Free - Massachusetts

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.