Free Civil Court Form 10 - Minnesota

State of Minnesota
County

District Court
Judicial District: Court File Number: Case Type: Probate

Select County

In the Matter of the Guardianship/ Conservatorship of:

Affidavit Regarding Background Study
Ward/Conservatee

, being duly sworn and under oath states as follows: 1. A Petition has been filed in this matter requesting my appointment as Guardian/Conservator for the above named Ward/Conservatee. I have been the subject of a background study within the past five years pursuant to Minn. Stat. §524.5-118. A true and correct copy of the background study is attached to this affidavit. I have not been arrested, charged with any crime, convicted of any crime, the subject of any criminal investigation, or the subject of any investigation regarding maltreatment of vulnerable adults or maltreatment of minors since date of the background study, except as follows:

2.

3. 4.

Date: Sworn/affirmed before me this day of , . Affiant's Signature Address: City/State/Zip: Telephone:
Notary Public \ Deputy Court Administrator

GAC102

State

ENG

Rev 8/03-D

www.courts.state.mn.us/forms

Page 1 of 1