Fill and Sign the Nj Statutory Form

DESIGNATION OF STANDBY GUARDIAN (New Jersey Permanent Statutes 3B:12-74) I, ______________________________________________ (name of parent or legal custodian) hereby name ___________________________________________ (name, home address and telephone number of standby guardian) as designated standby guardian of __________________________________________________________________________ (name of child(ren)), my child(ren). By this consent and designation, I am providing that the designated standby guardian's authority shall take effect if and when the following event or events occur: (choose as follows): (1) _____ my attending physician concludes that I am mentally incapacitated, and thus unable to care for my child(ren); or (2) _____ my attending physician concludes that I am physically debilitated, and thus unable to care for my child(ren), and I consent in writing before two witnesses to the designated standby guardian's authority taking effect; or (3) upon my death. In the event that the person designated above is unable or unwilling to act as guardian to my child(ren), I hereby name ___________________________________________ (name, address and telephone number of alternate designated standby guardian), as alternate designated standby guardian of my child(ren). I understand that this designation will expire six months from the date of this designation, and that the authority of the designated standby guardian, if any, will cease, unless by that date either I or the designated standby guardian petitions the court for appointment as standby guardian pursuant to section 6 of P.L.1995, c.76 (C.3B:12-72). I hereby authorize that the person designated standby guardian as set forth above shall be provided with a copy of the attending physician's statement. In the event that I am incapacitated or debilitated and a designated standby guardianship is activated pursuant to this statement, I declare that it is my intention to retain full parental rights to the extent consistent with my condition and, further, that I retain the authority to revoke the designated standby guardianship consistent with my rights herein at any time. ________________________________________________ Designator's Signature ________________________________________________ Date ________________________________________________ Witness' Signature ________________________________________________ Address ________________________________________________ ________________________________________________ Witness' Signature ________________________________________________ Address ________________________________________________