13-19740-360 TERMINATION OF GUARDIANSHIP PARENT QUESTIONNAIRE Page 1 of 8 Revised 6-28-16 Probate Code 2471601 SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN BERNARDINO Probate Division 247 West Third Street San Bernardino, CA 92416-0212 Termination of Guardianship Parent Questionnaire Guardianship of the: Person Estate Confidential Case Number: Case Name: NOTICE TO PARENT Please be advised the information provided on this questionnaire will be used to conduct a full relationship histories will be fully reported to the court. Regarding Termination of Guardianship of (list all minors names): 1. 4. 2. 5. 3. 6. I give ffice authority to release any information in its files to the records, employment records or psychological records. investigation in connection with my petition for termination of guardianship of a minor child. I have read and understand the above conditions and agree to them. PRINT NAME OF PARENT SIGNATURE OF PARENT Date COURT USE ONLY American LegalNet, Inc. www.FormsWorkFlow.com 13-19740-360 TERMINATION OF GUARDIANSHIP PARENT QUESTIONNAIRE Page 2 of 8 Revised 6-28-16 Probate Code 2471601 INFORMATION (ATTACH ADDITIONAL PAGE IF NECESSARY) Minor 1 Name: Race/ Ethnicity: Date of Birth: Age: Place of Birth: Address: With whom does the minor currently reside? Date Guardianship was Granted: Relationship to Petitioner : Has the minor ever had involvement with law enforcement? Yes No If yes, explain: Does the minor have a history of mental health issues/impairments? Yes No If yes, explain: Minor 2 Name: Race/ Ethnicity: Date of Birth: Age: Place of Birth: Address: With whom does the minor currently reside? Date Guardianship was Granted: Relationship to Petitioner : Has the minor ever had involvement with law enforcement? Yes No If yes, explain: Does the minor have a history of mental health issues/impairments? Yes No If yes, explain: Minor 3 Name: Race/ Ethnicity: Date of Birth: Age: Place of Birth: Address: With whom does the minor currently reside? Date Guardianship was Granted: Relationship to Petitioner : Has the minor ever had involvement with law enforcement? Yes No If yes, explain: Does the minor have a history of mental health issues/impairments? Yes No If yes, explain: American LegalNet, Inc. www.FormsWorkFlow.com 13-19740-360 TERMINATION OF GUARDIANSHIP PARENT QUESTIONNAIRE Page 3 of 8 Revised 6-28-16 Probate Code 2471601 I am the: Mother Father PERSONAL INFORMATION Your Full Name: Maiden Name: Aliases: Language(s) Spoken (includ ing sign language): Race/Ethnicity: Age: Date of Birth: Place of Birth: Social Security Number: HOME Address: How long at present residence? Rent Own If you have lived at this address for less than five years, please list your previous addresses: Telephone: ( ) TDD Mobile Phone: ( ) Do you have any guns or other weapons stored on the property? Yes No If yes, what type(s) of weapon(s)? Describe w here and how you store the weapon(s) ? EDUCATION Highest Grade Completed: Graduated High School? Yes No License(s) or Credential(s) Received: College Degree(s) Received: EMPLOYMENT Please bring confirmation of employment, including pay stubs, to the investigation interview . Employer Name: Phone: ( ) Employer Address: Job Title: Length of Service: Number: ( ) Who cares for the children if adults are employed outside of the home? HEALTH Name of your Health Insurance Plan: Present health status: Good Fair Poor If your health is fair or poor, please explain: American LegalNet, Inc. www.FormsWorkFlow.com 13-19740-360 TERMINATION OF GUARDIANSHIP PARENT QUESTIONNAIRE Page 4 of 8 Revised 6-28-16 Probate Code 2471601 Are you taking any medication? Yes No If yes, what kind and for what reason(s)? If you have any special health p roblems , please explain : If you have any mental/emotional p roblems , please explain : Have you ever used drugs or alcohol? Yes No If yes, provide details below: LAW ENFORCEMENT INFORMATION Have charges ever been filed against you for crimes other than minor traffic citations? Yes No If yes, please explain: Charge City/State Date Are you on parole or probation? Yes No