JV-075 (Rev. 03/18/2013)

PETITION FOR APPOINTMENT OF GUARDIAN OF A MINOR(SEPARATE PETITION FOR EACH CHILD)

DOCKET NUMBER Trial Court of MassachusettsJuvenile Court Department

NAME OF MINOR ADDRESS D.O.B.

14 years or older

GENDERMale Female

PETITIONER AND PROPOSED GUARDIAN(S)

NAME OF PETITIONER ADDRESS RELATIONSHIP TO MINOR

_____________________________

_____________________________

_____________________________

NAME OF PROPOSED CO-GUARDIAN ADDRESS RELATIONSHIP TO MINOR

_____________________________

_____________________________

_____________________________

NAME OF PROPOSED CO-GUARDIAN ADDRESS RELATIONSHIP TO MINOR

_____________________________

_____________________________

_____________________________

NAME OF PARENT ADDRESS TELEPHONE NO(S).

NAME OF PARENT ADDRESS TELEPHONE NO(S).

1. The petitioner(s) respectfully request that the above named proposed guardian(s) be appointed guardian(s) ofthe minor and alleges to this Court that appointment of a guardian(s) of the minor is necessary because:___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

ADDRESS RELATIONSHIP TO MINOR

RELATIONSHIP TO MINOR

_____________________________

_____________________________

_____________________________

ADDRESSNAME OF PETITIONER

PARENT(S)

If minor's parents are deceased, list siblings or adult relatives.NAME

Telephone Number

Telephone Number

Telephone Number

Telephone Number

Home:

Work:Cell:

Home:

Work:Cell:

JV-075 (Rev. 03/18/2013)

Page 2 Guardianship of , MinorDOCKET NUMBER

2. The petitioner alleges that the best interests of the child will be served by appointment of a guardian(s)pursuant to G.L. c. 190B, Article V.

3. The minor's parent(s) consent(s) does not consent to the appointment of the proposed guardian(s).(Attach the parent(s)' notorized consent if either one or both parents consent to the appointment.)

4. The minor's estate does does not exceed $100.00.

5. The minor does does not have any assets, e.g. bank accounts, property, any anticipated income,e.g. Social Security, interest. (If the minor has assets, identify below.)

6. The minor is is not entitled to benefits, estate, or income paid or payable by or through the U.S.Veterans Administration.

7. Is the minor eligible for membership in an American Indian tribe/band? Yes No If yes, whichtribe/band?

I declare under the penalties of perjury that the statements set forth in this petition are true and correct to thebest of my knowledge.

Description of Bank Accounts, Property, Social Security Estimate Value orAmount of Income

$

$

Total

DATE SIGNATURE OF PETITIONER

DATE SIGNATURE OF PETITIONER

PROPOSED GUARDIAN(S) CONSENT TO APPOINTMENT

I/we agree to serve as guardian/co-guardians of the minor if appointed by the Court and agree to serve by theterms of the appointment.

NOTARIZATION

DATE SIGNATURE OF PROPOSED CO-GUARDIAN

DATE SIGNATURE OF PROPOSED CO-GUARDIAN

Signed and made oath before me onthat this affidavit is his/her free act and deed.

Signed and made oath before me onthat this affidavit is his/her free act and deed.

Print Name

My Commission Expires

Notary Public

Print Name

My Commission Expires

Notary Public