-guardian and minor child Relative Friend/Neighbor Other 15. List all persons residing in the proposed guardian's 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 child's school? If yes, provide the name and address of the school the child will attend Yes No Don't Know 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