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					                   IN THE CIRCUIT COURT OF JACKSON COUNTY, MISSOURI
                                    PROBATE DIVISION
                               INDEPENDENCE/KANSAS CITY

IN THE MATTER OF:                                      )
                                                       )
      ,                                                ) Estate No.
          D.O.B.                                       )
                                                       )
                                  Minor.               )

                                               AFFIDAVIT

          The following information is submitted pursuant to R.S. Mo. § 452.480, in support of the
Petition for Limited Guardianship of the above-named minor.
   1. Said minor is presently living with Name and address.
   2. Said minor has lived in Jackson County, Missouri for the six months preceding the filing
          of the Petition for Limited Guardianship.
   3. I have not participated in other litigation concerning the custody of this child in this or
          any other state.
   4. I have no information of any custody proceeding concerning this child pending in a court
          of this or any other state.
   5. I have no knowledge of any person, not a party to these proceedings, who has physical
          custody of this child or claims to have custody or visitation rights with respect to this
          child.
      The undersigned swears that the matters set forth in the foregoing Affidavit are true and
correct to the undersigned’s best knowledge and belief, subject to penalty for making a false
affidavit or declaration.

___________________________                           ____________________________________
Date                                                       , Petitioner

STATE OF MISSOURI                 )
                                  ) ss.
COUNTY OF                         )

      Subscribed and sworn to before me, a Notary Public, this ____ day of
________________, 2011.

My Commission Expires:_____________                   ____________________________________
                                                      Notary Public

				
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posted:12/5/2011
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