JV-079 (Rev. 03/21/2013)

AUTHORIZATION FOR COURT ACTIVITYRECORD INFORMATION CHECK (CARI)

DOCKET NUMBERTrial Court of MassachusettsJuvenile Court Department

Guardianship of MinorDIVISION

I hereby authorize the Juvenile Court to conduct a court activity record information check todetermine whether I have a criminal record. I understand the court activity record informationcheck is intended for use by the Court in conjunction with my petition for guardianship of theabove named minor. I further understand that the Court will not consider a petition for aguardianship without conducting a court activity record information check of the guardian and theco-guardian, if applicable. Therefore, the information below is willingly supplied by me, and mysignature indicates my permission for this record check to be completed.

Proposed Guardian's Name:

Current Address:

Social Security No:

Gender: Male Female Date of Birth:

Place of Birth:

Maiden Name (if applicable):

Other Names or Aliases used:

Mother's Name:

Father's Name:

DATE SIGNATURE OF PROPOSED GUARDIAN

NOTARIZATION

The above signed made oath before me on that thisauthorization is his/her free act and deed.

Notary Public:

Print Name:

My Commission Expires:

FOR COURT USE ONLY

Results of CARI: CARI Check Conducted on:

Record (attached)

No Record

Sealed Record

DATE

SIGNATURE