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Guardianship Questionnaire GR001 - California
| Guardianship Questionnaire Form. This is a California form and can be used in Probate Stanislaus Local County . |
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Stanislaus County Superior Court Investigator GUARDIANSHIP QUESTIONNAIRE Minor's Name Case No. Proposed Guardian's (Circle One) (Paternal or Maternal) relationship to minor This form must be completed and returned with the Petition for Guardianship. If you find there is not enough room to complete your answer, use the space on the reverse of this form, clearly identifying the question. Do not leave any question blank. State N/A if the question does not apply to you. FAILURE TO COMPLETE AND RETURN THIS FORM WITH THE PETITION WHEN SERVED ON THE INVESTIGATOR MAY RESULT IN DELAYS. ***ATTACH A COPY(IES) OF BIRTH CERTIFICATE(S) OF CHILD(REN) AND ANY DEATH CERTIFICATE(S) OF NATURAL PARENTS (if applicable). PERSONAL HISTORY OF PETITIONER(S) PROPOSED GUARDIAN #1 FULL NAME: Date of Birth/Birth Place Social Security No. List Addresses for Past Five Years 1. Phone No. ( ) From Rent/Mortgage $ 2. Phone No. ( ) From Rent/Mortgage $ 3. Phone No. ( ) From Rent/Mortgage $ to ( ) Own ( ) Rent /Month to ( ) Own ( ) Rent /Month OTHER NAMES/MAIDEN CA ID/DL NO. to ( ) Own ( ) Rent /Month GR001 Page 1 of 12 Rev 02/04 American LegalNet, Inc. www.FormsWorkFlow.com PROPOSED GUARDIAN #1 continued Your Health (Circle) Good Fair Poor State Any Medical Conditions Currently Being Treated For: Medications Name, Amount, Reason, How Often Taken: Attending Counseling? (Circle) Type: Yes No Name of Counselor: Have You Ever Been Convicted Of An Offense Other Than A Minor Traffic Violation? (Circle) Yes No If Yes, Please List Date: City: Outcome: Have You Ever Been On Or Are You On Probation/Parole? (Circle) Yes Officer/Agent's Name: County/Phone No. How Much/Often? No Do You Drink Alcoholic Beverages? (Circle) Yes No What Drugs Do/Did You Use? When Did You Last Use? How Much/Often? (Circle) Daily Weekly Monthly Cost? Have You Ever Entered Or Completed An Alcohol Or Drug Treatment Program? (Circle) Yes No If Yes, Give Details: Have You Ever Had Contact With A Child Protective Service Agency? (Circle) Yes No If Yes, Give Details And County: GR001 Page 2 of 12 Rev 02/04 American LegalNet, Inc. www.FormsWorkFlow.com PROPOSED GUARDIAN #1 continued Have You Ever Been Arrested For Domestic Violence? If Yes, Give Details: Name And Address of Employer: Phone ( How Long? Hours: Other Income (Circle) AFDC Amount $ SOC. SEC. UNEMPLOYMENT CHILD SUPPORT For Whom Received: Yes No Result: MEDI-CAL ONLY ) Title: Days You Work: Gross Salary: Mo/Wk Have You Ever Filed Bankruptcy: (Circle) If So Date: Place: Have You, Your Spouse Or Either Parent Ever Been Involved In Any Of The Following? Received Counseling For Domestic Violence? (Circle) Domestic Dispute Where Law Enforcement Was Called: (Circle) Been The Subject Of A Domestic Or Civil Restraining Order? (Circle) Yes Yes Yes No No No If Yes For Any, Give Date/Place/Case No./Court/Law Enforcement Agency/And Details For Each Incident: PROPOSED GUARDIAN #2 FULL NAME: Date of Birth/Birth Place OTHER NAMES/MAIDEN CA ID/DL NO. GR001 Page 3 of 12 Rev 02/04 American LegalNet, Inc. www.FormsWorkFlow.com PROPOSED GUARDIAN #2 continued Social Security No. List Addresses for Past Five Years 