ALAMEDA COUNTY SUPERIOR COURT 125-12th Street, Suite 390 OAKLAND, CA 94607 (510) 636-8820 510-451-2269 FAX PROBATE GUARDIANSHIPS - PROBATE CODE DIVISION IV IMPORTANT INFORMATION REGARDING YOUR FILING - PLEASE READ The Court Investigator conducts an investigation and prepares a report on every petition for appointment of a guardian who is related to the child. Child Protective Services (CPS) conducts the investigation and prepares the report, if the proposed guardian is a non-relative. Everyone requesting a guardianship must do the following: 1. Mail a Copy of the petition and notice of hearing to Child Protective Services. 2. Complete the two page form titled “Guardianship Screening Pursuant to Probate Section 1516” and return it directly to Child Protective Services at: Child Protective Services, K-230 P.O. Box 1769 Oakland, CA 94604-1769 If these forms are not received by CPS at least 45 days prior to your hearing, you must appear in court on your hearing date to request a continuance. In addition, if you are not related to the child you must mail a copy of the petition and notice of hearing to: Director of Social Services 744 P Street, M.S. 19-31 Sacramento, CA 95814 Rev.: 10/24/08 (CI) American LegalNet, Inc. www.FormsWorkflow.com GUARDIANSHIP SCREENING PURSUANT TO PROBATE CODE SECTION 1516 GUARDIANSHIP OF: _____________________________________________________________________ PROBATE NO.:_________________________________ HEARING DATE:__________________________ IN ORDER TO PREVENT ANY DELAY IN YOUR HEARING, YOU MUST COMPLETE PAGE ONE OF THIS FORM IN ITS ENTIRETY AND FORWARD WITHIN FIVE DAYS TO: CHILD PROTECTIVE SERVICES, K-230 P. O. Box 1769 Oakland, CA 94604-1769 (510) 268-2463 A COPY OF EACH CHILD’S BIRTH CERTIFICATE MUST BE ATTACHED TO THIS FORM. *IT IS ESSENTIAL THAT THE RELATIONSHIP AND DATE OF BIRTH OF THE PROPOSED GUARDIAN(S) BE PROVIDED. Probate Number: Hearing Date: *************************************************************************************************************************** Name(s) of Proposed Ward(s): Date(s) of Birth: Address: Phone Number: Is this child a ward of the Court or on probation? YES/NO **************************************************************************************************************************** Name of proposed guardian(s): Date(s) of Birth: Address: Phone Number: Are you related to the mother or father of the minor child(ren)? . Is this relationship by blood or marriage? ***************************************************************************************************************************** Child’s mother’s name: _________________________ Father’s name:___________________________ Date of Birth: Address: _____________ Date of Birth:____________________________ _________________________ Address:________________________________ Who will object to this guardianship? ___________ *************************************************************************************************************************** Attorney of Record: Address: Phone Number: **ATTORNEY: This document will be forwarded directly to the Court from Child Protective Services.** DEPARTMENT OF SOCIAL SERVICES USE ONLY [ ] NO INFORMATION AVAILABLE [ ] INFORMATION AVAILABLE 1 of 2 (GP3) American LegalNet, Inc. www.FormsWorkflow.com Title 1516 FOR SOCIAL SERVICE DEPARTMENT USE ONLY GUARDIANSHIP OF: PROBATE NUMBER: HEARING DATE: SUMMARY OF INFORMATION 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com PROPOSED GUARDIAN’S QUESTIONNAIRE INSTRUCTIONS Please read these instructions carefully. If there is to be more than one guardian, each guardian must complete a separate copy of the questionnaire. All proposed guardians are required to complete this questionnaire. If you are a relative, return it to the Court Investigator’s Office. If you are not a relative return it to Child Protective Services Guardianship Unit. The information you provide will be used to prepare the report to the judge on your suitability as a guardian. This form is also available on the court’s website at: http://www.alameda.courts.ca.gov/courts/forms/guardianpacket.pdf Each guardian is expected to answer all questions honestly. On the last page you are required to sign the form and declare, under penalty of perjury, that all the information you have provided is true and correct. When completing this form please keep in mind that the term “proposed guardian” refers to the person who wants to become the guardian. The term “proposed ward” or “ward” refers to the child you are asking to become the guardian for. The term “petitioner” refers to the person who signed the petition asking the court to appoint a guardian. If you are asking to be appointed solely as guardian of the estate, a telephone interview will be conducted by the court investigator. If you are asking to be appointed as guardian of the person (or person and estate), a home visit is required. Everyone who lives in the home must be present during the home visit. After this form is received, a court investigator or social worker will contact you to make an appointment. If the form is not received promptly, your court hearing may be delayed up to 3 months. There is a fee for the Court Investigation. It is currently $800.00 and can be paid from the estate of the ward, if there is one, or by the proposed guardian or the parents. The fee may be waived under certain circumstances based on financial inability to pay. To obtain this waiver, you must file an Application for Waiver of Court Fees and Costs (also known as an IFP waiver) through the Clerk’s Office. In some cases you may make arrangements for monthly payments through Alameda County Central Collections. Please keep in mind: 1. ALL QUESTIONS MUST BE ANSWERED. 