(a) A designation of a standby guardian shall be in writing and shall be signed by the designating individual or by some other individual in the designating individual's presence and at the designating individual's express direction. The designation shall be attested to and subscribed by two or more competent witnesses. Neither the witness nor an individual signing on behalf of the designating individual may be named the standby guardian.

(b) A standby guardian designation shall set forth the name, address, and county of domicile of the designating individual and of the standby guardian; the name, address, county of domicile, and date of birth of the minor; and the circumstances which define the parent or guardian as a designating individual. With regard to a parent of the minor who is not the designating individual, the designation shall state, to the extent known, that parent's name and address and if that parent is deceased, has his or her parental rights terminated, and whether that parent cannot be located. The designation shall include a statement of consent, signed by the standby guardian, to serve in such capacity.

(c) A standby guardian designation shall be in substantially the following form and contain the following information:

DESIGNATION OF STANDBY GUARDIAN

(1) IDENTIFICATION OF DESIGNATING INDIVIDUAL: I, (insert name of

person designating the standby guardian), whose address is

(insert address) and whose county and state of domicile are

(insert name of county and state), am:

(Check and complete the ones which apply)

(A) The parent with physical custody of the minor child or children

listed below and my parental rights are not terminated; and the other

parent, whose name is (insert name of other parent) and whose

address is (insert address of other parent), of the minor

child or children listed below:

(A-1) Is deceased;

(A-2) Has his or her parental rights to the minor or minors

terminated;

(A-3) Cannot be found after a diligent search has been made; or

(A-4) Has consented to the designation of and service by the standby

guardian as set forth below; or

(B) The guardian of the minor child or children listed below, who is

duly appointed and serving pursuant to court order.

(2) IDENTIFICATION OF MINOR(S): The minor or minors for whom I am

designating a standby guardian are:

NAME ADDRESS (include county of DATE OF

domicile) BIRTH

(3) DESIGNATION AND IDENTIFICATION OF STANDBY GUARDIAN: Pursuant to Part 4

of Article 1 of Chapter 2 of Title 29 of the Official Code of Georgia

Annotated, I hereby designate (insert name of standby guardian),

whose address is (insert address) and whose county and state of

domicile are (insert name of county and state), to serve as the

standby guardian of the minor(s) whom I have identified above.

(4) POWERS OF STANDBY GUARDIAN: The standby guardian whom I have designated

above shall have all the rights, duties, and responsibilities under Georgia

law of a guardian of a minor who has been appointed by a court.

(5) DURATION OF STANDBY GUARDIANSHIP: I understand that upon a health care

professional determining in writing that, due to my physical or mental

health condition, I am not able to care for the minor(s) identified above,

this standby guardianship shall become effective and the person whom I have

designated above shall become the standby guardian of the person of the

minor(s).

I understand that I can revoke this standby guardianship by destroying this

document, obliterating it, or by revoking it in writing with proper

witnesses. I understand that if I wish to revoke the standby guardianship

after the health determination has been made I must file a notice of the

revocation of the standby guardianship with the probate court and mail a

copy of the notice of revocation to the standby guardian.

Finally, I understand that this standby guardianship will automatically end

120 days after the health care professional makes the determination that I

am unable to care for the minor(s), unless the standby guardian has filed a

petition for guardianship of the minor. If the standby guardian files such

a petition, the standby guardianship will remain in effect, unless

otherwise revoked, until the judge rules on the petition. In considering

such a petition for guardianship, I understand that the judge will give

preference for the appointment to the individual whom I name as the standby

guardian in this document.

(6) SIGNATURE: I certify that the statements contained herein are true and

correct, this day of , .

(Designating individual signs here)

(Print name of designating individual)

We, the undersigned witnesses, are at least 18 years of age, are not

designated as the standby guardian, and state that the designating

individual signed this designation in our presence.

(Signature of first witness) (Print first witness's address)

(Signature of second witness) (Print second witness's address)

(7) CONSENT OF PARENT (To be completed only if line A-4 in paragraph (1)

above has been checked):

I, (insert name of parent other than the one designating the

standby guardian), whose address is (insert address), am the

parent of the above named minor(s). I understand that by this form, an

individual is being designated to serve as a standby guardian of my child

(or children). I understand that this standby guardian will have all the

rights, duties, and responsibilities under Georgia law of a guardian of the

person of a minor who has been appointed by a court.

I further understand that I may object to this designation. Knowing this, I

consent to the designation of (insert name of standby guardian).

This day of , .

(Other parent signs here)

(Print name of other parent)

We, the undersigned witnesses, are at least 18 years of age, are not

designated as the standby guardian in this document, and state that the

above-named parent signed this consent in our presence.

(Signature of first witness) (Print first witness's address)

(Signature of second witness) (Print second witness's address)

(8) ACCEPTANCE OF DESIGNATION BY STANDBY GUARDIAN:

I, (insert name of designated standby guardian), am the

individual designated as the standby guardian in this document. I hereby

accept this designation with full knowledge that upon a health care

professional making a written determination that the parent of the minor(s)

is not able to care for the minor(s) due to his or her physical or mental

health or condition, I automatically take on this guardianship.

Further, I understand that I must file a notice of my becoming a standby

guardian, a copy of this designation, and a copy of the health

determination with the probate court as soon as the health determination

has been made. I understand that within 120 days of the health

determination being made I must petition the probate court to name me as

guardian of the minor(s).

This day of , .

(Standby guardian signs here)

(Print name of standby guardian)

We, the undersigned witnesses, are at least 18 years of age, are not

designated as the standby guardian in this document, and state that the

standby guardian signed this document in our presence.

(Signature of first witness) (Print first witness's address)

(Signature of second witness) (Print second witness's address)