Form SG-1 - Petition for standby guardianship
For Office Use Only
(Filling Fee Paid $ ________)
(Receipt No: ________ No: ________)
SURROGATE'S COURT OF THE STATE OF NEW YORK
COUNTY OF
________x PETITION FOR
Proceeding for the Appointment STANDBY GUARDIANSHIP
of a Standby Guardian for (SCPA 1726(3))
File No. ________
An Infant.
________x
TO THE SURROGATE'S COURT, COUNTY OF ____________,
It is respectfully alleged:
1. The name, relationship, domicile, and telephone number of the petitioner are as follows:
[Petitioner must be a parent or legal guardian of the infant. If legal guardian submit a copy of the order of appointment.]
Name:____________ [ ] Mother [ ] Father
Domicile: ____________
(Street Address) (City/Town/Village)
____________
(County) (State) (Zip) (Telephone Number)
Mailing address: ____________
(if different from domicile)
2. The name, domicile, date of birth and marital status of the infant are as follows: [Birth Certificate must be filed with this petition]
Name: ____________
(Date of Birth)
Domicile: ____________
(Street Address) (City/Town/Village)
____________
(County) (State) (Zip)
Mailing address: ____________
(if different from domicile)
SG-1 (4/98)
3. The names and addresses of the adult persons with whom the infant resides are: [If same as above so state]
Name: ____________
Domicile: ____________
(Street Address) (City/Town/Village)
____________
(County) (State) (Zip)
Mailing address: ____________
(if different from domicile)
4. The name and domicile of the proposed standby guardian are as follows:
Name: ____________
(Relationship, if any, to infant)
Domicile: ____________
(Street Address) (City/Town/Village)
____________
(County) (State) (Zip)
Mailing address: ____________
(if different from domicile)
5. The name and domicile, of the other parent of the infant and, if the infant is married, the infant's spouse, or if the other parent is deceased and there is no spouse, the grandparents residing within the county, are as follows:
Father/Mother: ____________
Domicile: ____________
Spouse: ____________
(Date of Birth)
Domicile: ____________
Maternal Grandparents: ____________
Domicile: ____________
Paternal Grandparents: ____________
Domicile: ____________
The foregoing persons are adult and competent, except: [If any of the above is an infant attach a Schedule containing the name of the infant, with whom he or she resides, whether he or she has a court-appointed guardian, and if so, provide the name and address of the guardian. If disability is other than infancy, fill out and attach Schedule A.]
6. No other persons or agencies are interested in this proceeding other than those mentioned above, except:
____________
____________
____________
7a. No guardian or standby guardian ever has been appointed for the infant except as follows: [See SCPA Section 1704 (3)]
____________
____________
b. Custody of the infant never has been surrendered by a person lawfully charged therewith, nor has custody of the infant been the subject of any court order, except as hereinafter listed: [So specify and attach copies of all surrenders, court orders, or divorce decrees]
8. [If you seek the appointment of a Standby Guardian of the person only, DO NOT complete this paragraph]
The estimated value of all real and personal property owned by the infant and the infant's resources are as follows:
a. PERSONAL PROPERTY [State exact title of all bank accounts with account number and balance. List insurance policies by Company, policy number, amount insured, name of insured and relationship to infant. List the value of infant's interest.]
____________
____________
____________
The personal property of the infant is not subject to the control of the infant's spouse under the laws of a jurisdiction other than New York. [If property is so subject, so state]
b. REAL PROPERTY [State whether the real property is encumbered and the amount of the encumbrance. Indicate whether property is to be occupied as a residence by the infant. Indicate rental income in (c.)(3) below. If a sale of the property is contemplated so state.]
Location of Property ____________
Gross Value $ ____________
Infant's interest ____________
c. ANNUAL INCOME OF INFANT FROM ALL SOURCES:
(1) Compensation or pension to be received from: ____________ $ ________
(2) Income from Trusts ____________ $ ________
(3) Income from Real Property ____________ $ ________
(4) Other Income ____________ $ ________
9. The authority of the standby guardian is to become effective upon the petitioner's [Check appropriate box]
a. [ ] incapacity only b. [ ] death only c. [ ] incapacity or death.
10. Petitioner suffers from a:
[ ] progressively chronic illness
[ ] fatal illness
[State the basis for the above statement, such as the date and source of the medical diagnosis. You need not identify the illness.]
11. The infant (is) (is not) a Native American Child subject to the Indian Child Welfare Act of 1978 ( 25 USC Section 1901 - 1963 ).
12. Petitioner (has) (does not have) knowledge that the person nominated to be Standby Guardian has ever been named as a subject of an indicated report filed pursuant to Title 6 of Article 6 of the Social Services Law, or has been the subject of or the respondent in a child protective proceeding commenced under Article 10 of the Family Court Act, which proceeding resulted in an order finding that the child is an abused or neglected child. [If the petitioner has such knowledge, attach an affidavit explaining in detail].
13. Completed and annexed hereto is the Request for Information Guardianship Form required to be submitted to the New York Central Register of Child Abuse and Maltreatment.
14. [Check appropriate box]:
a. [ ] Petitioner is able to attend any hearing to be scheduled by the court.
b. [ ] The petitioner is medically unable to appear and asks that the court dispense with his/her appearance.
15. No prior application has been made to any Court for the relief requested herein.
WHEREFORE, your petitioner respectfully prays that: [Check and complete all relief requested]
(a) Letters of Standby Guardianship of the
[ ] Person and Property
[ ] Person only
[ ] Property only be granted to ____________
____________
or such other person or corporation as may be entitled thereto upon petitioner's (death) (incapacity) (death or incapacity) [Delete if inapplicable] and that process issue to all interested persons who have not waived the issuance of same requiring them to show cause why such relief should not be granted.
(b) The standby guardian of the property be prohibited from collecting or receiving any money or property of the infant until he or she qualifies and complies with the provisions of SCPA 1708.
Dated: ________
______________
(Signature of Petitioner)
______________
(Print Name)
STATE OF NEW YORK )
) ss.:
COUNTY OF )
________, being duly sworn deposes and says that I am the petitioner above named. I have read the foregoing petition and the same is true of my own knowledge except as to matters therein stated to be alleged upon information and belief and as to those matters I believe them to be true.
Swore to before me this
________ day of ________ 19________
______________
(Signature of Petitioner)
______________
Notary Public
______________
(Print Name)
Commission Expires:
(Affix Notary Stamp or Seal)
Signature of Attorney: ____________
Print Name: ____________
Firm Name:____________ Tel. No.:________
Address of Attorney:____________
File #________
SURROGATE'S COURT OF THE STATE OF NEW YORK
COUNTY OF
________X
Proceeding for the Appointment SCHEDULE A
of a Standby Guardian for PERSONS UNDER DISABILITY
OTHER THAN INFANTS
An Infant.
________X
[use additional sheets if more than one]
1. Name:____________ Relationship:____________
Residence: ____________
With whom does this person reside? ____________
If this person is in prison, name of prison: ____________
Does this person have a court-appointed fiduciary? Yes [ ] No [ ]
If yes, give name, title and address: ____________
____________
If no, describe nature of disability: ____________
____________
If no, give name and address of relative or friend interested in his or her welfare:
____________