Illinois Statutory Short Form

Appointment of Short-Term Guardian

[It is important to read the following instructions:

By properly completing this form, a parent is appointing a guardian of a child of the parent for a period of up to 60 days.

A separate form should be completed for each child.

he person appointed as the guardian must sign the form, but need not do so at the same time as the parent or parents.

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This form may not be used to appoint a guardian if there is a guardian already appointed for the child.

Both living parents of a child may together appoint a guardian of the child for a period of up to 60 days through the use of this form. The parents need not sign the form at the same time.]

1. Parent and Child

I, ____________________________________________________________,

currently residing at ______________________________________________,
am a parent of the following child (or of a child to be born):

Name: __________________
(or "not yet born")

Birthdate : ______________
(or expected birthdate )

2. Guardian.

I hereby appoint the following person as the short-term guardian for my child:

Name:

_____________________________________

Address :

_____________________________________

_____________________________________

_____________________________________

3. Effective Date.

This appointment becomes effective: (check one if you wish it to be applicable)

____ On the date that I state in writing that I am no longer either willing or able to make and carry out day-to-day child care decisions concerning my child.

____ On the date that a physician familiar with my condition certifies in writing that I am no longer willing or able to make and carry out day-to-day child care decisions concerning my child.

____ On the date that I am admitted as an in-patient to a hospital or other health care institution.

____ On the following date: ____________________.

____ Other:

____________________________________________

____________________________________________

____________________________________________

____________________________________________

____________________________________________

[Note: If this section is not completed, the appointment is effective immediately upon the date the form is signed and dated below.]

4. Termination.

This appointment shall terminate 60 days after the effective date, unless it terminates sooner as determined by the event or date I have indicated below: (check one if you wish it to be applicable).

____ On the date that I state in writing that I am willing and able to make and carry out day-to-day child care decisions concerning my child.

____ On the date that a physician familiar with my condition certifies in writing that I am willing and able to make and carry out day-to-day child care decisions concerning my child.

____ On the date that I am discharged from the hospital or other health care institution where I was admitted as an in-patient, which established the effective date.
____ On the date which is _______ days (state a number of days, but no more than 60 days) after the effective date.

____ Other:

____________________________________________

____________________________________________

____________________________________________

____________________________________________

____________________________________________

[Note: If this section is not completed, the appointment will be effective for a period of 60 days, beginning on the effective date.]

5. Date and Signature of Appointing Parent.

Date:

________________________________________________
(month, day, year)

Signed:

________________________________________________
(appointing parent)

6. Witness.

I saw the parent sign this instrument or saw the parent direct someone to sign this instrument for the parent. Then I signed this instrument as a witness in the presence of the parent. I am not appointed in this instrument to act as the short-term guardian for the parent's child.

Witness:

________________________________________________
(name)

________________________________________________

________________________________________________

________________________________________________
(address)


Witness:

________________________________________________
(name)

________________________________________________

________________________________________________

________________________________________________
(address)

7. Acceptance of Short-Term Guardian.

I accept this appointment as short-term guardian.

Date:

________________________________________________
(month, day, year)

Signed:

________________________________________________
(short-term guardian)

8. Consent of Child's Other Parent.

I, _________________________________________________________________,

currently residing at ___________________________________________________,
hereby consent to this appointment.

Date:

________________________________________________
(month, day, year)

Signed:

________________________________________________
(consenting parent)

[Note: The signature of a consenting parent is not necessary if one of the following applies:

(i) the child's other parent has died; or

(ii) the whereabouts of the child's other parent are not known; or

(iii) the child's other parent is not willing or able to make and carry out day-to-day child care decisions concerning the child; or

(iv) the child's parents were never married and no court has issued an order establishing parentage.]