Commonwealth of Massachusetts
Plymouth Division The Trial Court Probate and Family Court Department Docket No.
AFFIDAVIT FOR TEMPORARY GUARDIANSHIP
Guardianship of I / We,
Print Name(s)
Of
hereby state that: 1. On or about
Date
, the situation of the proposed ward which
requires emergency attention is
2. The petitioner(s) seek(s) to avoid the particular harm of:
3. The actions with regard to the proposed ward which are reasonably necessary to avoid the occurrence of that harm are:
4. Check one of the following:
(NOT applicable to minors)
The proposed ward has executed a Health Care Proxy and/or a Durable Power of Attorney (copy attached) The proposed ward has not executed a Health Care Proxy and/or a Durable Power of Attorney I have been unable to determine if the proposed ward has executed a Health Care Proxy and/or a Durable Power of Attorney Signed this day of 20 , under the penalties of perjury.
CJ-P 113 (11/98)
SIgnature(s)
pcpfc - c.g.f.