RSCC-4A-E (2014/01)

ONTARIO Superior Court of Justice Consent to Act as Litigation Guardian

Form 4A Ont. Reg. No.: 258/98

Small Claims Court

Address

Phone Number

Claim No.

BETWEEN

Plaintiff(s)

and

Defendant(s)My name is Name

And I live at Street and number

City, province, postal code

Phone number and fax number

1. I consent to act as litigation guardian in this action for the

(Check one box only.)

plaintiff, named(Name of plaintiff)

and I acknowledge that I may be personally responsible for any costs awarded against me or against this person.

defendant, named(Name of defendant)

.

2. The above-named person is under the following disability:

(Check appropriate box(es).)

a minor whose birth date is(State date of birth of minor)

.

mentally incapable within the meaning of Section 6 or Section 45 of the Substitute Decisions Act, 1992 in respect of an issue in a proceeding.

an absentee within the meaning of the Absentees Act.

3. My relationship to the person under disability is(State your relationship to the person under disability.)

Les formules des tribunaux sont affichées en anglais et en français sur le site www.ontariocourtforms.on.ca. Visitez ce site pour des renseignements sur des formats accessibles.

RSCC-4A-E (2014/01)

Claim No.FORM 4A PAGE 2

4. I have no interest in this action contrary to that of the person under disability.

5. I am(Check one box only.)

represented and have given written authority to(Name of representative with authority to act in this proceeding)

of (Address for service)

(Phone number and fax number)

to act in this proceeding.

not represented by a representative.

, 20

(Signature of litigation guardian consenting)

(Signature of witness)

(Name of witness)

Note: Within seven (7) calendar days of changing your address for service, notify the court and all other parties in writing.

Consent to Act as Litigation Guardian Form 4A �Consent to Act as Litigation Guardian Form 4A - Page 2�

RSCC-4A-E (2014/01)

RSCC-4A-E (2014/01)

Consent to Act as Litigation Guardian Form 4A

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               ONTARIOSuperior Court of Justice

Consent to Act as Litigation Guardian

Form 4A Ont. Reg. No.: 258/98

BETWEEN

and

My name is 

And I live at

1. I consent to act as litigation guardian in this action for the

(Check one box only.)

and I acknowledge that I may be personally responsible for any costs awarded against me or against this person.

.

2. The above-named person is under the following disability:

(Check

appropriate box(es).)

.

3. My relationship to the person under disability is

Les formules des tribunaux sont affichées en anglais et en français sur le site www.ontariocourtforms.on.ca. Visitez ce site pour des renseignements sur des formats accessibles.

Consent to Act as Litigation Guardian Form 4A - Page 2

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FORM 4A

PAGE 2

4. I have no interest in this action contrary to that of the person under disability.

5. I am

(Check one box only.)

of  

to act in this proceeding.

, 20

Note:             Within seven (7) calendar days of changing your address for service, notify the court and all other parties in writing.

8.0.1291.1.339988.308172

Consent to Act as Litigation Guardian

Form 4A

Consent to Act as Litigation Guardian

TextField1: Small Claims Court: Address: Phone Number: Claim Number: Between. Plaintiff(s) : and. Defendant(s).: My name is. Name.: And I live at. Street and Number.: And I live at. City, province, postal code.: And I live at. Phone number and fax number.: 1. I consent to act as litigation guardian in this action for the. Check one box only. Plaintiff named.: 1. I consent to act as litigation guardian in this action for the. Name of plaintiff. : 1. I consent to act as litigation guardian in this action for the. Check one box only. Plaintiff named.: 1. I consent to act as litigation guardian in this action for the. Name of defendant. : 2. The above-named person is under the following disability: Check appropriate box(es). a minor whose birth date is.: 2. The above-named person is under the following disability:. State date of birth minor. Date. Enter date in format: year: 4 digits, month: 2 digits, day: 2 digits. Or select date from the drop down calendar. is in court.: 2. The above-named person is under the following disability: Check appropriate box(es). mentally incapable within the meaning of Section 6 or Section 45 of the Substitute Decisions Act, 1992 in respect of an issue in a proceeding.: 2. The above-named person is under the following disability: Check appropriate box(es). an absentee within the meaning of the Absentees Act.: 3. My relationship to the person under disability is. State your relationship to the person under disability.: 5. I am. Check one box only. represented and have given written authority to.: I am. Represented and have given written authority to. (Name of representative with authority to act in this proceeding).: of. Address for service.: to act in this proceeding.: 5. I am. Check one box only. not represented by a representative.: Day Month: Year : Signature of litigation guardian consenting: Signature of witness: Name of witness: Save Form: Print Form: Clear Form: