Affidavit Of Person To Be Appointed Guardian Or Conservator {PBGC13f}

Person Filing: Address (if not protected): City, State, Zip Code: Telephone: Email Address: Lawyer's Bar Number: Licensed Fiduciary Number: ____________________________________ Representing Self, without a Lawyer or Attorney for Petitioner OR FOR CLERK'S USE ONLY Respondent SUPERIOR COURT OF ARIZONA IN MARICOPA COUNTY In the Matter of the Guardianship and/or Conservatorship of: Case Number: PB AFFIDAVIT OF PERSON TO BE APPOINTED GUARDIAN OR CONSERVATOR A.R.S. § 14-5106 an Adult or a Minor INSTRUCTIONS: As required by Arizona law A.R.S. § 14-5106, indicate whether statements 1-11 below are true or false, and provide the information requested to complete "12" and "13". Explain any "false" statements on separate page(s) and attach to this document before filing. Sign the document in the presence of a Clerk of the Court or a Notary Public, and file along with the Petition for Appointment of Guardian and/or Conservator. UNDER PENALTY OF PERJURY, I SWEAR OR AFFIRM: 1. 2. True or True or False. False. I have not been convicted of a felony in any jurisdiction. I have not acted as a guardian or conservator for another person for at least three years before I filed this Petition. I know and understand the powers and duties I would have as a guardian and/or conservator. I have not had a power of attorney for anyone for at least three years before I filed this Petition. To the best of my knowledge, neither I nor any business in which I have an interest is listed in the Elder Abuse Registry at the Office of the Arizona Attorney General. If I have been a guardian/conservator before, I either filed the required documents on time, or within 3 months of receiving a notice from the court that the report/accounting was due. I have never been removed by the court as a guardian or conservator. PBGC13f - 050115 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com 3. 4. True or True or False. False. 5. True or False. 6. True or False. 7. True or False. ©Superior Court of Arizona in Maricopa County ALL RIGHTS RESERVED AFF Case No.: ____________________ 8. True or False. Neither I nor any business in which I have an interest has ever received anything of value greater than a total of one hundred dollars in any one year by gift, or will, or inheritance from an individual or the estate of an individual to whom I was not related by blood or marriage and for whom I served at any time as guardian, conservator, trustee, or attorney-in-fact. To the best of my knowledge, neither I nor any business in which I have an interest is named as a personal representative, trustee, devisee (beneficiary of a will), or other type of beneficiary for any individual to whom I am not related by blood or marriage and for whom I have ever served as guardian, conservator, trustee, or attorney-in-fact. I have no interest in any business that provides housing, health care, nursing care, residential care, assisted living, home health services, or comfort care services to any individual. 9. True or False. 10. True or False. (Explain every "false" above on separate page(s) and attach to this document before filing.) 11. My relationship to the proposed person in need of protection is: (Examples: parent/grandparent/sister/caregiver/friend) 12. I met the proposed ward under the following circumstances: OATH OR AFFIRMATION OF THE PERSON TO BE APPOINTED GUARDIAN AND/OR CONSERVATOR I swear or affirm that I have read and understand the contents of this document, and that the information I have provided is true and correct to the best of my knowledge and belief. Date Signature Printed Name STATE OF COUNTY OF Subscribed and sworn to or affirmed before me this: (date) . by (notary seal) Deputy Clerk or Notary Public NOTE: IF YOU ANSWERED "FALSE" TO ANY QUESTION ABOVE, YOU MUST ATTACH AN EXPLANATION AS INSTRUCTED ON THE NEXT PAGE. The page following is an instruction page only. Do NOT file it with the Court. ©Superior Court of Arizona in Maricopa County ALL RIGHTS RESERVED AFF PBGC13f - 050115 American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2 Case No.: ____________________ EXPLANATIONS THAT MUST BE ADDED TO THE AFFIDAVIT OF A PERSON WHO WANTS TO BE APPOINTED GUARDIAN OR CONSERVATOR (Required by Arizona Law: A.R.S. § 14-5106) For any corresponding numbered statement on the Affidavit which you marked "False", explain the following on a separate page or pages and attach to your Affidavit. The information provided in the attachment is covered by the same oath or affirmation and penalty of perjury as the Affidavit. FILE THE EXPLANATIONS WITH THE AFFIDAVIT, BUT DO NOT FILE THIS PAGE. 1. As to each felony for which you have been convicted, list: a. The nature of the offense. DO NOT FILE THIS SHEET b. The name and address of the sentencing court. WITH THE CLERK'S OFFICE c. The case number. d. The date of conviction. INSTRUCTION SHEET ONLY e. The terms of the sentence. f. The name and telephone number of any current probation or parole officer. g. The reasons why the conviction should not disqualify you from appointment. If you have acted as guardian or conservator within three years before filing this petition, list: a. The names of individuals for whom you are currently serving, and court case numbers. b. The names of individuals for whom your appointment has been terminated within the three-year period, and the court case number. State the total number of persons for whom you have served as a guardian or conservator. If you have acted under a power of attorney for the proposed ward/protected person, explain: a. The date the power of attorney was signed. b. The place where it was signed. c. The actions you have taken pursuant to the power of attorney. d. Whether the power of attorney is currently in effect. If you do not have the required information, please explain how you intend to obtain this information. State the reason for such listing on Elder Abuse Registry and the name of any business in which you have an interest that is listed on the Registry. List the name and location of the court and the name and case number of the files in which you were delinquent in filing the required report. List the name and location of the court, the name and case number of each file, and the circumstances of your removal. State the number of occasions on which you and/or any business in which you have an interest received such gifts, list and describe the gifts, the dates received, and list the value of each. State the number of occasions on which