Fillable COURT CODE: PAG Self-Represented DISTRICT COURT CLARK COUNTY, (Family Law Self Help Center)

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COURT CODE: PAG Self-Represented DISTRICT COURT CLARK COUNTY, (Family Law Self Help Center)

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© 2018 Family Court Self-Help Center
Page 1 of 21 – Petition for Appointment of Guardian (4-6 Children)
COURT CODE: PAG
Your Name:
Address:
City, State, Zip:
Telephone:
Email Address:
Self-Represented
DISTRICT COURT
CLARK COUNTY, NEVADA
In the Matter of the Guardianship of the:
Person
Estate
Person and Estate
of:
___________
_________________________,
___________
_________________________,
___________
_________________________,
___________
_________________________,
___________
_________________________,
___________
_________________________
(
name of children who need a guardian)
Proposed Protected Minors.
CASE NO.: ____________________
DEPT: ____________________
PETITION FOR APPOINTMENT OF GUARDIAN(S) OVER A CHILD
Petitioner(s) (proposed guardian’s name) _____________________________________
and (proposed second guardian’s name; if only one guardian, write “N/A”)
____________________________________ would like to be appointed the Guardian(s) over
the above-named children. In accordance with 2017 Nevada Laws Ch. 172 (A.B. 319),
Petitioner(s) respectfully represents the following to this Honorable Court:
Petitioner’s Information (the first proposed guardian)
1. Full legal name: ______________________________________________________.
2. Date of birth: ___________________________.
Page 2 of 21 – Petition for Appointment of Guardian (4-6 Children)
3. Relationship to children in need of a guardian: __________________________________.
4. Residence address:
_________________________________________
Address
_________________________________________
City, State, Zip Code
Mailing address (if different than residence address):
_________________________________________
Address
_________________________________________
City, State, Zip Code
5. Qualifications. (Answer each item listed; “Has” answers must be explained)
The Petitioner: (☒ check one for each)
has has not been convicted of a crime of moral turpitude, a crime involving
domestic violence or a crime involving the abuse, neglect,
exploitation, isolation or abandonment of a child, his or her spouse,
his or her parent or any other adult.
Explain if Yes: ___________________________________________
________________________________________________________
has has never been convicted of a felony.
Explain if Yes: Petitioner was convicted of (describe conviction)
________________________________________________________
Petitioner ( check one) □ was / □ was not placed on parole and (
check one) □ was / □ was not placed on probation for that felony.
has has not filed for bankruptcy within the past 7 years.
is is not a party to pending criminal or civil litigation.
Explain if Yes: ___________________________________________
________________________________________________________
Page 3 of 21 – Petition for Appointment of Guardian (4-6 Children)
Co-Petitioner’s Information (the second proposed guardian)
Not Applicable (check if there is only one proposed guardian, and go to page 4)
6. Full legal name: ______________________________________________________.
7. Date of birth: ___________________________.
8. Relationship to children in need of a guardian: ___________________________________.
9. Residence address:
_________________________________________
Address
_________________________________________
City, State, Zip Code
Mailing address (if different than residence address):
_________________________________________
Address
_________________________________________
City, State, Zip Code
10. Qualifications. (Answer each item listed; “Has” answers must be explained)
The Co-petitioner: (☒ check one for each)
has has not been convicted of a crime of moral turpitude, a crime involving
domestic violence or a crime involving the abuse, neglect,
exploitation, isolation or abandonment of a child, his or her spouse,
his or her parent or any other adult.
Explain if Yes: ___________________________________________
________________________________________________________
has has never been convicted of a felony.
Explain if Yes: The Petitioner was convicted of (describe conviction)
________________________________________________________
The Petitioner ( check one) □ was / □ was not placed on parole and
( check one) □ was / □ was not placed on probation for that felony.
has has not filed for bankruptcy within the past 7 years.
is is not a party to pending criminal or civil litigation.
Explain if Yes: ___________________________________________
________________________________________________________
Page 4 of 21 – Petition for Appointment of Guardian (4-6 Children)
First Child’s Information
11. Child’s full legal name: _____________________________________________________.
12. Child’s date of birth: ___________________________; current age: _______. The child
will become 18 years old on (date) ____________________.
13. Petitioner(s) believe the child ( check one) will / will not need a guardian when
the child turns 18 years old. If yes, explain why a guardian will still be needed:
________________________________________________________________________.
14. The child has been a resident of the State of (state) __________________________ since
(date) ________________________.
