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SUPREME COURT OF THE STATE OF NEW YORK

COUNTY OF _____________

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In the Matter of ________________________,

Petitioner

INDEX NO. ____________

OATH AND

DESIGNATION

As Guardian of ______________________,

An Incapacitated Person

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STATE OF NEW YORK

COUNTY OF ______________

(1) OATH OF THE GUARDIAN

I, _________________, being duly sworn, depose and say:

(a) I am a citizen of the United States and over the age of eighteen (18) years,

(b) I will well, faithfully and honestly discharge the duties as Guardian for

____Personal Needs

____Property Management [check one or both from Court Order] of ____________________, whom the Court has found to be incapacitated.

(2) DESIGNATION OF THE CLERK FOR SERVICE OF PROCESS:

I, ________________________, residing at _____________________________, as Guardian for____________________, who resides at _________________________, ___________County, hereby designate the Clerk of the Supreme Court,______________ County, and his successor in office as the person on whom service of any process issuing from said Court in the proceeding, or in any other proceeding, which shall affect the person or property of __________________________, the incapacitated person, in like manner and with like effect as if it were served personally upon me whenever I cannot be found and served within the State of New York after due diligence is used.

[Signed in front of Notary] _____________________

[Print name of Guardian] ___________________________

ACKNOWLEDGMENT

STATE OF NEW YORK :

COUNTY OF__________ :

On the___ day of _______________, 200_, before me personally

appeared ______________________, to me known and known to me to

be the individual described in and who executed the foregoing Combined Oath

and Designation of Guardian, and [s]he personally acknowledged to me that

[s]he executed the same.

____________________________

NOTARY PUBLIC

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