Pennsylvania Consolidated & Unconsolidated Statutes
Chapter 56 - Standby and Temporary Guardianship
Section 5611 - Designation

(a) General rule.--A custodial parent, a legal custodian or legal guardian may designate a standby guardian by means of a written designation unless the minor has another parent or adoptive parent:
(1) whose parental rights have not been terminated or relinquished;
(2) whose whereabouts are known; and
(3) who is willing and able to make and carry out the day-to-day child-care decisions concerning the minor.
(b) Exception where other parent consents.--Notwithstanding subsection (a), a parent, legal custodian or legal guardian may designate a standby guardian with the consent of the other parent.
(c) Contents.--
(1) A designation of a standby guardianship shall identify the custodial parent, legal custodian or legal guardian making the designation, the minor or minors, any other parent, the standby guardian and the triggering event or events upon which a named standby guardian shall become a coguardian or guardian. If desired, different standby guardians may be designated for different triggering events. The designation shall also include the signed consent of the standby guardian and the signed consent of any other parent or an indication why the other parent's consent is not necessary.
(2) The designation shall be signed by the designating parent, legal custodian or legal guardian in the presence of two witnesses who are 18 years of age or older and not otherwise named in the designation, who shall also sign the designation. If the parent, legal custodian or legal guardian is physically unable to sign the designation, the parent, legal custodian or legal guardian may direct another person not named in the designation to sign on the parent's, the legal custodian's or the legal guardian's behalf in the presence of the parent, legal custodian or legal guardian and the witnesses.
(3) A parent, legal custodian or legal guardian may also but need not designate an alternate in the designation.
(4) A designation may but need not be in the following form:
I (insert name of designator) do hereby appoint (insert name, address and telephone number of standby guardian) as the standby guardian of (insert name(s) of minor(s)) to take effect upon the occurrence of the following triggering event or events (insert specific triggering events).
I hereby revoke all former wills and codicils to the extent that there is a conflict between those formerly executed documents and this, my duly executed standby guardian designation.
I am the (insert designator's relationship to minor(s)) of (insert name(s) of minor(s)).
(Insert name(s) of minor(s)'s other parent(s)) is the father/mother of (insert name(s) of minor(s)).
His/her address is:

(Check all that apply):
He/she died on (insert date of death).
His/her parental rights were terminated or
relinquished on (insert date of termination or
relinquishment).
His/her whereabouts are unknown. I understand that
all living parents whose rights have not been
terminated must be given notice of this designation
pursuant to the Pennsylvania Rules of Civil
Procedure or a petition to approve this designation
may not be granted by the court.
He/she is unwilling and unable to make and carry
out day-to-day child-care decisions concerning the
minor.
He/she consents to this designation and has signed
this form below.
By this designation I am granting (insert name of standby guardian) the authority to act for 60 days following the occurrence of the triggering event as a coguardian with me or, in the event of my death, as guardian of my minor child(ren).
Optional: I hereby nominate (insert name, address and telephone number of alternate standby guardian) as the alternate standby guardian to assume the duties of the standby guardian named above in the event the standby guardian is unable or refuses to act as a standby guardian.
If I have indicated more than one triggering event, it is my intent that the triggering event which occurs first shall take precedence. If I have indicated "my death" as the triggering event, it is my intent that the person named in the designation to be standby guardian for my minor child(ren) in the event of my death shall be appointed as guardian of my minor child(ren) when I die.
It is my intention to retain full parental rights to the extent consistent with my condition and to retain the authority to revoke the standby guardianship if I so choose.
This designation is made after careful reflection, while I am of sound mind.
_________________________ ___________________________
(Date) (Designator's signature)
_________________________ ___________________________
(Witness's signature) (Witness's signature)
_________________________ ___________________________
(Number and Street) (Number and Street)
__________________________ ___________________________
(City, State and Zip Code) (City, State and Zip Code)
If applicable: I (insert name of other parent)
hereby consent to this designation.
____________________ ______________________________
(Date) (Signature of other parent)
________________________________________________________
(Address of other parent)
I, (insert name of standby guardian) hereby accept my nomination as standby guardian of (insert minor(s)'s name(s)). I understand that my rights and responsibilities toward the minor child(ren) named above will become effective upon the occurrence of the above-stated triggering event or events. I further understand that in order to continue caring for the child(ren), I must file a petition with the court within 60 days of the occurrence of the triggering event.
_____________________ ________________________
(Date) (Signature of standby guardian)
(June 22, 2000, P.L.443, No.59, eff. 60 days)