P.O. BOX 102
In The Matter Of The Guardianship Of: )
) Case No: _____________________
And concerning: )
Respondent/Natural Parent
COMES NOW, ________________________________, the natural ___________________ of
the above-named child(ren) and states to the Court the following:
1. That he/she is the natural ____________________ of the above-named child(ren). That the
child(ren) are enrolled as members of the Cheyenne and Arapaho Tribes or are eligible for
enrollment with the Cheyenne and Arapaho Tribes.
2. That the child(ren)’s true and correct name and date of birth are:
3. That he/she understands that the child(ren)’s guardianship will be petitioned for by
________________________________________, child(ren)’s _______________________.
4. That he/she, ____________________________ is an adult born ______/______/______ and
that he/she has completed __________ grades of school; that he/she can read, write and
understands the English language.
5. That he/she is an enrolled member of the Cheyenne and Arapaho Tribes.
6. That he/she consents to the jurisdiction of this Court and waives any objection he/she may
enter to this Court’s jurisdiction or power to enter an Order Of Guardianship regarding
his/her child(ren).
7. That he/she understands that he/she has the right to refuse to consent to the guardianship of
his/her children, that he/she has the right to obtain and talk to an attorney before he/she
8. That he/she consents to the guardianship of his/her child(ren) for the reason that he/she
believes that said guardianship is in the best interest of the child(ren).
9. That the child(ren) have been in the physical custody and care of ______________________
for about _______________ and that he/she has observed the child(ren) with the petitioner.
10. That his/her consent to guardianship is given voluntarily and unequivocally.
11. That he/she has not received or been promised any money or anything of value for his/her
consent to this guardianship of his/her children.
12. That guardianships, once made permanent are reviewed annually and that the natural parent
can request a hearing at any time by Motion To Dissolve The Guardianship.
IN WITNESS WHEREOF, I, __________________________, have subscribed my name
this _____________ day of ____________________, 20__________.
Natural Parent’s Name
City/State/Zip Code
Area Code/Telephone Number
State of: )
) ss.
County of: )
Subscribed and sworn to before me this ____________ day of ______________________, 20____.
Notary Public