Fill and Sign the Nureg 0750 Vol 16 Book Ii of Ii Nuclear Regulatory Nrc Form

IN THE CI RCUI T COURT OF __ __________________ COUNTY, W EST VI RGINIA IN THE MATTER OF : ________________________________________ Civil Action No. ________________________________________ ______-______-______ ________________________________________ Minor(s) Under the Age of 18 Years AFFIDAVI T IN SUP PORT OF MOTION FOR EX PARTE ORDER LIMITING ACCE SS TO COURT FI LE STATE OF WEST VIR GINIA COUNTY OF _____________________________, to wit: 1. I, ____________________________________________________, am the Petitioner in the Petition for Appointment of Guardian institu ting th is pro ceeding. Th is affidavit and accom panying Mo tion to Limit Access to C ourt File are filed with the foregoing Petition, pursuant to Trial Court Rule 10.03. 2. My fa miliarity with th e m inor(s) who ar e th e sub ject of the P etition, and the facts set forth therein, is based upon: _____________________________________\ ______________ [State fa mily rela tionship or other ties with the minor(s) na med in petition, and ________________________________________________________________________\ ______any other facts showing knowledge of relevant cir cumstances. ] ________________________________________________________________________\ ______ ________________________________________________________________________\ ______ ________________________________________________________________________\ _____. 3. Upon m y knowledge of the m atters set fo rth in the Petition, and any other facts set forth below, I am of the good faith belief that wit hout lim itation of access to the court file in this proceed ing, as requested in the acco mpanying moti on, th ere is significant potential for adverse harm or consequences to the best in terests of the m inor(s) or others _______________________ ___________________________________, in this proceed ing . name(s) if applicable Infant Guardianship – F orm 12 / 6-04 \ Page 1 of 2 4. The circum stances giving rise to the a bove-stated potential for such adverse harm or consequences are as follows: _______________________________________\ ____________ ________________________________________________________________________\ ______ ________________________________________________________________________\ ______ ________________________________________________________________________\ _____. 5. Based upon inform ation and belief, ot her facts su pporting the lim itation of access to the cou rt file in th is p roceed ing are: _______ _______________________________________ ________________________________________________________________________\ ______ ________________________________________________________________________\ ______ ________________________________________________________________________\ ______ ________________________________________________________________________\ ______ ____________________________________________________ [A ttach ad dition al pages as neede d.] Further the affiant saith not. Dated this ________ day of _______________________, 20_______. ______________________________ A ffiant Taken, subscribed, and sworn or affi rm ed before me this ________ day of _______________________, 20_______. My comm ission expires: \ . ______________________________ Notary Public Infant Guardianship – F orm 12 / 6-04 \ Page 2 of 2