1. Phone No. ( ) From Rent/Mortgage $ 2. Phone No. ( ) From Rent/Mortgage $ 3. Phone No. ( ) From Rent/Mortgage $ Your Health (Circle) to ( ) Own ( ) Rent /Month Good Fair Poor to ( ) Own ( ) Rent /Month to ( ) Own ( ) Rent /Month State Any Medical Conditions Currently Being Treated For: Medications Name, Amount, Reason, How Often Taken: Attending Counseling? (Circle) Type: Yes No Name of Counselor: Have You Ever Been Convicted Of An Offense Other Than A Minor Traffic Violation? (Circle) Yes No If Yes, Please List Date: City: Outcome: Have You Ever Been On Or Are You On Probation/Parole? (Circle) Yes No GR001 Page 4 of 12 Rev 02/04 American LegalNet, Inc. www.FormsWorkFlow.com PROPOSED GUARDIAN #2 continued Officer/Agent's Name: County/Phone No. How Much/Often? Do You Drink Alcoholic Beverages? (Circle) Yes No What Drugs Do/Did You Use? When Did You Last Use? How Much/Often? (Circle) Daily Weekly Monthly Cost? Have You Ever Entered Or Completed An Alcohol Or Drug Treatment Program? (Circle) Yes No If Yes, Give Details: Have You Ever Had Contact With A Child Protective Service Agency? (Circle) Yes No If Yes, Give Details And County: Have You Ever Been Arrested For Domestic Violence? If Yes, Give Details: Name And Address of Employer: Phone ( How Long? Hours: Other Income (Circle) AFDC Amount $ SOC. SEC. UNEMPLOYMENT CHILD SUPPORT For Whom Received: Yes No Result: MEDI-CAL ONLY ) Title: Days You Work: Gross Salary: Mo/Wk Have You Ever Filed Bankruptcy: (Circle) If So Date: Place: GR001 Page 5 of 12 Rev 02/04 American LegalNet, Inc. www.FormsWorkFlow.com PROPOSED GUARDIAN #2 continued Have You, Your Spouse Or Either Parent Ever Been Involved In Any Of The Following? Received Counseling For Domestic Violence? (Circle) Domestic Dispute Where Law Enforcement Was Called: (Circle) Been The Subject Of A Domestic Or Civil Restraining Order? (Circle) Yes Yes Yes No No No If Yes For Any, Give Date/Place/Case No./Court/Law Enforcement Agency/And Details For Each Incident: OTHER ADULTS RESIDING IN THE HOME OF PROPOSED GUARDIAN(S) Full Name: Relationship: Other Names/Maiden: Date of Birth: Occupation: No Does This Person Have Any Criminal Record: (Circle) Yes If Yes, Where/When? Full Name: Relationship: Charges: Other Names/Maiden: Date of Birth: Occupation: No Does This Person Have Any Criminal Record: (Circle) Yes If Yes, Where/When? Full Name: Relationship: Charges: Other Names/Maiden: Date of Birth: Occupation: No Does This Person Have Any Criminal Record: (Circle) Yes If Yes, Where/When? Charges: GR001 Page 6 of 12 Rev 02/04 American LegalNet, Inc. www.FormsWorkFlow.com OTHER CHILDREN RESIDING IN THE HOME OF PROPOSED GUARDIAN(S) Full Name: Name And Address of School: Relationship: Full Name: Name And Address of School: Relationship: Full Name: Name And Address of School: Relationship: Date Of Birth: Date Of Birth: Date Of Birth: BIRTH PARENTS Natural Mother Full Name: Date of Birth: CA ID/DL No. Other Names/Maiden Social Security No. Last Known Address/Dates Lived There Name And Address Of Employer Telephone No. Is Mother In Agreement With Guardianship? (Circle) Yes No No Does Mother Contribute To Support Of Child? (Circle) Yes If Yes, How? Does Mother Visit With The Child? (Circle) If Yes, How Often? Yes No GR001 Page 7 of 12 Rev 02/04 American LegalNet, Inc. www.FormsWorkFlow.com BIRTH PARENTS Natural
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