15. The child currently lives at the following address:
_________________________________________
Address
_________________________________________
City, State, Zip Code
The child has lived at the above address since (date) ________________________.
16. Does the child receive Medicaid, or has this child ever received Medicaid? (☒ check one)
No
Yes
17. Is the child a member of a federally recognized tribe? (☒ check one)
No
Yes, the tribe is (write tribe’s name) __________________________________
18. Is the child a citizen of another country? (☒ check one)
No
Yes, the child is a citizen of (write country name) __________________________
Page 5 of 21 – Petition for Appointment of Guardian (4-6 Children)
Second Child’s Information
19. Child’s full legal name: _____________________________________________________.
20. Child’s date of birth: ___________________________; current age: _______. The child
will become 18 years old on (date) ____________________.
21. Petitioner(s) believe the child ( check one) will / will not need a guardian when
the child turns 18 years old. If yes, explain why a guardian will still be needed:
________________________________________________________________________.
22. The child has been a resident of the State of (state) __________________________ since
(date) ________________________.
23. The child currently lives at the following address:
_________________________________________
Address
_________________________________________
City, State, Zip Code
The child has lived at the above address since (date) ________________________.
24. Does the child receive Medicaid, or has this child ever received Medicaid? (☒ check one)
No
Yes
25. Is the child a member of a federally recognized tribe? (☒ check one)
No
Yes, the tribe is (write tribe’s name) __________________________________
26. Is the child a citizen of another country? (☒ check one)
No
Yes, the child is a citizen of (write country name) __________________________
Page 6 of 21 – Petition for Appointment of Guardian (4-6 Children)
Third Child’s Information
27. Child’s full legal name: _____________________________________________________.
28. Child’s date of birth: ___________________________; current age: _______. The child
will become 18 years old on (date) ____________________.
29. Petitioner(s) believe the child ( check one) will / will not need a guardian when
the child turns 18 years old. If yes, explain why a guardian will still be needed:
________________________________________________________________________.
30. The child has been a resident of the State of (state) __________________________ since
(date) ________________________.
31. The child currently lives at the following address:
_________________________________________
Address
_________________________________________
City, State, Zip Code
The child has lived at the above address since (date) ________________________.
32. Does the child receive Medicaid, or has this child ever received Medicaid? (☒ check one)
No
Yes
33. Is the child a member of a federally recognized tribe? (☒ check one)
No
Yes, the tribe is (write tribe’s name) __________________________________
34. Is the child a citizen of another country? (☒ check one)
No
Yes, the child is a citizen of (write country name) __________________________
Page 7 of 21 – Petition for Appointment of Guardian (4-6 Children)
Fourth Child’s Information
35. Child’s full legal name: _____________________________________________________.
36. Child’s date of birth: ___________________________; current age: _______. The child
will become 18 years old on (date) ____________________.
37. Petitioner(s) believe the child ( check one) will / will not need a guardian when
the child turns 18 years old. If yes, explain why a guardian will still be needed:
________________________________________________________________________.
38. The child has been a resident of the State of (state) __________________________ since
(date) ________________________.
39. The child currently lives at the following address:
_________________________________________
Address
_________________________________________
City, State, Zip Code
The child has lived at the above address since (date) ________________________.
40. Does the child receive Medicaid, or has this child ever received Medicaid? (☒ check one)
No
Yes
41. Is the child a member of a federally recognized tribe? (☒ check one)
No
Yes, the tribe is (write tribe’s name) __________________________________
42. Is the child a citizen of another country? (☒ check one)
No
Yes, the child is a citizen of (write country name) __________________________
Page 8 of 21 – Petition for Appointment of Guardian (4-6 Children)
Fifth Child’s Information
Not Applicable (check if there are only 4 children, and go to next page)
43. Child’s full legal name: _____________________________________________________.
44. Child’s date of birth: ___________________________; current age: _______. The child
will become 18 years old on (date) ____________________.
45. Petitioner(s) believe the child ( check one) will / will not need a guardian when
the child turns 18 years old. If yes, explain why a guardian will still be needed:
________________________________________________________________________.
46. The child has been a resident of the State of (state) __________________________ since
(date) ________________________.
47. The child currently lives at the following address:
_________________________________________
Address
_________________________________________
City, State, Zip Code
The child has lived at the above address since (date) ________________________.
