MARIN COUNTY SUPERIOR COURT Court Investigator's Office PROPOSED GUARDIAN INFORMATION FORM Important Information Regarding Your Filing - Please Read Everyone requesting a guardianship must do the following: 1) Complete and sign the following forms: a. Petition for Appointment of Guardian of the Person (Form GC-210(P)) or Petition for Appointment of Guardian of Minor (Form GC-210); b. Guardianship Petition – Child Information Attachment (Form GC-210(CA); c. Declaration Under Uniform Child Custody, Jurisdiction and Enforcement Act (UCCJEA)(Form FL-105/GC-120); d. Confidential Guardian Screening Form (Form GC-212); e. Notice of Hearing - Guardianship or Conservatorship (Form GC-020); f. The attached questionnaire. 2) After you have completed and signed the above forms, make two copies of each of the forms listed in a. through e. above and file them with the Marin Superior Court Clerk’s Office at 3501 Civic Center Drive, Room 113, San Rafael, CA 94903. You should make a copy of the attached questionnaire for your records, but you only need to bring the original to the Court Clerk’s Office. 3) There are additional forms you will need to complete and bring to court before your hearing. They include: a. b. Letters of Guardianship (Form GC-250); c. 4) Order Appointing Guardian of Minor (Form GC-240); Duties of Guardian (Form GC-248) The Court Clerk will set a court date and forward all of your paperwork to the agency that will conduct the investigation and prepare the report for the court. If you are related to the child the investigation is conducted by the Court Investigator and if you are not related to the child, the investigation is conducted by Marin County Children and Family Services. They are located at: Marin County Superior Court Court Investigator's Office 3501 Civic Center Drive, Room 116 San Rafael, CA 94903 (415) 473-7187 (415) 473-3715, Fax PR007 (Rev. 3/09) Marin County Children & Family Services Adoptions, Foster Care Licensing & Guardianship Unit 3250 Kerner Blvd. San Rafael, CA 94903 (415) 473-2200 PROPOSED GUARDIAN INFORMATION FORM Page 1 of 12 American LegalNet, Inc. www.FormsWorkflow.com PROPOSED GUARDIAN INFORMATION FORM 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. 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: www.marincourt.org. 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. You only need to fill out Section I and V only. The cost of the investigation is $150.00. 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. There is a fee for the Court Investigation. It is currently $625.00 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 Marin Court Accounting Department, (415) 473-6236. Please keep in mind: 1. ALL QUESTIONS MUST BE ANSWERED. 2. IF YOU NEED ASSISTANCE IN FILLING OUT THE FORMS OR HAVE QUESTIONS ABOUT THE LEGAL REQUIREMENTS, PLEASE CALL THE COURT’S SELF-HELP CENTER AT (415) 492-1111. PR007 (Rev. 3/09) PROPOSED GUARDIAN INFORMATION FORM Page 2 of 12 American LegalNet, Inc. www.FormsWorkflow.com 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 ("proposed ward"): Name Date of Birth Name Date of Birth Name Date of Birth More children listed on back NAME(S) OF PROPOSED GUARDIAN(S): Name Name How are you related to the proposed ward?: 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 Address City Home No. Work No. Date of Birth State Zip Code Cell No. Place of Birth Marital Status: Married Widowed Single Separated Divorced Domestic Partnership 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) and date(s) of event (divorce, separation or death) that ended the relationship: Name Date of Event Name Date of Event Name Date of Event PR007 (Rev. 3/09) PROPOSED GUARDIAN INFORMATION FORM Page 3 of 12 American LegalNet, Inc. www.FormsWorkflow.com Provide the names of your children (even if they are adults and not living with you): Name D.O.B. Address Arrested? Name D.O.B. Address Arrested? Name D.O.B. Address Arrested? Name D.O.B. Address Arrested? No Yes No Yes No Yes Yes No More children listed on back 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 what they are for: Name of Medication Reason Name of Medication Reason Name of Medication Reason Have you ever been in counseling? No Yes If yes, what was the reason for counseling? Drugs Alcohol Grief Domestic Violence Other: Please explain: EDUCATIONAL HISTORY: Last School Attended Where When Degree(s) Earned Where When Other Courses Taken MILITARY HISTORY: Branch of Service Type of Discharge: PR007 (Rev. 3/09) Date Entered Honorable General Good of Service PROPOSED GUARDIAN INFORMATION FORM Date Discharged Dishonorable Page 4 of 12 American LegalNet, Inc. www.FormsWorkflow.com EMPLOYMENT: Are you employed? No Yes Name of Employer Address City State Job Title Zip Code Length of Employment Job Responsibilities/Duties Are you retired, or have you been at your current employment for less than five years? No Yes If yes, please list your work history for the past five years: Name of Employer Dates Employed From: Name of Employer To: Dates Employed From: Name of Employer To: Dates Employed From: Name of Employer To: