New York Codes, Rules and Regulations
Title 22 - JUDICIARY
Subtitle D - Forms
Chapter VII - Surrogate's Court Forms
Subchapter A - Forms Authorized By Section 207.52
Surrogate's Forms
Form SG-5 - Affidavit and consent of proposed standby guardian pursuant to SCPA 1726(3)
SURROGATE'S COURT OF THE STATE OF NEW YORK
COUNTY OF ________
________x AFFIDAVIT AND CONSENT
Proceeding for the Appointment OF PROPOSED STANDBY
of a Standby Guardian for GUARDIAN PURSUANT TO
SCPA 1726 (3)
________
An Infant.
________x File No. ________
STATE OF NEW YORK)
) ss.:
COUNTY OF ________)
________, being duly sworn, deposes and says:
1. I am a competent person over the age of eighteen years, and I submit this affidavit in support of the petition to have me appointed standby guardian of the [ ] person only, [ ] property only, or [ ] person and property of the above named infant. [Check one]
2. I have known the subject infant since ________ by reason of the following [State relationship, if any]:
____________
____________
____________
____________
3. I reside at ____________
and the other resident members of my household are [Include all persons residing there and their respective ages]:
____________
____________
____________
____________
____________
____________
____________
____________
4. Except for minor treaffic offenses and adjudications as a youthful offender or juvenile delinquent:
(a) Have you ever been convicted of a crime [ ] yes [ ] no
(b) Have you ever forfeited bail or other collateral [ ] yes [ ] no
(c) Do you have criminal charges pending against you [ ] yes [ ] no
(d) Do you have a physician impairment or mental or medical condition that would interfere with your ability to perform the duties of guardian of the infant [ ] yes [ ] no
(e) Have you ever used controlled substances or narcotics or been addicted to alcohol [ ] yes [ ] no
[If you have answered "yes" to any of the questions set forth in (a) - (e), set forth details in space provided].
____________
____________
____________
5. I am willing and able to undertake the care, custody and control of the infant until the infant attains the age of eighteen or until the court determines otherwise.
6. Upon the petitioner's [ ] incapacity, [ ] death, [ ] or incapacity or death, or upon written consent, I agree to file all necessary documentation with the court within 90 days of the receipt of the determination of the incapacity, death certificate, or written consent.
________________
Signature of the Proposed Standby Guardian
Sworn to before me this
________ day of ________, 19________
______________
Notary Public
Commission Expires:
(Affix Notary Stamp or Seal)