48. Does the child receive Medicaid, or has this child ever received Medicaid? (☒ check one)
No
Yes
49. Is the child a member of a federally recognized tribe? (☒ check one)
No
Yes, the tribe is (write tribe’s name) __________________________________
50. Is the child a citizen of another country? (☒ check one)
No
Yes, the child is a citizen of (write country name) __________________________
Page 9 of 21 – Petition for Appointment of Guardian (4-6 Children)
Sixth Child’s Information
Not Applicable (check if there are only 4-5 children, and go to next page)
51. Child’s full legal name: _____________________________________________________.
52. Child’s date of birth: ___________________________; current age: _______. The child
will become 18 years old on (date) ____________________.
53. Petitioner(s) believe the child ( check one) will / will not need a guardian when
the child turns 18 years old. If yes, explain why a guardian will still be needed:
________________________________________________________________________.
54. The child has been a resident of the State of (state) __________________________ since
(date) ________________________.
55. The child currently lives at the following address:
_________________________________________
Address
_________________________________________
City, State, Zip Code
The child has lived at the above address since (date) ________________________.
56. Does the child receive Medicaid, or has this child ever received Medicaid? (☒ check one)
No
Yes
57. Is the child a member of a federally recognized tribe? (☒ check one)
No
Yes, the tribe is (write tribe’s name) __________________________________
58. Is the child a citizen of another country? (☒ check one)
No
Yes, the child is a citizen of (write country name) __________________________
Page 10 of 21 – Petition for Appointment of Guardian (4-6 Children)
Common Parent
(list the parent who is the same parent for all of the children)
59. The first parent is (name) __________________________________________________.
( check if applicable)
This parent is deceased. *File a copy of the death certificate with this Petition.*
This parent’s parental rights over the child were terminated by a court order.
*File a copy of the termination order with this Petition.*
60. This parent is the ( check one): mother / father of all the children in this petition.
61. This parent currently lives at the following address:
_________________________________________
Address
_________________________________________
City, State, Zip Code
Mailing address (if different than residence address):
_________________________________________
Address
_________________________________________
City, State, Zip Code
62. Consent ( check one):
This parent agrees to this proposed guardianship and will file a proper notarized
consent.
This parent does not consent to the proposed guardianship, or cannot be located to
consent.
63. This parent is unable to care for the children because (explain):
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Page 11 of 21 – Petition for Appointment of Guardian (4-6 Children)
Second Parent
64. The second parent is (name) _________________________________________________.
( check if applicable):
This parent is deceased. *File a copy of the death certificate with this Petition.*
This parent’s parental rights over the child were terminated by a court order.
*File a copy of the termination order with this Petition.*
This parent is an unknown father. There is no father listed on the child’s birth
certificate. There has never been a court order regarding child support, custody, or a
finding of paternity.
65. This parent is the ( check one): mother / father of ( check one):
All of the children
Only some of the children: (children’s names) __________________________
66. This parent currently lives at the following address:
_________________________________________
Address
_________________________________________
City, State, Zip Code
Mailing address (if different than residence address):
_________________________________________
Address
_________________________________________
City, State, Zip Code
67. Consent ( check one):
This parent agrees to this proposed guardianship and will file a proper notarized
consent.
This parent does not consent to the proposed guardianship, or cannot be located to
consent.
68. This parent is unable to care for the children because (explain):
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Page 12 of 21 – Petition for Appointment of Guardian (4-6 Children)
Third Parent
Not Applicable (check if there are only 2 parents, and go to next page)
69. The third parent is (name) _________________________________________________.
( check if applicable):
This parent is deceased. *File a copy of the death certificate with this Petition.*
This parent’s parental rights over the child were terminated by a court order.
*File a copy of the termination order with this Petition.*
This parent is an unknown father. There is no father listed on the child’s birth
certificate. There has never been a court order regarding child support, custody, or a
finding of paternity.
70. This parent is the ( check one): mother / father of ( check one):
All of the children
Only some of the children: (children’s names) __________________________
71. This parent currently lives at the following address:
_________________________________________
Address
_________________________________________
City, State, Zip Code
Mailing address (if different than residence address):
_________________________________________
Address
_________________________________________
City, State, Zip Code
72. Consent ( check one):
This parent agrees to this proposed guardianship and will file a proper notarized
consent.
This parent does not consent to the proposed guardianship, or cannot be located to
consent.
73. This parent is unable to care for the children because (explain):
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Page 13 of 21 – Petition for Appointment of Guardian (4-6 Children)
Fourth Parent
Not Applicable (check if there are only 2-3 parents, and go to next page)
74. The fourth parent is (name) _________________________________________________.
(S check if applicable):
¨ This parent is deceased. *File a copy of the death certificate with this Petition.*
¨ This parent’s parental rights over the child were terminated by a court order.