2. IF YOU NEED ASSISTANCE IN FILLING OUT THIS QUESTIONNAIRE, PLEASE CALL THE COURT’S SELF-HELP CENTER AT (510) 272-1393. 3. IF THE PROPOSED GUARDIAN IS A RELATIVE, SEND THE COMPLETED QUESTIONNAIRE TO THE COURT INVESTIGATOR’S OFFICE. IF THE PROPOSED GUARDIAN IS A NONRELATIVE SEND IT TO CHILD PROTECTIVE SERVICES. COURT INVESTIGATOR’S OFFICE 125-12th STREET, SUITE 390 OAKLAND, CA 94607-4912 CHILD PROTECTIVE SERVICES, K-230 P.O. BOX 1769 OAKLAND, CA 94604-1769 American LegalNet, Inc. www.FormsWorkflow.com PROPOSED GUARDIAN’S QUESTIONNAIRE YOU MUST ANSWER ALL QUESTIONS. (Write in “n/a” if a question does not apply to your situation.) CASE NO. HEARING DATE: CHILD(REN) NEEDING GUARDIAN: NAME DATE OF BIRTH 1. 2. 3. More children listed on back. (Note: Child needing guardian is also called “proposed ward.”) NAME(S) OF PROPOSED GUARDIAN(S) _____________________________________________________ Will you or anyone else in the home require an interpreter? YES NO Language :__________________ SECTION I SOCIAL HISTORY OF PROPOSED GUARDIAN (Probate Code 1513(a)(1)): (This information is about the person who wants to be guardian. Please complete a separate questionnaire for each proposed guardian.) Name: Date of Birth Your Daytime phone number: Home Address: ___________________________________________________________________________ Home phone number: Place of Birth: Social Security No.: Driver’s License No.: Do you have a criminal history, including any arrests? Yes No Note: The Court Investigator will conduct a criminal background check. Are you Married Widowed Single Separated Divorced If married or separated, what is the name of your spouse? Were you previously married or living with someone in a long-term, live-in relationship? Yes No If yes, provide name(s) of “Ex,” date of event (divorce, separation or death) that ended the relationship. NAME DATE (of death, divorce, separation) NAME DATE List your children (even if they are adults and not living with you. Also provide their date of birth, address, and whether they have ever been arrested/charged with a crime) NAME BIRTH DATE ADDRESS ARRESTED? YES NO YES NO YES NO YES NO YES NO More children listed on back. 1 of 9 American LegalNet, Inc. www.FormsWorkflow.com YOUR HEALTH CONDITION: Please describe any current physical or mental health problems. Are you being treated by a doctor or other health care practitioner? YES NO If yes, why? Please list any medications you are currently taking and state what they are for ________________________ ________________________________________________________________________________________ Have you ever been in counseling? If yes, reason for counseling: YES Drugs NO Alcohol Grief Domestic Violence Other Explain:_ ________________________________________________________________________________________ ________________________________________________________________________________________ EDUCATIONAL HISTORY: Last school attended: ________ Degree(s) earned: ___________ Where & When: _____ Where & When: _________________ Other courses taken: MILITARY HISTORY: Branch of Service: Type of Discharge: Date Entered: Honorable General Date Discharged: Good of Service Dishonorable EMPLOYMENT: Are you employed? YES NO Name of Employer Address: Length of employment: Job Title: Responsibilities/duties: Are you retired or have you been at your current employment for less than five years? If yes, please list your work history for the past five years: YES NO Name of Employer Employed From To Name of Employer Employed From To Name of Employer Employed From To Name of Employer Employed From To PROPOSED GUARDIAN’S FINANCIAL INFORMATION: Income: Monthly take-home pay $______________________________ Other monthly income: Welfare SSI Unemployment Spousal/Child Support Investments Total Monthly Income $ Amount $ $ $ $ $ 2 OF 9 Does anyone else contribute money to the household? YES NO American LegalNet, Inc. www.FormsWorkflow.com If yes, who? _______________________________ How much? $_______________________________ Does anyone else contribute money for the support of the child(ren) needing the guardianship? YES NO If yes, who? ________________________________ How much? $_______________________________ Your financial Resources Checking Accounts Savings Accounts Other Investments Balance $ Balance $ Value $ Expenses: Names of the persons you support: Rent $ /month Mortgage $ /month Credit Card Debts/Car Payment/other regular monthly payments $ Total monthly expenses $ Are you financially able to support the child(ren)? If no, what