IN THE CHANCERY COURT OF_____________COUNTY, MISSISSIPPI

JUDICIAL DISTRICT

IN THE MATTER OF THE	CAUSE NO. __________________________

GUARDIANSHIP OF

______________________________________, A MINOR

BY PETITIONER(S) _________________________________

THE RELIEF SOUGHT HEREIN MAY AFFECT YOUR LEGAL RIGHTS. YOU HAVE A RIGHT TO NOTICE OF ANY HEARING ON THIS PETITION, TO ATTEND ANY SUCH HEARING, AND TO BE REPRESENTED BY AN ATTORNEY.

PETITION FOR APPOINTMENT OF GUARDIAN(S) OF A MINOR

UNDER § 93-20-202

______________________________________, a person interested in the welfare of the

(Petitioner)

minor referenced herein, hereby certifies:

1. Petitioner resides at ___________________________________________________________

(Street Address)	(City/State/Zip)

2. Petitioner's relationship to the minor: _____________________________________________

3. The following minor is in need of a guardian:

_____________________________________________________	________________________

(Name of Minor)	(Date of Birth)

_____________________________________________________	________________________

(Current Street Address, City/State/Zip)	(Current County of Residence)

4. The names and physical addresses of the minor's biological parents are (attach birth certificate if available):

Mother: _____________________________________________________________________

(Name of Mother)	(Physical Address, City/State/Zip)

Mother's mailing address if different: _______________________________________________

Father: _____________________________________________________________________

(Name of Father)	(Physical Address, City/State/Zip)

Father's mailing address if different: _______________________________________________

5. If one or both of the minor's biological parents are no longer living (attach death certificate), the minor's next closest relatives are:

__________________________ ______________ ___________________________________

(Name)	(Relationship to Minor)	(Street Address, City/State/Zip)

__________________________ ______________ ___________________________________

(Name)	(Relationship to Minor)	(Street Address, City/State/Zip)

__________________________ ______________ ___________________________________

(Name)	(Relationship to Minor)	(Street Address, City/State/Zip)

6. Attorney(s) for the parents of the minor, if any (in any action or capacity):

__________________________ ______________ ___________________________________

(Attorney's Name)	(Parent represented)	(Street Address, City/State/Zip)

__________________________ ______________ ___________________________________

(Attorney's Name)	(Parent represented)	(Street Address, City/State/Zip)

7. As required under §§ 93-20-202 and 93-27-101 et seq., (if the required information is not furnished, the court, upon motion of a party or its own motion, may stay the proceeding until the information is furnished) the child has lived at the following places and with the following persons over the last five (5) years:

A. At _________________________________________________________________________

(Street Address, City/State/Zip)

with ___________________________________ from _______________ to ________________

(Name)	(Date)	(Date)

Current address of the person(s) named above (if different from address listed above):

___________________________________________________________________________

(Street Address, City/State/Zip)

B. At _________________________________________________________________________

(Street Address, City/State/Zip)

with ___________________________________ from _______________ to ________________

(Name)	(Date)	(Date)

Current address of the person(s) named above (if different from address listed above):

___________________________________________________________________________

(Street Address, City/State/Zip)

C. At _________________________________________________________________________

(Street Address, City/State/Zip)

with ___________________________________ from _______________ to ________________

(Name)	(Date)	(Date)

Current address of the person(s) named above (if different from address listed above):

___________________________________________________________________________

(Street Address, City/State/Zip)

D. At _________________________________________________________________________

(Street Address, City/State/Zip)

with ___________________________________ from _______________ to ________________

(Name)	(Date)	(Date)

Current address of the person(s) named above (if different from address listed above):

___________________________________________________________________________

(Street Address, City/State/Zip)

(If necessary, continue list here on another sheet of paper.)

8. As required under §§ 93-20-202 and 93-27-101 et seq., (if the required information is not furnished, the court, upon motion of a party or its own motion, may stay the proceeding until the information is furnished),

A. Petitioner has/has not participated as a party or witness or in any other capacity, in any other

(CIRCLE ONE)

proceeding concerning the custody of or visitation with the child.

If so, identify the court, the case number, and the date of the child custody determination, if

any: __________________________________________________________________________

(List the court, the case number, and the date of the child custody determination)

B. Petitioner knows/does not know of any proceeding that could affect the current proceeding,

(CIRCLE ONE)

including proceedings for enforcement and proceedings relating to domestic violence, protective

orders, termination of parental rights, and adoptions.

