WILLIAM DONALD SCHAEFER, Governor                            Ch. 574

(3) A DESIGNATION MAY, BUT NEED NOT, BE IN THE FOLLOWING FORM:

DESIGNATION OF STANDBY GUARDIAN

I (NAME OF PARENT) HEREBY DESIGNATE (NAME, HOME ADDRESS, AND
TELEPHONE NUMBER OF STANDBY GUARDIAN) AS STANDBY GUARDIAN OF THE
PERSON AND PROPERTY OF MY CHILD(REN) (NAME OF CHILD(REN)).

(YOU MAY, IF YOU WISH, PROVIDE THAT THE STANDBY GUARDIAN'S
AUTHORITY SHALL EXTEND ONLY TO THE PERSON, OR ONLY TO THE PROPERTY, OF
YOUR CHILD, BY CROSSING OUT "PERSON" OR "PROPERTY", WHICHEVER IS
INAPPLICABLE, ABOVE.)

THE STANDBY GUARDIAN'S AUTHORITY SHALL TAKE EFFECT IF AND WHEN
EITHER:

(1)      MY DOCTOR CONCLUDES I AM MENTALLY INCAPACITATED, AND
THUS UNABLE TO CARE FOR MY CHILD(REN); OR

(2)      MY DOCTOR 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 STANDBY GUARDIAN'S AUTHORITY TAKING
EFFECT.

IF THE PERSON I DESIGNATE ABOVE IS UNABLE OR UNWILLING TO ACT AS
GUARDIAN FOR MY CHILD(REN), I HEREBY DESIGNATE (NAME, HOME ADDRESS,
AND TELEPHONE NUMBER OF ALTERNATE STANDBY GUARDIAN), AS STANDBY
GUARDIAN OF MY CHILD(REN).

I ALSO UNDERSTAND THAT MY STANDBY GUARDIAN'S AUTHORITY WILL
CEASE 60 180 DAYS AFTER BEGINNING UNLESS BY THAT DATE MY STANDBY
GUARDIAN PETITIONS THE COURT FOR APPOINTMENT AS GUARDIAN.

I UNDERSTAND THAT I RETAIN FULL PARENTAL RIGHTS EVEN AFTER THE
BEGINNING OF THE STANDBY GUARDIAN'S AUTHORITY, AND MAY REVOKE THE
STANDBY GUARDIANSHIP AT ANY TIME.

PARENT'S SIGNATURE:_______________________________________________________

ADDRESS:____________________________________________

DATE:________________________________________________________________________

I DECLARE THAT THE PERSON WHOSE NAME APPEARS ABOVE SIGNED THIS
DOCUMENT IN MY PRESENCE, OR WAS PHYSICALLY UNABLE TO SIGN AND ASKED
ANOTHER TO SIGN THIS DOCUMENT, WHO DID SO IN MY PRESENCE. I FURTHER
DECLARE THAT I AM AT LEAST 18 YEARS OLD AND AM NOT THE PERSON
DESIGNATED AS STANDBY GUARDIAN.

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