[It is important to read the following instructions:

A standby guardian is someone who has been appointed by the court as the person who will act as guardian of the child when the child's parents die or are no longer willing or able to make and carry out day-to-day child care decisions concerning the child.

By properly completing this form, a parent is naming the person that the parent wants to be appointed as the standby guardian of the child or children of the parent.

Both parents of a child may join together and co-sign this form.

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Signing the form does not appoint the standby guardian; to be appointed, a petition must be filed and approved by the court.]

1. Parent and Child.

I, ___________________ currently residing at _____________________________________,
am a parent of the following child:

Name:

_________________________

Birthdate:

_________________________

2. Standby Guardian.

I hereby designate the following person to be appointed as standby guardian for my child or children listed above:

Name:

_________________________

Address:

______________________________________

______________________________________

______________________________________

3. Successor Standby Guardian.

If the person named in item 2 above cannot or will not act as standby guardian, I designate the following person to be appointed as successor standby guardian for my child or children:

Name:

_________________________

Address:

______________________________________

______________________________________

______________________________________

4. Date and Signature.

This designation is made this _____ day of ________, ____.

Signed:
______________________________________________
(appointing parent)

5. Witness.

I saw the parent sign this designation or the parent told me that the parent signed the designation. Then I signed the designation as a witness in the presence of the parent. I am not designated in this instrument to act as a standby guardian for the parent's child or children.

Witness:
________________________________________________
(name)

________________________________________________

________________________________________________

________________________________________________
(address)

Witness:

________________________________________________
(name)

________________________________________________

________________________________________________

________________________________________________
(address)