IN THE CIRCUI T COURT OF ____________________ COUNTY, WEST VIRGINIA IN THE MATTER OF : ________________________________________ Civil Action No. ________________________________________ ______-______-______ ________________________________________ Minor(s) Under the Age of 18 Years AFFIDAVI T IN SUPPORT OF MOTION FOR EX PARTE ORDER LIMITING ACCE SS TO COURT FILE STATE OF WEST VIRGINIA COUNTY OF _____________________________, to wit: 1. I, ____________________________________________________, am the Petitioner in the Petition for Appointment of Guardian instituting this proceeding. This affidavit and accompanying Motion to Limit Access to Court File are filed with the foregoing Petition, pursuant to Trial Court Rule 10.03. 2. My familiarity with the minor(s) who are the subject of the Petition, and the facts set forth therein, is based upon: _____________________________________ ______________ [State family relationship or other ties with the minor(s) named in petition, and ________________________________________________________________________ ______ any other facts showing knowledge of relevant circumstances.] ________________________________________________________________________ ______ ________________________________________________________________________ ______ ________________________________________________________________________ _____. 3. Upon my knowledge of the matters set forth in the Petition, and any other facts set forth below, I am of the good faith belief that without limitation of access to the court file in this proceeding, as requested in the accompanying motion, there is significant potential for adverse harm or consequences to the best interests of the minor(s) or others _______________________ name(s) if applicable ___________________________________, in this proceeding. Infant Guardianship Form 12 / 6-04 Page 1 of 2 >>>> 2 4. The circumstances giving rise to the above-stated potential for such adverse harm or consequences are as follows: _______________________________________ ____________ ________________________________________________________________________ ______ ________________________________________________________________________ ______ ________________________________________________________________________ _____. 5. Based upon information and belief, other facts supporting the limitation of access to the court file in this proceeding are: ______________________________________________ ________________________________________________________________________ ______ ________________________________________________________________________ ______ ________________________________________________________________________ ______ ________________________________________________________________________ ______ ____________________________________________________[Attach additional pages as needed.] Further the affiant saith not. Dated this ________ day of _______________________, 20_______. ______________________________ A ffiant Taken, subscribed, and sworn or affirmed before me this ________ day of _______________________, 20_______. My commission expires: . ______________________________ Notary Public Infant Guardianship Form 12 / 6-04 Page 2 of 2