*File a copy of the termination order with this Petition.*
¨ This parent is an unknown father. There is no father listed on the child’s birth
certificate. There has never been a court order regarding child support, custody, or a
finding of paternity.
75. This parent is the (S check one): o mother / o father of (S check one):
o All of the children
o Only some of the children: (children’s names) __________________________
76. This parent currently lives at the following address:
_________________________________________
Address
_________________________________________
City, State, Zip Code
Mailing address (if different than residence address):
_________________________________________
Address
_________________________________________
City, State, Zip Code
77. Consent ( check one):
This parent agrees to this proposed guardianship and will file a proper notarized
consent.
This parent does not consent to the proposed guardianship, or cannot be located to
consent.
78. This parent is unable to care for the children because (explain):
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Page 14 of 21 – Petition for Appointment of Guardian (4-6 Children)
Fifth Parent
Not Applicable (check if there are only 2-4 parents, and go to next page)
79. The fifth parent is (name) _________________________________________________.
(S check if applicable):
¨ This parent is deceased. *File a copy of the death certificate with this Petition.*
¨ This parent’s parental rights over the child were terminated by a court order.
*File a copy of the termination order with this Petition.*
¨ This parent is an unknown father. There is no father listed on the child’s birth
certificate. There has never been a court order regarding child support, custody, or a
finding of paternity.
80. This parent is the (S check one): o mother / o father of (S check one):
o All of the children
o Only some of the children: (children’s names) __________________________
81. This parent currently lives at the following address:
_________________________________________
Address
_________________________________________
City, State, Zip Code
Mailing address (if different than residence address):
_________________________________________
Address
_________________________________________
City, State, Zip Code
82. Consent ( check one):
This parent agrees to this proposed guardianship and will file a proper notarized
consent.
This parent does not consent to the proposed guardianship, or cannot be located to
consent.
83. This parent is unable to care for the children because (explain):
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Page 15 of 21 – Petition for Appointment of Guardian (4-6 Children)
Sixth Parent
Not Applicable (check if there are only 2-5 parents, and go to next page)
84. The sixth parent is (name) _________________________________________________.
(S check if applicable):
¨ This parent is deceased. *File a copy of the death certificate with this Petition.*
¨ This parent’s parental rights over the child were terminated by a court order.
*File a copy of the termination order with this Petition.*
¨ This parent is an unknown father. There is no father listed on the child’s birth
certificate. There has never been a court order regarding child support, custody, or a
finding of paternity.
85. This parent is the (S check one): o mother / o father of (S check one):
o All of the children
o Only some of the children: (children’s names) __________________________
86. This parent currently lives at the following address:
_________________________________________
Address
_________________________________________
City, State, Zip Code
Mailing address (if different than residence address):
_________________________________________
Address
_________________________________________
City, State, Zip Code
87. Consent ( check one):
This parent agrees to this proposed guardianship and will file a proper notarized
consent.
This parent does not consent to the proposed guardianship, or cannot be located to
consent.
88. This parent is unable to care for the children because (explain):
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Page 16 of 21 – Petition for Appointment of Guardian (4-6 Children)
Seventh Parent
Not Applicable (check if there are only 2-6 parents, and go to next page)
89. The seventh parent is (name) _________________________________________________.
(S check if applicable):
¨ This parent is deceased. *File a copy of the death certificate with this Petition.*
¨ This parent’s parental rights over the child were terminated by a court order.
*File a copy of the termination order with this Petition.*
¨ This parent is an unknown father. There is no father listed on the child’s birth
certificate. There has never been a court order regarding child support, custody, or a
finding of paternity.
90. This parent is the (S check one): o mother / o father of (S check one):
o All of the children
o Only some of the children: (children’s names) __________________________
91. This parent currently lives at the following address:
_________________________________________
Address
_________________________________________
City, State, Zip Code
Mailing address (if different than residence address):
_________________________________________
Address
_________________________________________
City, State, Zip Code
92. Consent ( check one):
This parent agrees to this proposed guardianship and will file a proper notarized
consent.
This parent does not consent to the proposed guardianship, or cannot be located to
consent.
93. This parent is unable to care for the children because (explain):
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Page 17 of 21 – Petition for Appointment of Guardian (4-6 Children)
General Information
94. The children are currently under the care of (name and address of person caring for the
children):
_________________________________________
Name
_________________________________________
Address
_________________________________________
City, State, Zip Code
The person above is caring for the children because (explain why the children are under
the care of the person above):
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
95. A guardianship is needed for the children because (explain in detail):
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________.
