Fill and Sign the Petition is Made for Guardianship over the Minors Person Form

NHJB-2024-F (12/01/2010) Page 1 of 5 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 (PERSON ONLY) RSA 463 The petitioner states the following: 1. Petition is made for guardianship over the minor's person: 2. Petitioner Name Relationship to Minor Mailing Address Telephone Petitioner Name Relationship to Minor Mailing Address Telephone 3. Attorney for Petitioner Telephone Mailing Address 4. The minor is: under OR over the age of fourteen. (Attach copy of birth certificate.) Minor's Legal Name Date of Birth Mailing Address Telephone Alternate Names Alternate Addresses 5. Name of minor's natural parents. If both parents are deceased, attach a list of the names and addresses of the minor's grandparents, adult siblings , aunts and uncles. (Attach copy of death certificate of deceased par ent(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. 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 Case Name: Case Number: PETITION FOR GUARDIANSHIP OF MINOR (PERSON ONLY) NHJB-2024-F (12/01/2010) Page 2 of 5 Questions 7 – 11 are required under RSA 458-A, the Uniform Child Custody Jurisdiction and Enforcement Act (UCCJEA). It is important that you answer these questions with as much detail and accuracy as possible. Lack of adequate information could significantly delay orders being issued in your case. There are several situations that might result in New Hampshire exercising jurisdiction over a child. The continuous presence of the child in New Hampshire for six (6) months is not the only basis for jurisdiction. In some emergency situations, the court may be able to exercise jurisdiction on a temporary basis. 7. List the places where the minor child has lived in the last five (5) years and the names of the people s/he lived with at that time, if you know. Start with where the child lives now and work backward in time. Dates From/To Town/City, State Parent(s)/Care taker Current Address/Contact Address of Parent/Caretaker Which Child If more space is needed, attach Extra Page (NHJB-2656-FPS) . I have attached Form NHJB-2656-FPS because additional space was needed. 8. Are there any person(s), not a party to this proceeding, who have physical custody of the child or who claim to have custody, physical custody or parenting time rights? Yes No If yes, list name(s) and address(es) of person(s): 9. Check one of the following: I have not participated in any court case(s) concerning the custody, visitation, parenting time or placement of the child in this or any other state. OR I have participated in court case(s) concerning the custody, visitation, parenting time or placement of the child in this or any other state. I have participated in the following: Name of Court State Case No. Date of Court Order 10. Are there any actions for enforcement, or proceedings relating to domestic violence, domestic relations, protective orders, marriage dissolution, paternity, legitimation, custody, parental rights and responsibilities, termination of parent al rights, adoption, juvenile, or other proceedings in any court in any state affecting the child named in this petition or parents of that child? Yes No If yes, complete the following: Name of Court State Case No. Type of Court Case Case Name: Case Number: PETITION FOR GUARDIANSHIP OF MINOR (PERSON ONLY) NHJB-2024-F (12/01/2010) Page 3 of 5 11. Optional: I am alleging, under oath, that my or my child/ren’s health, safety, or liberty would be jeopardized by the disclosure of i dentifying information set forth in this Petition. To support my allegation, I state as follows: 12. 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 13. List names and addresses of any person(s) nominated as guardian(s) of the person in the will of a deceased parent. Name Relation ship to minor Address Telephone 14. 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 cour t with a completed Criminal Record Release Authorizat ion form and a DHHS Record Re lease Authorization form. 15. Is an adoption of the minor by the proposed guardian(s) contemplated? Yes No 16. Is the minor entitled to receive local, state or federal benefits and/or entitlements? Yes No 17. 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 18. Is there an existing court visitation order for this child? Yes No If yes, attach a copy of that order to this petition. 19. Is there any reason t hat this child should not vi sit with his/her parents? Yes No If yes, state clearly and s pecifically any reason(s). 20. Is this guardianship being sought by the Department of Health and Human Serv ices as part of a permanency plan pursuant to the Adopt ion and Safe Families Act of 1997? Yes No 21. Is the child an American Indian child as de fined by the Indian Child Welfare Act? Yes No If yes, the name 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 22. 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. Case Name: Case Number: PETITION FOR GUARDIANSHIP OF MINOR (PERSON ONLY) NHJB-2024-F (12/01/2010) Page 4 of 5 23. State specific facts which are claimed to demonstrate that the appointment of a guardian is in the best interests of the minor. (A ttach additional pages as needed. Make each allegation a separate paragraph and number each paragraph.) REQUEST FOR TEMPORARY ORDERS and/or PERMANENT ORDERS The petitioner(s) request(s) that the fo llowing relief be granted in the best interests of the minor, after a hearing on the merits. (State clearly, and number separately, your requests to the court.) 24. FOR EX PARTE RELIEF ONLY. State additional facts or attach an affidavit (statement under oath) alleging facts involving the circumst ances of the minor which establish that unless the ex parte relief is granted, the minor will, or is likely to, suffer immedi ate or irreparable harm or injury. 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.) I acknowledge that I have a continuing duty to inform the court of any court action in this or any other state that could affect the child in this case. I swear or affirm that the foregoing information is true and correct to the best of my knowledge. Date Signature of Petitioner Date Signature of Petitioner 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 Case Name: Case Number: PETITION FOR GUARDIANSHIP OF MINOR (PERSON ONLY) NHJB-2024-F (12/01/2010) Page 5 of 5 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 guardian(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 on a TEMPORARY or PERMANENT basis, and letters of guar dianship be issued. Recommended: Date Signature of Marital Master Printed Name of Marital Master So Ordered: I hereby certify that I have r ead the recommendation(s) and agree tha t, to the extent the marital master/judicial referee/hearing officer has made factual findings, she/he has applied the correct legal standard to the facts determined by the marital master/judicial referee/hearing officer. Date Signature of Judge Printed Name of Judge