Dates Employed From: To: PROPOSED GUARDIAN’S FINANCIAL INFORMATION: FINANCIAL RESOURCES: INCOME: Monthly take-home pay: Other monthly income: Welfare SSI Unemployment Spousal/Child Support Investments $ Total Monthly Income: Checking Account Balance: Savings Account Balance: Value of Other Investments: $ $ $ $ $ $ $ $ $ Does anyone else contribute money to the household? If yes, who? Yes Yes No How much? $ Does anyone else contribute money for the support of the child(ren) needing the guardianship? If yes, who? No How much? $ EXPENSES: Names of the persons you support: PR007 (Rev. 3/09) PROPOSED GUARDIAN INFORMATION FORM Page 5 of 12 American LegalNet, Inc. www.FormsWorkflow.com Rent Mortgage Credit Card Car Payment Other: Other: $ $ $ $ $ $ Total Monthly Expenses: $ Are you financially able to support the child(ren)? Yes No If no, what assistance will you receive? Have you applied for, or are you already receiving financial assistance for this child? Welfare Social Security Medi-Cal Child Support Yes Yes Yes Yes No No No No Amount Amount Amount Amount $ $ $ $ Is someone else, such as a parent, receiving the above benefits for the child(ren)? Yes Unknown No Who? REFERENCES: Please list three references who have known you at least five years and who are friends, not relatives. Please let them know that we will be contacting them by mail or telephone. Name Address Daytime Phone No. City Name Address Zip Code Daytime Phone No. City Name Address State State Zip Code Daytime Phone No. City State Zip Code If you cannot provide three non-relative references, please explain: PR007 (Rev. 3/09) PROPOSED GUARDIAN INFORMATION FORM Page 6 of 12 American LegalNet, Inc. www.FormsWorkflow.com SECTION II APPROPRIATENESS OF THE HOME ENVIRONMENT: Apartment/condominium Single family home # of Bedrooms: # of Bathrooms: Length of time at current address: Will the proposed ward have own room? If shared, with whom? Name: No Yes Age: Do you have any guns or other weapons stored on the property? Yes No If yes, what type of weapon(s)? Where and how stored? Is there a swimming pool and/or hot tub ? No Yes If yes, where? List any pets in the home: OTHER CHILDREN IN THE HOME (under 18 years of age): Name D.O.B. School Attending Relation to Guardian Name D.O.B. School Attending Relation to Guardian Name D.O.B. School Attending Relation to Guardian Name D.O.B. School Attending Relation to Guardian OTHER ADULTS IN THE HOME (18 years and over): Name D.O.B Soc. Sec. # Employer/School Relation to Guardian Name D.O.B Soc. Sec. # Employer/School Relation to Guardian Name D.O.B Soc. Sec. # Employer/School Relation to Guardian Name D.O.B Soc. Sec. # Employer/School Relation to Guardian PR007 (Rev. 3/09) PROPOSED GUARDIAN INFORMATION FORM Page 7 of 12 American LegalNet, Inc. www.FormsWorkflow.com SECTION III SOCIAL HISTORY OF THE PROPOSED WARD(S): Please complete the following about the child(ren) needing a guardian: Name of Proposed Ward Sex D.O.B Place of Birth Soc. Sec. # Does the child have any brothers and/or sisters? (if yes, please list them below) Does the child visit his/her brothers and/or sisters? Name of Brother or Sister No Age Name of Brother or Sister Age Name of Proposed Ward Sex D.O.B Yes Yes If yes, how often? Person with whom they live Person with whom they live Place of Birth Soc. Sec. # Does the child have any brothers and/or sisters? (if yes, please list them below) Does the child visit his/her brothers and/or sisters? Name of Brother or Sister No Age Name of Brother or Sister Age Name of Proposed Ward Sex D.O.B Yes Yes Person with whom they live Place of Birth Name of Brother or Sister No Age Name of Brother or Sister Age Yes No If yes, how often? Person with whom they live Soc. Sec. # Does the child have any brothers and/or sisters? (if yes, please list them below) Does the child visit his/her brothers and/or sisters? No Yes No If yes, how often? Person with whom they live Person with whom they live More children listed on back Are there any specific religious or cultural heritage, such as Native American ancestry, that would be a factor in future plans? Yes No Are or were the child’s parents, grandparents, or great-grandparents members of a tribe, band, or Alaska Native Village? Yes No Are or were the child’s parents, grandparents, or great-grandparents members of, or hold shares in, an Alaska Native corporation? Yes No Has the child or any members of the child's family or extended family ever lived on an Indian reservation, Rancheria, federal trust property, Alaska Native village or other type of predominantly Indian community? Yes PR007 (Rev. 3/09) No PROPOSED GUARDIAN INFORMATION FORM Page 8 of 12 American LegalNet, Inc. www.FormsWorkflow.com Has the child or any members of the child's family or extended family ever attended an Indian school or other facility primarily intended for Native Americans, Indians, or Alaska Natives? Yes No Has the child or any members of the child's family or extended family ever received services or participated in programs primarily directed toward Native American, Indian or Alaska Native people, such as health