96. The children have lived at the following places with the following people within the last 5
years (list the places the child has lived in the last 5 years):
Time Period (mo/yr
– mo/yr)
Name of Person the Child
Lived With:
City and State
i.e., 5/17-9/17
Sue Jones (grandma)
Las Vegas, NV
________ - _______
________ - _______
________ - _______
________ - _______
________ - _______
Page 18 of 21 – Petition for Appointment of Guardian (4-6 Children)
The names and current addresses of each non-parent the child lived with during the last
five years are:
97. Participation in Other Cases. Have Petitioner(s) ever participated in any case
concerning the children as a party, witness, or in some other capacity? (☒ check one)
No.
Yes, I have participated in the following cases concerning the children (provide all
specifics including the state, the court name, the case number and the date of the child
custody order, if any):
98. Knowledge of Other Cases. Do Petitioner(s) know of any other case that could affect
this case, such as other custody cases, domestic violence cases, protection order cases, or
adoptions / terminations? (☒ check one)
No.
Yes, the following cases that could affect this case (provide all specifics including the
state, the court name, the parties involved, the case number and the type of case):
99. Current Custody Case: Is there a custody order concerning the children? (☒ check one)
No.
Yes, there is a current order concerning custody of the child. The order is from the
State of _________________ and was filed on (date) _______________. If the order
was not registered with this Court, a copy of the order will be filed with this Petition.
100. Persons Who Can Claim Custody / Visitation. Is there anyone other than Petitioner(s)
or other parties to this case who has custody of the child or who can claim a right to
custody or visitation with the child? (☒ check one)
No.
Page 19 of 21 – Petition for Appointment of Guardian (4-6 Children)
Yes, the following people have custody or can claim custody/visitation of the child:
(list names and addresses of anyone who claims custody/visitation rights):
101. Abuse/Neglect Report: (S check one)
o The guardianship IS NOT requested because of an investigation of abuse or neglect
conducted by Child Protective Services (CPS) or law enforcement.
o The guardianship IS requested because of an investigation by Child Protective
Services (CPS) or other similar agency. The investigating agency is (name of
agency) ________________________________________. The caseworker’s name
is (caseworker name) _____________________________________________. The
investigating agency (S check one) o does / o does not approve of this
guardianship and the placement of the child with the proposed Guardians.
102. The children’s parent or legal guardian (S check one) o has / o has not nominated a
guardian in writing. The nominated guardian is (name) ___________________________.
103. Are the children parties to any pending criminal or civil lawsuit? (☒ check one)
¨ No
¨ Yes (explain) _______________________________________________________
104. Are Petitioner(s) seeking guardianship in order to initiate litigation? (☒ check one)
¨ No
¨ Yes (explain) _______________________________________________________
105. Compensation. Are Petitioner(s) currently being paid for services as a guardian to more
than one protected person who is not related to you by blood or marriage? (S check one):
¨ No, Petitioner(s) is not/are not being paid for services as a guardian.
Page 20 of 21 – Petition for Appointment of Guardian (4-6 Children)
Yes, Petitioner(s) is/are being paid for services as a guardian for (number) ______
children.
106. Petitioner(s) is/are competent and capable of acting as guardian of the above proposed
protected minors and hereby consents to act in this capacity.
107. Confidential Information Sheet – Guardianship must be completed and filed. You must
provide at least one form of identification (listed on the sheet) for each person.
108. Exhibit A: List of All of the Children’s Relatives must be completed and attached to this
petition.
109. Exhibit B: Information Regarding the Children’s Estate must be completed and
attached to this petition if you are requesting guardianship over the child’s estate. If you
are appointed the Guardian, the Court will determine how to safeguard the child’s funds.
The Court will decide whether to:
• Require the funds to be placed into a blocked account.
• Require you to obtain a bond in an amount equal to the total amount of the child’s
liquid assets.
110. Other Exhibits: If you have a letter from a governmental agency in this state which
conducts investigations, or a certificate signed by any other person whom the court finds
qualified to execute a certificate, the letter/certificate must be attached to this petition.
Petitioner(s) request(s) that this guardianship be granted, that the relief requested be
granted as stated herein, and for such other and further relief as the Court may deem just and
proper.
DATED (month) ________________________ (day) _______, 20___.
