MERCED COUNTY SUPERIOR COURT COURT INVESTIGATIONS GUARDIANSHIP QUESTIONNAIRE Minor's Name Case No. Petitioner's (paternal or maternal) relationship to the minor: This questionnaire MUST be completed and served to the Court Investigator with the Petition for Appointment of Guardianship. If you find there is not enough room to complete your answer, use the reverse of the page or attach a separate sheet of paper clearly identifying the question. DO NOT leave any question blank. State N/A if the question does not apply to you. IF THERE IS A PROPOSED CO-GUARDIAN WHO IS NOT LISTED AS SPOUSE OR SIGNIFICANT OTHER, AN ADDITIONAL FORM MUST BE COMPLETED FOR THAT PERSON. FAILURE TO SERVE THE COURT INVESTIGATOR WITH THIS FORM AND COPIES OF ALL DOCUMENTS FILED IN THIS MATTER MAY RESULT IN DELAYS. Hearing Date: For clarification or questions regarding this questionnaire or the guardianship procedure please contact: Michelle C. Pomicpic Merced County Superior Court Investigator (209) 725-4190 Monday through Friday 8:00 a.m. to 4:00 p.m. MER-0014 (Rev. 02/2008) COURT INVESTIGATIONS GUARDIANSHIP QUESTIONNAIRE Page 1 of 7 American LegalNet, Inc. www.FormsWorkFlow.com PERSONAL HISTORY PROPOSED GUARDIAN FULL NAME OTHER NAMES/MAIDEN DATE OF BIRTH/BIRTHPLACE LIST ALL ADDRESSES FOR THE PAST 5 YEARS 1. PHONE NO. FROM OWN RENT RENT/MORTGAGE $ CA ID/DL NO. SOCIAL SECURITY NO. 2. PHONE NO. FROM /MONTH 1-7 OWN RENT RENT/MORTGAGE $ 8 9 10 3. PHONE NO. FROM /MONTH 11 MASTERS OWN RENT RENT/MORTGAGE $ 12 TO TO TO /MONTH LAST GRADE OF SCHOOL ATTENDED SOME COLLEGE FATHER'S NAME COLLEGE GRADUATE MOTHER'S NAME YOUR HEALTH GOOD FAIR POOR NAME OF YOUR PHYSICIAN: STATE ANY MEDICAL CONDITIONS YOU ARE CURRENTLY BEING TREATED FOR: MEDICATIONS - NAME, AMOUNT, REASON, HOW OFTEN TAKEN: ATTENDING COUNSELING? YES NO TYPE: COUNSELOR: HAVE YOU EVER BEEN CONVICTED FOR AN OFFENSE OTHER THAN A MINOR TRAFFIC VIOLATION? YES NO IF YES, PLEASE LIST: DATE CITY VIOLATION OUTCOME HAVE YOU EVER BEEN OR ARE YOU ON PROBATION/PAROLE? YES NO IF YES, PLEASE LIST: DATE CITY OFFICER/AGENT/TELEPHONE NO. DO YOU DRINK ALCOHOLIC BEVERAGES? WHAT DRUGS DO/DID YOU USE? YES NO HOW MUCH/OFTEN? WHEN DID YOU LAST USE? HOW MUCH/OFTEN? DAILY WEEKLY MONTHLY COST? HAVE YOU EVER ENTERED OR COMPLETED AN ALCOHOL OR DRUG TREATMENT PROGRAM? YES NO HAVE YOU EVER HAD CONTACT WITH A CHILD PROTECTIVE SERVICE AGENCY? YES NO IF YES, GIVE DETAILS: IF YES, GIVE DETAILS AND COUNTY: ARE YOU MARRIED DIVORCED SEPARATED WIDOWED LIVING TOGETHER DATE/REASON FOR END OF MARRIAGE: DATES AND PLACE OF ALL MARRIAGES: CHILDREN OF THE MARRIAGE: MER-0014 (Rev. 02/2008) COURT INVESTIGATIONS GUARDIANSHIP QUESTIONNAIRE Page 2 of 7 American LegalNet, Inc. www.FormsWorkFlow.com PERSONAL HISTORY SPOUSE OR SIGNIFICANT OTHER FULL NAME DATE OF BIRTH/BIRTHPLACE LIST ALL ADDRESSES FOR THE PAST 5 YEARS 1. PHONE NO. FROM OWN RENT RENT/MORTGAGE $ 2. PHONE NO. FROM /MONTH 1-7 OWN RENT RENT/MORTGAGE $ 8 9 10 3. PHONE NO. FROM OWN RENT /MONTH RENT/MORTGAGE $ 11 12 MASTERS CA ID/DL NO. OTHER NAMES/MAIDEN SOCIAL SECURITY NO. TO TO TO /MONTH LAST GRADE OF SCHOOL ATTENDED SOME COLLEGE FATHER'S NAME YOUR HEALTH GOOD FAIR POOR COLLEGE GRADUATE MOTHER'S NAME NAME OF YOUR PHYSICIAN: STATE ANY MEDICAL CONDITIONS YOU ARE