or dental services from an Indian health service or Tribal Temporary Assistance to Needy Families? Yes No SCHOOL AND/OR DAY CARE: Please attach a copy of the child’s most recent report card to this questionnaire. Also, please contact the school or day care and let them know we will be contacting them by mail or telephone. Name of School or Day Care Grade Level Address City Director/Principal's Name Is Day Care Licensed? State Teacher's Name Telephone No. No Yes Zip Code Fax No. How is the child doing in school? Does the child have any problems with teachers or other children in school? What school and non-school activities does the child participate in? Does the child have any special educational needs? If yes, please explain: How do you plan to provide for these needs? Yes No Is the child receiving Special Education/Resource Services? If yes, please explain: Yes No Is the child receiving services through the Regional Center? Case Manager: No Yes Telephone No. MEDICAL/HEALTH CARE: Please contact the doctor or clinic to let them know we will be contacting them by mail or telephone. Doctor's Name Address Medical Insurance City State Medical Insurance No. Date of last appointment: Telephone No. Fax No. For what reason: Are all required immunizations current? PR007 (Rev. 3/09) Zip Code Yes PROPOSED GUARDIAN INFORMATION FORM No Page 9 of 12 American LegalNet, Inc. www.FormsWorkflow.com Does the child have any medical problems, physical or developmental disabilities, etc.? If yes, please explain: How do you plan to provide for these needs? Yes No Does the child take any prescribed medications? If yes, please list them: Yes No Does the child have any behavioral, emotional or psychological problems? If yes, please explain: Yes No Has the child ever been hospitalized? If yes, please explain: Yes No Has the child received counseling in the past? If yes, for what reason? Yes No Is the child still receiving counseling? If yes, how often? Yes No Counselor's Name Address City Telephone No. State Zip Code Fax No. Please let the counselor know we will be contacting him/her by mail or telephone. 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. The parents are: Separated Married Living together Divorced Mother's Name Soc. Sec. # Date of Birth If Deceased, Date of Death Employer's Name Telephone No. Monthly Income Is the mother paying child support? If yes, amount $ Yes No Does proposed ward(s) see the mother? If yes, how often? If no, please explain Yes No Does the mother agree with the guardianship? Yes No Unknown Does the mother have Native American Ancestry? Yes No Unknown PR007 (Rev. 3/09) PROPOSED GUARDIAN INFORMATION FORM Unknown Page 10 of 12 American LegalNet, Inc. www.FormsWorkflow.com Father's Name Soc. Sec. # Date of Birth If Deceased, Date of Death Telephone No. Employer's Name Monthly Income Is the father paying child support? If yes, amount $ Yes No Does proposed ward(s) see the father? If yes, how often? If no, please explain Yes No Does the father agree with the guardianship? Yes No Unknown Does the father have Native American Ancestry? Yes No Unknown Unknown To your knowledge, are the natural parents: Involved in drugs? Yes No Unknown If yes, Mother Father Both In jail or prison? If yes, where? Yes No Unknown If yes, Mother Father Both In the military? If yes, where? Yes No Unknown If yes, Mother Father Both SECTION V Complete this section if you want to be appointed guardian of the estate. If not, skip to Section VI. GUARDIANSHIP OF THE ESTATE: Where is the money or property coming from that the child is receiving: INHERITANCE: Attach a copy of the will or provide: Date of death: Name of deceased person: Probate Case No.: Estate administered in (County): (State): Child will be inheriting: Real Property - address: Value of minor(s) interest: $ Cash: $ Stocks/Bonds: $ Other: Location: Location: INSURANCE BENEFIT: Name of Insured: Relation to Child: Value $ GIFT: Name of Giftor: Nature of Asset (cash, real property, etc.): PR007 (Rev. 3/09) Relation to Child: Value $ PROPOSED GUARDIAN INFORMATION FORM Page 11 of 12 American LegalNet, Inc. www.FormsWorkflow.com PERSONAL INJURY SETTLEMENT: Case No.: Value $ Case was settled in (County): (State): 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? Location: Yes No Unknown No Unknown Balance $ Name(s) on individual and/or joint accounts: Does the minor already have any other investments or property? Yes Describe: 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? Please provide the name, address and phone number of one person who will always know how to get in contact with you. Name Telephone No. Address City State Zip Code Name of attorney or person who helped you complete this form: Name Telephone No. Address State Bar No. City State Telephone No. Zip Code Fax No. VERIFICATION I/We the undersigned declare under the penalty of perjury that the foregoing is true and correct. Executed in (City) , California on (Date) PRINT NAME SIGNATURE PRINT NAME SIGNATURE PR007 (Rev. 3/09) PROPOSED GUARDIAN INFORMATION FORM Page 12 of 12 American LegalNet, Inc. www.FormsWorkflow.com