Phone Number ( ) Have you filed a restraining order, or have you had a restraining order filed against you? Yes No If yes, please explain: Have you or anyone living in your home ever been accused of child abuse or child molestation? Yes No If yes, please explain: Have you had previous involvement with Child Protective Services? Yes No If yes, please explain the circumstances in detail (attach an additional page if necessary): Details County/Stat e Date Has the minor been exposed to domestic violence? Yes No If yes, please explain: American LegalNet, Inc. www.FormsWorkFlow.com 13-19740-360 TERMINATION OF GUARDIANSHIP PARENT QUESTIONNAIRE Page 5 of 8 Revised 6-28-16 Probate Code 2471601 Other Children Living In Your Home under the Age of 18 ( ATTACH ADDITIONAL PAGE IF NECESSARY) Name Relationship Date of Birth Place of Birth Grade Level Developmental Disabilities Does any adult in the home have any problem that could affect the minor (s) , for example, child abuse/molest ation , criminal background, violent b ehavior, or alcohol or drug use ? Yes No If yes, explain: Is there a custody or visitation order for the minor(s)? Yes No Date of Order: Case Number: Where did the proceeding take place? County: State: MARRIAGE AND CHILDREN Marital Status: Married Widowed Single Divorced If currently married or separated, what is the name of your spouse? Name of any previous spouse: Date of divorce or death ending the marriage: Name your children, even if they are adults and not living with you ( a ttach additional sheet if necessary). Birth Date Address Name/ Relationship of adult with whom child lives Other Adults Living In Your Home over the Age of 18 ( ATTACH ADDITIONAL PAGE IF NECESSARY) Name Social Security Number Date of Birth Relationship to you Child Protective Services History Criminal History American LegalNet, Inc. www.FormsWorkFlow.com 13-19740-360 TERMINATION OF GUARDIANSHIP PARENT QUESTIONNAIRE Page 6 of 8 Revised 6-28-16 Probate Code 2471601 Not applicable PERSONAL INFORMATION S p Full Name: Maiden Name: Aliases: Language(s) Spoken (includes sign language): Race/Ethnicity: Age: Date of Birth: Place of Birth: Social Security Number: Telephone: ( ) TDD Mobile Phone: ( ) EMPLOYMENT Please bring confirmation of employment, including pay stubs, to the investigation interview . Employer Name: Phone: ( ) Employer Address: Job Title: Length of Service: HEALTH Present health status: Good Fair Poor Does your spouse tak e any medication? Yes No Does your spouse have any Special Health Problems ? Yes No Does your spouse have any Mental/Emotional Problems ? Yes No Has your spouse ever used drugs or alcohol? Yes No LAW ENFORCEMENT INFORMATION Have charges ever been filed against your spouse for crimes other than minor traffic citations? Yes No Is your spouse on parole or probation? Yes No Phone Number ( ) Ha s you r spouse had previous involvement with Child Protective Services? Yes No American LegalNet, Inc. www.FormsWorkFlow.com 13-19740-360 TERMINATION OF GUARDIANSHIP PARENT QUESTIONNAIRE Page 7 of 8 Revised 6-28-16 Probate Code 2471601 GUARDIANSHIP INFORMATION Explain why the guardianship was needed when it was established (be specific). Why is the guardianship no longer necessary? Be specific about what efforts you made to resolve the problems that led to the need for the guardianship. For example, if you had a drug problem , please tell us the name of the program you attended or completed. Why is it in the best interests of the minor(s) to end the guardianship? How would they benefit or be better off after the termination? Please describe the amount of contact you have had with the minor (s) since the guardianship was established. For example, how often did you visit and for low long ( e.g., for the day or overnight ) ? Please describe how your visits have been with the minor (s) . Describe any problems that have arisen and how you have resolved them. American LegalNet, Inc. www.FormsWorkFlow.com 13-19740-360 TERMINATION OF GUARDIANSHIP PARENT QUESTIONNAIRE Page 8 of 8 Revised 6-28-16 Probate Code 2471601 If the minor has any devel