Order Appointing Temporary Guardian For An Incapacitated Person {MPC 620}

NOTARIZED AND VERIFIED CONSENT OR NOMINATION BY MINOR In the Interests of: First Name Middle Name Docket No. Commonwealth of Massachusetts The Trial Court Probate and Family Court Division Last Name Minor I, First Name Middle Name Last Name (full name of minor) am 14 years of age or older and I: Consent to the appointment of First Name M.I. Last Name (full name) as my guardian(s) pursuant to G.L. c. 190B, § 5-203. Do not consent to the appointment of First Name M.I. Last Name (full name) as my guardian(s) pursuant to G.L. c. 190B, 5-203. § Nominate First Name M.I. Last Name (full name), as my guardian(s) pursuant to G.L. c. 190B, §5-207. VERIFICATION AND ACKNOWLEDGMENT I swear/affirm under oath that I have read the foregoing Consent or Nomination by Minor and that the statements set forth therein are true and correct to the best of my knowledge. Date Signature of Minor (Address) (City/Town) (State) (Apt, Unit, No. etc.) (Zip) Primary Phone # NOTARIZATION , ss On this day of , 20 , Date personally appeared before me, the undersigned notary public, and proved to me through satisfactory evidence of identification, which was , to be the person whose name is signed on the preceding or attached document in my presence. Signature of Notary Public (Print name) My Commission Expires MPC 441 (5/30/11) page 1 of 1 www.FormsWorkFlow.com