ATTACHMENT PB-4005 For Court use only: Temp hrg date: Perm hrg date: __________________ __________________ REFERRAL FOR COURT INVESTIGATOR & QUESTIONNAIRE - GUARDIANSHIP Case Number (if you have one): (name): Guardianship of Person Yes No Estate Do you think anyone will disagree with the guardianship? If yes, who? Name: Telephone number: Yes No Has Child Protective Services (CPS) ever been called about the child(ren) in this case? If yes, which County: Santa Clara Other (County name): Yes No Are there any custody orders about the child(ren) in this case? If yes, which County: Santa Clara Other (County name): Information about the CHILD(REN) Child Name: Birth Date: Social Security Number: School, Grade, School Telephone Number : Child Name: Birth Date: Social Security number: School, Grade, School Telephone Number : Child Name: Birth Date: Social Security Number: School, Grade, School Telephone Number : Check if there are more children in the case add information about them on another page. CONFIDENTIAL ­ DO NOT PUT IN COURT FILE REFERRAL FOR COURT INVESTIGATOR & QUESTIONNAIRE - GUARDIANSHIP (PROBATE) Rev. 1/01/07 PB-4005 Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com ATTACHMENT PB-4005 Information about the PROPOSED GUARDIANS'S ATTORNEY Proposed Guardian doesn't have an attorney Name: Address: Phone Number: Fax Number: Information about the PROPOSED GUARDIAN(S) Proposed Guardian Name: Relationship to child(ren): Birth Date: Social Security Number: Driver's License Number : Home Address: Home Phone Number: Work Address: Work Phone Number: Fax Number: Cell Phone Number: Grandparent Aunt/Uncle Other: : Proposed Guardian Name: : Relationship to child(ren): Birth Date: Social Security Number: Driver's License Number : Home Address: Home Phone Number: Work Address: Work Phone Number: Grandparent Aunt/Uncle Other: Cell Phone Number: Fax Number: All proposed Guardians must answer these questions: 1. Have you ever been convicted of a misdemeanor or felony offense ? If yes, what offense(s): Date: Yes County: No 2. Is there a social worker, probation or parole officer supervising you or ANY person who lives with you ? Yes No If yes, explain: CONFIDENTIAL ­ DO NOT PUT IN COURT FILE REFERRAL FOR COURT INVESTIGATOR & QUESTIONNAIRE - GUARDIANSHIP (Probate) Rev. 1/.01/07 PB-4005 Page 2 of 3 American LegalNet, Inc. www.FormsWorkflow.com ATTACHMENT PB-4005 I/We declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date: Proposed Guardian 1 signs here: Date: Proposed Guardian 2 signs here: Information about OTHER ADULTS (age 18 or older) WHO LIVE IN YOUR HOME Name: Birth Date: Social Security Number: Driver's License Number : State: Name: Birth Date: Social Security Number: Driver's License Number : State: Name: Birth Date: Social Security Number: Driver's License Number : State: Name: Birth Date: Social Security Number: Driver's License Number : State: Name: Birth Date: Social Security Number: Driver's License Number : State: More adults live in my home. I've attached information about them on a separate page. CONFIDENTIAL ­ DO NOT PUT IN COURT FILE REFERRAL FOR COURT INVESTIGATOR & QUESTIONNAIRE - GUARDIANSHIP (Probate) Rev. 1/.01/07 PB-4005 Page 3 of 3 American LegalNet, Inc. www.FormsWorkflow.com