Fill and Sign the Appointment of a Limited Guardian Form

Your Name: ______________________________ Your Address: ___________________________________ Your City, State, ZIP: _____________________________ Your Telephone No: _____________________________ Superior Court of New Jersey Chancery Division ______________ County Probate Part IN THE MATTER OF ___________________, A MINOR Docket No.: ____________________ CIVIL ACTION VERIFIED COMPLAINT FOR THE APPOINTMENT OF A LIMITED GUARDIAN FOR _________________, A MINOR, FOR THE SOLE PURPOSE OF THE SEPTEMBER 11TH VICTIM COMPENSATION FUND OF 2001 The plaintiff, ________________________, resi ding at ___________________, in the City/Borough/Township of _____________, County of ____________ and State of New Jersey, by way of verified complaint for entry of a judgment appointing a limited guardian for ____________________, a minor, says: 1. On September 11, 2001, ________________________ died testate/intestate domiciled at ______________________________, in the City/Borou gh/Township of ______________, County of _________________ and State of __________________. 2. The decedent left a minor chil d, ____________________, who is unmarried and was born on _____________________. The minor resides and is present in this county. 3. The decedent died without having dispos ed of the guardianship of the said minor and no guardian has been appointed by order of any court and no other proceeding for the appointment of a guardian is pending in any court. Revised 03/02/2004, CN 10509-English page 1 of 7 4. The minor is to receive a distribution approved by the September 11, 2001 Victims Compensation Fund =s Special Master. An election for the minor to receive all/part of said distribution in periodic payments requires the ex ecution of the periodic payment agreement by the minor =s guardian. The within application requests the appointment of a limited guardian to carry out September 11th Victim Compensation Fund of 2001 periodic payment planning. 5. The names and residences of his/her ne arest of kin, of the persons standing in loco parentis and of the persons with whom he resides, are as follows: Name Residence R ela tio nsh ip All of the above named are of full age except the following: ______________________ 6. All competent adult persons, whose right to letters of guardianship is prior or equal to that of the plaintiff, all persons standing in loco parentis and all competent adult persons with whom the minor resides, have renounced an y claim of guardianship and requested the appointment of the plaintiff [ or, proof is filed herewith that due no tice of this application has been given to all competent adult persons whose right to letters of guardianship is prior or equal to that of the plaintiff, all persons standing in loco parentis and all competent adult persons with whom the minor resides, whose renunciations are not produced herewith ]: Wherefore, the plaintiff demand s judgment granting to himself/herself letters of limited guardianship of the property of the sai d ____________________, a minor, for the purpose of September 11th Victim Compensation Fund of 2001 periodic payment planning on behalf of the said minor. _______________________________ [Signature] Dated: ___________________ Revised 03/02/2004, CN 10509-English page 2 of 7 VERIFICATION State of New Jersey, County of __________________} ss. _________________________ being duly sworn according to law deposes and says: 1. I am the plaintiff in the within complaint. 2. I have read the foregoing complaint and the allegations thereof are true to the best of my knowledge and belief. _______________________________ [Signature] Subscribed and sworn to before me this _______ day of _____________, 2004. Revised 03/02/2004, CN 10509-English page 3 of 7 Superior Court of New Jersey Chancery Division ______________ County Probate Part IN THE MATTER OF ___________________, A MINOR Docket No.: __________________ CIVIL ACTION JUDGMENT GRANTING LETTERS OF LIMITED GUARDIANSHIP FOR _____________________, A MINOR, FOR THE SOLE PURPOSE OF SEPTEMBER 11TH VICTIM COMPENSATION FUND OF 2001 This matter having been opened to the Court by ____________________ and it appearing that ________________________ died on Se ptember 11, 2001, leaving in this state his/her minor child, ______________________, and it further appearing that the said minor is to receive a distribution from the September 11 Victims Comp ensation Fund of 2001 and an election for the minor to receive all or part of said distribution in periodic payments requires the execution of the periodic payment agreement by the minor =s guardian, and it further appearing that all competent adult persons who constitute the next-of- kin of the minor and all persons standing in loco parentis and all competent adult persons with whom he resi des, have renounced any right or claim they may have to guardianship or received notice of the within application. It is on this __________ day of _____________, 2004, ORDERED and ADJUDGED that: 1. ____________________ be and hereby is appointed Limited Guardian of the Estate of _______ _____________, a minor, and that Letters of Limited Guardianship of the Estate be issued upon his/her qualify according to law. Revised 03/02/2004, CN 10509-English page 4 of 7 2 . N o s u r e t y b o n d o r o t h e r s e c u r i t y s h a l l b e r e q u i r e d , s i n c e th e w i t h i n j u d g m e n t i s l i m i t e d to executing a periodic payment planning as authorized by federal law and regulation. 3. Upon qualifying, the Surrogate of _________________ County shall issue Letters of Limited Guardianship of the Esta te and, thereupon, the limited guardian be and hereby is authorized to execute any and all documents and instruments necessary to enter into a periodic payment agreement for all or part of the September 11 Victims Compensation Fund of 2001 payable to the minor. Said limitation sha ll be stated in the Letters of Guardianship. ______________________________________ J.S.C. Revised 03/02/2004, CN 10509-English page 5 of 7 Superior Court of New Jersey Chancery Division ______________ County Probate Part IN THE MATTE R OF __________ __________, A MINOR Docket No.: ______________________ CIVIL ACTION ACCEPTANCE OF LIMITED GUARDIAN–SHIP FOR ____________________, A MINOR, FOR THE SOLE PURPOSE OF SEPTEMBER 11TH VICTIM COM–PENSATION FUND OF 2001 I, ___________________________, residing at __________________________________, County of ________________ and State of New Jersey, having been appointed by a judgment of the Superior Court of New Jersey, Chancery Division, Probate Part, entered on ___________, 2004, Limited Guardian of the Estate of ____________________, a minor, to perform those acts, including executing documents and instruments, necessary to enter into a periodic payment agreement for all or part of the September 11 Victims Compensation Fund of 2001 compensation payable to the minor, do hereby declare my acceptance of said limited guardianship. Dated: __________________, 2004 ___________________________________________ [signature] Signed in the Presence of _____________________________ Probate Clerk Revised 03/02/2004, CN 10509-English page 6 of 7 Letters of Limited Guardianship State of New Jersey S uperior Court of New Jersey, Chancery Division, Probate Part I, _______________________, Surrogate of _______________ County, do hereby certify that on _____________________, 2004, the Superior Cour t of New Jersey, Chancery Division, Probate Part, appointed ___________________________, Limi ted Guardian of the Estate of ____________________, a minor. ____________ ____________, having qualified as required by law, has the power conferred by law to do and perform those acts, and no other, necessary to enter into a periodic payment agreement for all or part of the September 11 Victims Compensation Fund of 2001 compensation payable to the minor. [Surrogate's Seal] ____________________________________ [Surrogate Signature] Revised 03/02/2004, CN 10509-English page 7 of 7