CURRENTLY BEING TREATED FOR: MEDICATIONS-NAME, AMOUNT, REASON, HOW OFTEN TAKEN: ATTENDING COUNSELING? YES NO TYPE: IF YES, PLEASE LIST: DATE CITY COUNSELOR: HAVE YOU EVER BEEN CONVICTED FOR AN OFFENSE OTHER THAN A MINOR TRAFFIC VIOLATION? YES NO HAVE YOU EVER BEEN OR ARE YOU ON PROBATION/PAROLE? YES NO VIOLATION OUTCOME IF YES, PLEASE LIST: DATE CITY OFFICER/AGENT/TELEPHONE NO. DO YOU DRINK ALCOHOLIC BEVERAGES? WHAT DRUGS DO/DID YOU USE? HOW MUCH/OFTEN? DAILY YES NO HOW MUCH/OFTEN? WHEN DID YOU LAST USE? WEEKLY MONTHLY COST? HAVE YOU EVER ENTERED OR COMPLETED AN ALCOHOL OR DRUG TREATMENT PROGRAM? YES NO HAVE YOU EVER HAD CONTACT WITH A CHILD PROTECTIVE SERVICE AGENCY? YES NO IF YES, GIVE DETAILS: IF YES, GIVE DETAILS AND COUNTY: ARE YOU MARRIED DIVORCED SEPARATED WIDOWED LIVING TOGETHER DATES AND PLACE OF ALL MARRIAGES: CHILDREN OF THE MARRIAGE: DATE/REASON FOR END OF MARRIAGE: MER-0014 (Rev. 02/2008) COURT INVESTIGATIONS GUARDIANSHIP QUESTIONNAIRE Page 3 of 7 American LegalNet, Inc. www.FormsWorkFlow.com EMPLOYMENT / FINANCIAL PROPOSED GUARDIAN NAME/ADDRESS/PHONE OF EMPLOYER HOW LONG? OTHER INCOME AMOUNT $ TANF DAYS/HOURS YOU WORK SOCIAL SECURITY MO/WK UNEMPLOYMENT TITLE: GROSS SALARY/MO. CHILD SUPPORT MEDI-CAL RECEIVED FROM: NAME/ADDRESS/PHONE OF PREVIOUS EMPLOYERS: (GIVE DATES OF EMPLOYMENT AND REASON FOR TERMINATION) WHERE DO YOU BANK? (COMPLETE ADDRESS) TYPES OF ACCOUNTS: ACCOUNT NUMBERS: HAVE YOU EVER FILED FOR BANKRUPTCY? YES NO IF YES, GIVE DATE PLACE AND RESULT: DO YOU SUPPORT ANYONE OUTSIDE OF YOUR RESIDENCE? YES NO IF YES GIVE NAME/RELATIONSHIP AND REASON: SPOUSE/SIGNIFICANT OTHER NAME/ADDRESS/PHONE OF EMPLOYER HOW LONG? OTHER INCOME AMOUNT $ TANF DAYS/HOURS YOU WORK SOCIAL SECURITY MO/WK UNEMPLOYMENT TITLE: GROSS SALARY/MO. CHILD SUPPORT MEDI-CAL RECEIVED FROM: NAME/ADDRESS/PHONE OF PREVIOUS EMPLOYERS: (GIVE DATES OF EMPLOYMENT AND REASON FOR TERMINATION) WHERE DO YOU BANK? (COMPLETE ADDRESS) TYPES OF ACCOUNTS: ACCOUNT NUMBERS: HAVE YOU EVER FILED FOR BANKRUPTCY? YES NO IF YES, GIVE DATE PLACE AND RESULT: DO YOU SUPPORT ANYONE OUTSIDE OF YOUR RESIDENCE? YES NO IF YES GIVE NAME/RELATIONSHIP AND REASON: MER-0014 (Rev. 02/2008) COURT INVESTIGATIONS GUARDIANSHIP QUESTIONNAIRE Page 4 of 7 American LegalNet, Inc. www.FormsWorkFlow.com RESIDENCE ARE THERE ANY OTHER ADULTS RESIDING IN THE HOME? YES NO IF YES: NAME DOB CA ID/DL NO. SOCIAL SECURITY NO. RELATIONSHIP ARE THERE ANY OTHER CHILDREN RESIDING IN THE HOME? YES NO IF YES: NAME DOB RELATIONSHIP GUARDIANSHIP CHILD CHILD TO BE UNDER GUARDIANSHIP: NAME DOB RELATIONSHIP ANY NATIVE AMERICAN BLOOD? PERCENTAGE? TRIBE? NAME/ADDRESS OF SCHOOL GRADE: TEACHER: NAME/ADDRESS OF PHYSICIAN DID MOTHER RECEIVE PRENATAL CARE? DOES CHILD HAVE MEDICAL PROBLEMS? YES YES NO NO FULL TERM BIRTH? IF YES, EXPLAIN: YES NO WAS THERE A DRUG TEST AT BIRTH? YES NO IF YES, RESULTS: DOES CHILD HAVE BEHAVIORAL PROBLEMS? YES NO IF YES, EXPLAIN: DIFFICULTIES IN SCHOOL? YES NO IF YES, EXPLAIN: SPECIAL EDUCATION NEEDS? YES NO IF YES, EXPLAIN: CRIMINAL INVOLVEMENT? YES NO IF YES, EXPLAIN: CURRENT SOCIAL WORKER? IS CHILD IN A DAYCARE PROGRAM? YES YES NO NO IF YES, NAME: IF YES, PROVIDER: GIVE ALL OF THE ABOVE INFORMATION ON ALL CHILDREN PROPOSED TO BE UNDER GUARDIANSHIP. YO