Illinois Temporary Guardianship Form: Appointment of Short-Term Guardian (755 ILCS 5/11-5.4)

Appointment of Short-Term Guardian (Illinois)

Temporary Guardianship Form under Section 11-5.4 of the Illinois Probate Act of 1975 (755 ILCS 5/11-5.4)

[Instructions: By properly completing this form, a parent or the guardian of the person of the child appoints a guardian of the child for a period of up to 365 days. Use a separate form for each child. The person appointed must sign the acceptance in Part 7, but need not sign at the same time as the parent. Both living parents may together appoint a short-term guardian; they need not sign at the same time. A parent on active military duty may appoint a short-term guardian for the period of active duty plus 30 days. This form may not be used if a guardian has already been appointed for the child, except by that guardian.]

1. Parent (or Guardian) and Child

I, [Name of appointing parent or guardian], currently residing at [Address], am a parent (or the guardian of the person) of the following child: [Name and date of birth of child, or “not yet born” and the expected date of birth].

2. Short-Term Guardian

I hereby appoint the following person as the short-term guardian for the child: [Name and address of appointed person].
Telephone: [Phone] · Relationship to child: [Grandparent / aunt / uncle / adult sibling / family friend / other]

3. Effective Date

This appointment becomes effective (check one if you wish it to apply):

☐ On the date that I state in writing that I am no longer either willing or able to make and carry out day-to-day child care decisions concerning the child.
☐ On the date that a physician familiar with my condition certifies in writing that I am no longer willing or able to make and carry out day-to-day child care decisions concerning the child.
☐ On the date that I am admitted as an in-patient to a hospital or other health care institution.
☐ On the following date: [Date].
☐ On the date my active duty service begins: [Date].
☐ Upon an administrative separation, as defined in Section 11-1 of the Probate Act.
☐ Other: [Describe].

[If nothing is checked, the appointment is effective immediately upon the date this form is signed and dated below.]

4. Termination

This appointment shall terminate 365 days after the effective date, unless it terminates on the event or date checked below:

☐ On the date that I state in writing that I am willing and able to make and carry out day-to-day child care decisions concerning the child, but not more than 365 days after the effective date.
☐ On the date that a physician familiar with my condition certifies in writing that I am willing and able to make and carry out day-to-day child care decisions concerning the child, but not more than 365 days after the effective date.
☐ On the date that I am discharged from the hospital or other health care institution where I was admitted as an in-patient, which established the effective date, but not more than 365 days after the effective date.
☐ On the date which is [number, no more than 365] days after the effective date.
☐ On a date no more than 30 days after my active duty service is scheduled to end: [Date active duty service is scheduled to end].
☐ In the event the administrative separation, as defined in Section 11-1 of the Probate Act, has been resolved.
☐ Other: [Describe].

[If nothing is checked, the appointment is effective for 365 days, beginning on the effective date.]

5. Limits on Authority (Optional)

Unless limited here, the short-term guardian has the authority of a guardian of the person of a minor, but no authority over the child’s estate, except to apply for and receive benefits for the child from federal, State or local programs (755 ILCS 5/11-13.2). The short-term guardian may not: [for example, take the child out of Illinois for more than [number] days, or consent to non-emergency surgery, without first contacting me].

Information for the guardian: health insurance [Insurer, member ID] · pediatrician [Name, Phone] · allergies and medications [List] · school [Name, grade].

6. Date and Signature of Appointing Parent or Guardian

This appointment is made this [day] day of [month and year].

Signed: ___________________________ (appointing parent or guardian)

Witnesses. I saw the parent (or the guardian of the person of the child) sign this instrument or I saw the parent (or the guardian of the person of the child) direct someone to sign this instrument for the parent (or the guardian). Then I signed this instrument as a witness in the presence of the parent (or the guardian). I am not appointed in this instrument to act as the short-term guardian for the child.

Witness 1: ___________________________ Printed name and address: [ ]
Witness 2: ___________________________ Printed name and address: [ ]

7. Acceptance of Short-Term Guardian

I accept this appointment as short-term guardian on this [day] day of [month and year].

Signed: ___________________________ (short-term guardian)

8. Consent of Child’s Other Parent

I, [Name of the child’s other living parent], currently residing at [Address], hereby consent to this appointment on this [day] day of [month and year].

Signed: ___________________________ (consenting parent)

[The signature of a consenting parent is not necessary if: (i) the child’s other parent has died; (ii) the whereabouts of the child’s other parent are not known; (iii) the child’s other parent is not willing or able to make and carry out day-to-day child care decisions concerning the child; or (iv) the child’s parents were never married and no court has issued an order establishing parentage.]

Revocation

This appointment may be amended or revoked by the appointing parent or guardian at any time and in any manner communicated to the short-term guardian or to any other person. Anyone other than the short-term guardian who is told of a revocation or amendment must make all reasonable efforts to inform the short-term guardian as promptly as possible (755 ILCS 5/11-5.4(d)).

Before You Sign (Delete This Section)

• One child per form. The statute’s instructions call for a separate form for each child.

• Two witnesses, not a notary. Both must be at least 18, see you sign, and must not be the person you appoint. A notary is optional.

• Other parent. If the other parent is involved and able to care for the child, you need that parent’s signature in Part 8.

• School. The appointment alone does not settle school residency. If the child will attend school in the guardian’s district, ask the district first; a short-term guardianship counts for residency only if a court enters a permanent guardianship order within 60 days of enrollment.

• One at a time. Only one short-term guardianship can be in force for a child. Revoke the old one before signing a new one.

• Longer plans. For a plan that should outlast 365 days, also designate a standby guardian in writing before two adult witnesses (755 ILCS 5/11-5.3); a court then decides whether to appoint that person.