assistance will you receive? YES NO Have you applied for or, are you already receiving financial assistance for this child ? YES NO Welfare Amount $ Social Security Amount $ Medi-Cal Amount $________________ Child Support Amount $________________ Is someone else, such as a parent, receiving the above benefits for the child(ran)? UNKNOWN YES NO Who: REFERENCES: Please list three references who have known you at least five years and who are friends, not relatives. Give complete name, complete address, including zip codes and daytime phone numbers. Please notify them that we will be contacting them by letter or telephone. NAME ADDRESS DAYTIME TELEPHONE If you cannot provide 3 non-relative references, please explain: HOBBIES: Please describe any hobbies or activities you enjoy in your spare time: Anything else about you that relates to your ability to be a guardian: ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ 3 of 9 American LegalNet, Inc. www.FormsWorkflow.com SECTION II APPROPRIATENESS OF THE HOME ENVIRONMENT: Single family home Apartment/condominium Number of bedrooms _____ number of bathrooms _____ How long have you lived here? Will ward have own room YES NO. If shared, with whom? Name: age: Do you have any guns or other weapons stored on the property? YES NO If yes, what type of weapon? ______________________ Where and how stored? ______________________ Is there a swimming pool or hot tub? YES NO If Yes, where is it located? _______________________ Pets in the home: _________________________________________________________________________ OTHER CHILDREN IN THE HOME: (under 18 years of age) Name Birth date School Attending OTHER ADULTS IN THE HOME: (18 and over) Name Birth date Social Security # Relation to guardian Employer/school Relation to guardian Does any adult in the home have any problem that could affect the minor, for example, child abuse/molest, criminal background, violent behavior, alcohol or drug problem? NO YES Explain, Have the police ever been to your home? YES NO Does anyone in the home object to the guardianship? YES NO If yes, who? How do other family members feel about having proposed ward(s) in the home? SECTION III SOCIAL HISTORY OF THE PROPOSED WARD(S): Please complete the following about the child(ren) needing a guardian: Name Sex Date of Birth Place of Birth Social Security # More listed on back 4 of 9 1. Has the child(ren) been involved with the Juvenile Court? YES NO DON’T KNOW American LegalNet, Inc. www.FormsWorkflow.com 2. Does the child(ren) have a Social Worker? YES NO DON’T KNOW If, yes, who is the Social Worker? __________________________ Telephone No. _______________ 3. Is the child(ren) subject to any existing legal custody orders? If yes, type of order: guardianship divorce YES paternity NO juvenile court DON’T KNOW adoption proceedings. Date of the order: ____________________ Case Number: _________________________________ and where the proceeding took place: (County)_______________________ (State) ______________ 4. Does someone object to this petition? YES NO Who? 5. _____ Are you related to the child? If yes, are you related to the child’s Related by: YES NO Mother Father Blood Marriage How are you related? (for example: I am the child’s mother’s sister) If not related, how do you know the child? 6. Why do you need the guardianship? _____________________________________________________________________________________ 7. Who brought the child(ren) to you? ____________________________________________ ___ Why? ________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ 8. Please describe the child’s adjustment to your home ____________________________________________________________________________ 9. Does the child have brothers and sisters? YES NO Please provide names & ages of the brothers and sisters and name of person with whom they live: NAMES of child’s brothers and sisters AGE 10. Does the child visit his/her brothers and/or sisters? YES WITH WHOM THEY LIVE NO How often?___________________ 5 of 9 American LegalNet, Inc. www.FormsWorkflow.com 11. Is there any specific religious or cultural heritage, such as Native American ancestry, that would be a factor in future plans? _________________________________________________________________________ 12. Does the family have Native American ancestry or receive any medical or other services/benefits from a tribe? YES NO UNKNOWN If yes, please explain:______________________________________ 13. Has the child(ren) been subjected to abuse, neglect, or abandonment? UNKNOWN YES NO If yes, explain: SCHOOL AND/OR DAY CARE: Please contact the school or daycare and let them know we will be contacting them. Also, please attach a copy of the child’s most recent report card to this questionnaire.. Name Director or Principal Address Phone Number Fax Number: Teacher’s Name Grade level Is Daycare Licensed? __________ How is the child doing in school? (Attach copy of recent report card.) Does the child have any problems with teachers or other children in school? What school and non-school activities does the child participate in? (school sports, scouting, dance, Little League, martial