IN THE CIRCUIT COURT OF THE NINETEENTH JUDICIAL CIRCUIT
LAKE COUNTY, ILLINOIS
ESTATE OF ___________________________________ )
Return Date: ____________________
)
)
)
Case No. ________________________
_____________________________________________ )
a minor
)
AFFIDAVIT OF PETITIONING GUARDIAN OF THE PERSON FOR A MINOR CHILD
I, __________________________________________________, petitioner for guardianship of the person for
(Name of Petitioner)
_________________________________________________, a minor child, do hereby state under oath and subject to
(Name of Minor)
penalties of perjury, as follows:
1. That I have:
Never been known by any other name OR
Used the following name(s): _________________________________________________________________
2. That I am ____________ years old; I am male female;
3. My date of birth is ___________________;
(MM/DD/YYYY)
4. That I currently reside at ______________________________________________________________________
5. In addition to my current residences, I have also lived at the following addresses in the last five years: _________
__________________________________________________________________________________________
6. That I am of sound mind and have not been adjudicated as disabled by any court of law;
a. That I have not been convicted of a felony OR
b. That I have been convicted of a felony, the specific circumstances of which are as follows:
1.
____________________________________________________________________________________
____________________________________________________________________________________
2.
____________________________________________________________________________________
____________________________________________________________________________________
7. That I do hereby consent and submit to a criminal background check and review of the Department of Children
and Family Services Register.
CERTIFICATION
Under penalties of perjury as provided by law pursuant to Section 1-109 of the Code of Civil Procedure, the
undersigned certifies that the statements set forth in this instrument are true and correct.
Date: __________________________, 20_____.
_____________________________________
Signature of Petitioner
Prepared by:
Name: ____________________________________________
DCFS Check:
Attorney’s Name: ____________________________________
Negative
Address: __________________________________________
Results attached
City: ______________________________ State: __________
Signature:
Phone: ______________________Zip Code: _____________
Date:
Fax: ______________________________________________
ARDC #: __________________________________________
171P-385 (12/11)
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