Fill and Sign the Jurisdiction in Child Custody and Abduction Cases Ncjrs Form

NHJB-2162-P (01/02/2014) Page 1 of 4 THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) Guardianship of PETITION FOR GUARDIANSHIP OF MINOR The petitioner states the following: 1. Petition is made for guardianship over the minor's: Person and Estate Person Only Estate Only 2. Petitioner name Relationship to minor Mailing address Telephone Petitioner name Relationship to minor Mailing address Telephone 3. Attorney name Telephone Mailing address Bar ID# 4. The minor is: under OR over the age of fourteen. (Attach certified copy of birth certificate.) Minor's legal name Date of birth Mailing address Telephone Alternate names Alternate addresses 5. Name of minor's birth or adoptive parents. If both parents are deceased, attach a list of the names and addresses of the minor's grandparents, adult si blings, aunts and uncles. (Attach copy of death certificate of deceased parent(s), if applicable.) Father name Date of birth Mailing address Telephone Residence address (if different from above) Mother name Date of birth Mailing address Telephone Residence address (if different from above) 6. List the names and addresses of any persons having the principal care and custody of the minor during the 60 days preceding the filing of this petition. Name Relationship to minor Address Telephone Case Name: Guardianship of Case Number: PETITION FOR GUARDIANSHIP OF MINOR NHJB-2162-P (01/02/2014) Page 2 of 4 7. Proposed guardian name Date of birth Relationship to minor Occupation Mailing address Telephone Proposed guardian name Date of birth Relationship to minor Occupation Mailing address Telephone 8. List names and addresses of any person(s) nominated as guardian(s) of the person and/or the estate of the minor in the will of a deceased parent. Name Relationship to minor Address Telephone 9. List names and addresses of any adults, other than the proposed guardian, who will be living in the same home as the minor. Those persons must provide the court with a completed Criminal Record Release Authorizatio n form and a DHHS Record Re lease Authorization form. 10. Are there any pending adoption , juvenile, domestic violence, marriage dissolution, domestic relations, paternity, legitimation , custody or other proceedings affe cting minor or parents of this minor? Yes No If yes, attach a s eparate sheet identifying and explaining each. 11. Is an adoption of the minor by the proposed guardian(s) contemplated? Yes No 12. Is the minor entitled to receive lo cal, state or federal benefits and/or entitlements? Yes No 13. Is there an existing child support order for this child? Yes No If yes, is support collec ted by the Division of Child Support Services? Yes No If no, are you seeking a child suppor t order as part of this guardianship? Yes No 14. Is there an existing court visitation order for this child? Yes No If yes, attach a copy of that order to this petition. 15. Is there any reason t hat this child should not visit with his/her parents? Yes No If yes, state clearly and specifically any reason(s). Attach pages if needed. 16. Is this guardianship being sought by the Department of Health and Human Services as part of a permanency plan pursuant to the Adopt ion and Safe Families Act of 1997? Yes No 17. Is the child an American Indian child as defined by the Indian Child Welfare Act? Yes No If yes, the nam e and address of the tribe are: Is the tribe recognized by the federal government as eligible for federal services or certain Alaskan native corporations as defined in 43 U.S.C. §1602(c)? Yes No Case Name: Guardianship of Case Number: PETITION FOR GUARDIANSHIP OF MINOR NHJB-2162-P (01/02/2014) Page 3 of 4 18. Is this petition filed in c onjunction with a settlement of minor's action, per RSA 464-A:42? Yes No If yes, attach a copy of the petition or proposed petition seeking approval and all supplemental documentatio n to be filed with the Superior or District Division. 19. If applying for guardianshi p over the minor's estate, provide the prob able value and general character of the estate below: DESCRIPTION Real Estate $ Personal Property $ Income (include local, state and federal benefits) $ Debts $ 20. State specific facts which ar e claimed to demonstrate that the appointment of a guardian is in the best interests of the minor. (Attach additional pages as needed. Make each allegation a separate paragraph and num ber each paragraph.) REQUEST FOR TEMPORARY ORDERS and/or PERMANENT ORDERS The petitioner(s) request(s) that the following relief be granted in the best inte rests of the minor, after a hearing on the merits. (State clearly, and number separately, your requests to the court.) 21. FOR EX PARTE RELIEF ONLY. State additional facts or attach an affidavit (statement under oath) alleging facts involving th e circumstances of the minor wh ich establish that unless the ex parte relief is granted, the mi nor will, or is likely to, suffer imm ediate or irreparable harm or injury. Case Name: Guardianship of Case Number: PETITION FOR GUARDIANSHIP OF MINOR NHJB-2162-P (01/02/2014) Page 4 of 4 REQUEST FOR EX PARTE ORDERS The petitioner(s) request(s) that the following ex parte (emergency) relief be granted. (State clearly, and number separately, your requests to the court.) Date Petitioner Signature Date Petitioner Signature State of , County of This instrument was acknowledged bef ore me on by My Commission Expires Affix Seal, if any Signature of Notarial Officer / Title FOR COURT USE ONLY. The following consents, if required, will be obtained by the judge at the time of the hearing. We hereby voluntarily and knowingly gi ve consent to the appointment of as g uard ia n(s ). Date Parent Signature Date Parent Signature Date Minor Signature Date Guardian Signature Date Guardian Signature ORDER Upon consideration of this petition, it is decreed that the petition be granted an d letters of guardianship be issued. Prior to the issuance of said letters, the guardian is ordered to file with the court, within days of this order, a fiduciar y bond in the amount of $ , without sureties with corporate sureties. Date Signature of Judge Printed Name of Judge