MPC 740 (5/30/11) ofpage

A MINOR

DECREE AND ORDER OF APPOINTMENT OF GUARDIAN of a

MINOR

Commonwealth of Massachusetts The Trial Court

Probate and Family Court

Docket No.

In the Interests of:

First Name Last NameMiddle NameDivision

(date), after hearing on

Upon the Petition for Appointment of Guardian of filed

(date), the Court FINDS THAT:

is a minor whose date of birth is(date)

.

is the Minor's mother father (hereinafter referred to as "Parent One")

is the Minor's mother father (hereinafter referred to as "Parent Two")

Venue is proper.

The minor child, who is over age 14, nominated said guardian.

Parent One consented to said petition.

Parent Two consented to said petition.

Parent One, after proper notice, did not object to said petition.

Parent Two, after proper notice, did not object to said petition.

Parent One's parental rights have been terminated.

Parent Two's parental rights have been terminated.

Parent One is deceased.

Parent Two is deceased.

Parent One, after hearing, is found to be currently unfit unavailable to parent said Minor for the following reasons:

unavailable to parent said Minor for the following reasons:unfitParent Two, after hearing, is found to be currently

IT IS THEREFORE ORDERED AND DECREED that the following person(s) is/are appointed as Guardian of said Minor

Last NameName:

First Name M.I.

(Address) (City/Town) (State) (Zip)

Primary Phone #: (Apt, Unit, No. etc.)

MPC 740 (5/30/11)

In the Interests of:

ofpage

Last NameFirst Name Middle Name

Docket No.

Last NameName:

First Name M.I.

(Address) (City/Town) (State) (Zip)

Primary Phone #: (Apt, Unit, No. etc.)

The Court directs the issuance of Letters of Appointment of Guardianship as follows:

The Letters shall expire on:

The powers and duties of the Guardian are unrestricted, except the Guardian may not consent to extraordinary

The powers and duties of the Guardian are limited by the following restrictions:

medical treatment pursuant to G.L. c. 190B, §5-306A

the Minor's 18th birthday

or(date)

IT IS FURTHER ORDERED THAT:

The Guardian(s) shall, on or before one year from the date of this decree, and annually thereafter, file an Annual Report of Guardian. Failure of the Guardian(s) to do so may result in the revocation of this Decree.

The Guardian(s) is/are prohibited from permanently removing the child from the Commonwealth without an order of

the Court.

Parent One shall have the following rights to contact with the minor child:

The Guardian(s) shall notify the Court in writing within 30 days of any changes to his/her home address, or telephone number or of that of the Minor.

1.

2.

3.

4. The Guardian shall serve:

without surety on his,her, or their bond:

because the minor has no estate

for the following good cause

personal suretieswith corporate surety on his/her/their bond in the amount of

pursuant to G.L. c. 190B, §5-410

5.

Parent Two shall have the following rights to contact with the minor child:

MPC 740 (5/30/11)

In the Interests of:

ofpage

Last NameFirst Name Middle Name

Docket No.

Parent One shall pay child support in the amount of $ beginning(date)

by wage/suspended wage assignment.

Parent Two shall pay child support in the amount of $ beginning(date)

by wage/suspended wage assignment.

6.

The parties shall comply with a stipulation or agreement dated7.(date)which is filed with the Court and expressly made part of this Order.

,

Other:8.

Date