Form 12	Statement for appointment as a litigation guardian in protection order proceeding
Family Violence Act 2016
(see s 78)
Personal Violence Act 2016
(see s 72)

In the Magistrates Court of the Australian Capital Territory

FVO / PPO / WPO ........ / ........

............................................................................................................(full name)
Applicant
............................................................................................................(full name)
Respondent

I, .................................................................................................................. (full name of applicant for appointment as litigation guardian), state that:
1.	To the best of my knowledge, ................................................................. 	(full name of the person with impaired decision making ability) (‘the assisted person’) 	*does / *does not have a disability guardian;
* Delete whichever is inapplicable

2.	My relationship with the assisted person is that I am the assisted 	person’s ........................................................................................(eg 	brother, sister, daughter, son, carer, neighbour, friend, no relationship);
3.	I have no interest in the proceeding that is adverse to the interests of the 	assisted person;
4.	I agree to be appointed as the assisted person’s litigation guardian in this 	proceeding.

...................................................................	Dated: ______ /______ /20______
(Signature of applicant for appointment as litigation guardian)

................................................................................................................................
(Name of applicant for appointment as litigation guardian)