(Second Petitioner’s Signature)
(Printed Name)
(First Petitioner’s Signature)
(Printed Name)
/s/
/s/
Page 21 of 21 – Petition for Appointment of Guardian (4-6 Children)
VERIFICATION
I, (name of first petitioner) ________________________________________, declare
that I am the Petitioner in the within action; that I have read the foregoing Petition For
Appointment of Guardians and know the contents thereof; that the same is true of my
knowledge except as to those matters therein stated upon information and belief and as to those
matters, I believe them to be true.
I declare under penalty of perjury under the law of the State of Nevada that the
foregoing is true and correct.
__________________________________________
FIRST PETITIONER’S SIGNATURE
VERIFICATION
I, (name of second petitioner) ________________________________________, declare
that I am the Co-Petitioner in the within action; that I have read the foregoing Petition For
Appointment of Guardians and know the contents thereof; that the same is true of my
knowledge except as to those matters therein stated upon information and belief and as to those
matters, I believe them to be true.
I declare under penalty of perjury under the law of the State of Nevada that the
foregoing is true and correct.
__________________________________________
SECOND PETITIONER’S SIGNATURE
/s/
/s/
EXHIBIT A: List All of the Children’s Relatives
Parents:
Name: ____________________________
Address: __________________________
____________________________
□ Address Unknown □ Deceased
Name: ____________________________
Address: __________________________
____________________________
□ Address Unknown □ Deceased
Name: ____________________________
Address: __________________________
____________________________
□ Address Unknown □ Deceased
Name: ____________________________
Address: __________________________
____________________________
□ Address Unknown □ Deceased
Brothers and Sisters (age 14 and older):
Name: ____________________________
Address: __________________________
____________________________
□ Address Unknown
Name: ____________________________
Address: __________________________
____________________________
□ Address Unknown
Name: ____________________________
Address: __________________________
____________________________
□ Address Unknown
Name: ____________________________
Address: __________________________
____________________________
□ Address Unknown
Grandparents:
Name: ____________________________
Address: __________________________
____________________________
□ Address Unknown □ Deceased
Name: ____________________________
Address: __________________________
____________________________
□ Address Unknown □ Deceased
Name: ____________________________
Address: __________________________
____________________________
□ Address Unknown □ Deceased
Name: ____________________________
Address: __________________________
____________________________
□ Address Unknown □ Deceased
Name: ____________________________
Address: __________________________
____________________________
□ Address Unknown □ Deceased
Name: ____________________________
Address: __________________________
____________________________
□ Address Unknown □ Deceased
Name: ____________________________
Address: __________________________
____________________________
□ Address Unknown □ Deceased
Name: ____________________________
Address: __________________________
____________________________
□ Address Unknown □ Deceased
EXHIBIT B: Information Regarding the Proposed Protected Minor’s Estate
Complete this page only if you are requesting guardianship over the estate.
1. The proposed protected minor ( check all that apply)
Has no assets or income
Has assets and income (list below)
Is entitled or will be entitled to assets or income (list below)
2. The proposed protected minor receives income from the following: (include all income,
including Social Security, Department of Veteran’s Affairs, pensions, etc. If none, write
“N/A”. If there are not enough lines below, write “SEE ATTACHED” and attach a page
with the additional income sources.) (check and answer all that apply)
Child Support Yes No monthly: $_______________________
Social Security Yes No monthly: $_______________________
Veterans Affairs Yes No monthly: $_______________________
a. __________________________________ monthly: $_______________________
b. __________________________________ monthly: $_______________________
3. Is there a Representative Payee receiving benefits on behalf of the proposed protected
minor? No Yes, the person is (name) ____________________________________.
4. The proposed protected minor assets are: (include all assets including checking / savings /
investment accounts, real estate, vehicles, inheritances, including insurance policies, etc. If
none, write “N/A”. If there are not enough lines below, write “SEE ATTACHED” and
attach a page containing the additional assets.)
a. __________________________________ value: $_______________________
b. __________________________________ value: $_______________________
c. __________________________________ value: $_______________________
d. __________________________________ value: $_______________________
e. __________________________________ value: $_______________________
f. __________________________________ value: $_______________________
g. __________________________________ value: $_______________________
h. __________________________________ value: $_______________________
i. __________________________________ value: $_______________________
You will be required to file a detailed Inventory listing all of the protected person’s assets
within 60 days of your appointment.
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COURT CODE: PAG Self-Represented DISTRICT COURT CLARK COUNTY, (Family Law Self Help Center)

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Completed 15 January 2021

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