If so, identify the court, the case number, and the nature of the proceeding:

______________________________________________________________________________

(List the court, the case number, and the nature of the proceeding)

C. Petitioner knows/does not know the names and addresses of any person not a party to the

(CIRCLE ONE)

proceeding who has physical custody of the child or claims rights of legal custody or physical

custody of, or visitation with, the child.

If so, identify the names and addresses of those persons:

______________________________________________________________________________

(List the names of persons who have or claim rights of physical or legal custody or visitation)

9. Disclosure of bankruptcy or criminal history:

(a)	Petitioner has/has not been a debtor in a bankruptcy, insolvency, or receivership proceeding;

(CIRCLE ONE)

(b)Petitioner has/has not been convicted of any of the following:

(CIRCLE ONE)

(i) A felony;

(ii) A crime involving dishonesty, neglect, violence, or use of physical force; or

(iii) Other crime relevant to the functions the person would assume as guardian or conservator.

10. It is necessary or convenient that a guardian be appointed for the minor because:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

11. The Petitioner(s) should be selected as guardian for the minor because:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

12. The minor does/does not have property other than personal effects.

(CIRCLE ONE)

If so, provide a list of the property and its estimated value:

Item:	Value:

___________________________________________________________ __________________

___________________________________________________________ __________________

___________________________________________________________ __________________

___________________________________________________________ __________________

13. The minor does/does not receive income and/or financial assistance.

(CIRCLE ONE)

WHEREFORE, Petitioner(s) requests appointment by this Court as Guardian of

___________________________________.

(Name of Minor)

CERTIFICATION

Under penalties of perjury as provided by law pursuant to § 97-9-61 of the Mississippi Code Annotated, the undersigned certifies the statements set forth in this instrument are true and correct.

RESPECTFULLY SUBMITTED, this the ________ day of ___________, 20_____.

________________________________, Petitioner

________________________________, Co-Petitioner

________________________________, Natural Mother

________________________________, Natural Father

*Every person or attorney who shall file a false affidavit shall be guilty of perjury and shall be punished as provided by law. (Miss.Code.Ann. § 97-9-19) Perjury committed on any judicial trial or inquiry other than on the trial of any indictment for a capital offense or for any other felony, or in any other case, is punishable by imprisonment for up to ten years. (Miss.Code.Ann. § 97-9-61)

Prepared by:

Name: _________________________________ Pro se

Address: _____________________________________

City: _________________________ State___________

Phone: _______________________ Zip: ____________

Email address: _________________________________

ATTESTATION OF PETITIONER

STATE OF MISSISSIPPI

COUNTY OF ____________

Personally appeared before me, the undersigned authority, in and for the aforesaid jurisdiction, ___________________, who having been by me first duly sworn stated on his/her oath that the matters and things stated in the above foregoing instrument are true and correct as therein stated.

___________________________

(Type Name Here)

SWORN TO AND SUBSCRIBED before me this the ____day of ________, 20____.

____________________________

NOTARY PUBLIC

My Commission Expires: _________________

ATTESTATION OF CO-PETITIONER

(if one exists)

STATE OF MISSISSIPPI

COUNTY OF ____________

Personally appeared before me, the undersigned authority, in and for the aforesaid jurisdiction, ___________________, who having been by me first duly sworn stated on his/her oath that the matters and things stated in the above foregoing instrument are true and correct as therein stated.

___________________________

(Type Name Here)

SWORN TO AND SUBSCRIBED before me this the ____day of ________, 20____.

____________________________

NOTARY PUBLIC

My Commission Expires: _________________

ATTESTATION OF NATURAL MOTHER

STATE OF MISSISSIPPI

COUNTY OF ____________

Personally appeared before me, the undersigned authority, in and for the aforesaid jurisdiction, ___________________, who having been by me first duly sworn stated on her oath that the matters and things stated in the above foregoing instrument are true and correct as therein stated.

___________________________

(Type Name Here)

SWORN TO AND SUBSCRIBED before me this the ____day of ________, 20____.

____________________________

NOTARY PUBLIC

My Commission Expires: _________________

ATTESTATION OF NATURAL FATHER

STATE OF MISSISSIPPI

COUNTY OF ____________

Personally appeared before me, the undersigned authority, in and for the aforesaid jurisdiction, ___________________, who having been by me first duly sworn stated on his oath that the matters and things stated in the above foregoing instrument are true and correct as therein stated.

___________________________

(Type Name Here)

SWORN TO AND SUBSCRIBED before me this the ____day of ________, 20____.

____________________________

NOTARY PUBLIC

My Commission Expires: _________________