arts, soccer) Does the child have any special educational needs? Describe YES NO Is the child receiving Special Education/Resource Services? Describe YES NO Is the child receiving services through the Regional Center? YES NO Case manager: Telephone No. If the child has special needs, what are your plans to provide for these needs? ________________________________________________________________________________________ MEDICAL/HEALTH CARE: (Please contact doctor/clinic to let them know we will be contacting them. Also, please attach a copy of the child’s immunization record.) Doctor’s Name: Address: Phone Number: Fax Number: ___________________________________ Medical Insurance: Medical Number: Date of last appointment: For what: 6 of 9 American LegalNet, Inc. www.FormsWorkflow.com Are all required immunizations current? YES NO Does the child have any medical problems, physical or developmental disabilities, etc.? If yes, what is your plan to meet these needs: Does the child take any prescribed medications? YES YES NO NO If yes, what? _____________________________________________________________________________ Does the child have any behaviorial, emotional or psychological problems? YES NO Describe Has the child ever been hospitalized? YES NO Has the child received counseling in the past? YES NO If yes, what for: _____ Is the child still receiving counseling? YES NO If yes, how often? Name of counselor: Address: Phone Number: Fax Number: _________________ Let counselor know we will be contacting him/her. SECTION IV INFORMATION ABOUT THE NATURAL PARENTS OF PROPOSED WARD(S): The Court Investigator may need to contact the parents so current information is needed. Are the parents Mother’s Name: Married Separated Divorced Date of Birth: Live together SSN: If deceased, date of death: Address: Phone Number: Employed at: ___ Monthly Income: $____________________ Is mother paying child support? YES Does proposed ward(s) see mother? NO YES DON’T KNOW Amount $ NO Explain: Does the mother agree with the guardianship? YES Does the mother have Native American Ancestry? YES __________ NO DON’T KNOW NO DON’T KNOW Father’s Name: Date of Birth: If deceased, date of death: Address: Phone Number: Employed at: ___ Monthly Income: $____________________ Is father paying child support? YES Does the proposed ward(s) see father? NO YES DON’T KNOW Amount NO Explain:_________________________________ Does the father agree with the guardianship? YES NO DON’T KNOW Does the father have Native American Ancestry? YES NO DON’T KNOW To your knowledge, are natural parents: Involved in drugs? YES NO DON’T KNOW Which parent? 7 OF 9 In jail or prison? YES NO DON’T KNOW Which parent ? Where? ____ American LegalNet, Inc. www.FormsWorkflow.com In the military? YES NO Don’t KNOW Which parent?_______________Where? __________ SECTION V - GUARDIANSHIP OF THE ESTATE COMPLETE THIS SECTION IF YOU WANT TO BE APPOINTED GUARDIAN OF THE ESTATE. IF NOT NEEDED, SKIP THIS SECTION AND CONTINUE ON TO THE NEXT PAGE Where is the money or property coming from that the child will be receiving: Inheritance - Attach a copy of the will or provide Name of the deceased person__________________________ Date of death: Probate Case No.______________ Estate administered in (county) (state) Child will be inheriting: Real Property - Address Value of minor’s interest $ Cash, $ Location Stock/Bonds $ Location Other, describe Insurance benefit, Name of insured________________________________ Relation to child _________ Value $_______________ Gift from (Name) (relation) Nature of asset (cash, real property, etc.) ______________________ Value $____________________ Personal Injury Settlement – Case No. ________________, in (county) _____________________, (state)____________________ where the case was settled. Value $ _____________________________ Other source, describe Value $ What are your plans for managing the estate? (Money to be placed in a blocked bank account? investments? rental of real property? etc.) Does the minor already have money in an individual or joint account? YES NO DON’T KNOW Location: __________________________, balance: $___________________name(s) on individual and/or joint accounts: Does the minor already have any other investments or property? YES NO DON’T KNOW What ____________________________________________ Value $_________________ Do you expect to request to use the minor’s estate for any purpose (taxes, tax preparation, bond premiums, court costs/fees and other expenses)? YES NO If yes, what expenses will you request the court to approve? _______________________________________ 8 of 9 American LegalNet, Inc. www.FormsWorkflow.com Please provide the name, address and phone number of one person who will always know how to get in contact with you. (Name) (Address) (Telephone) Name of attorney or person who helped you complete this form Address Bar No. ____________________ Phone Number Fax Number VERIFICATION I/We the undersigned declare under the penalty of perjury that the foregoing is true and correct. Executed in California on City . Date Signatures 9 of 9 Rev: 10/24/08 (CI) American LegalNet, Inc. www.FormsWorkflow.com