MERCED COUNTY SUPERIOR COURT COURT INVESTIGATIONS GUARDIANSHIP QUESTIONNAIRE Minor's Name Case No. Hearing Date: 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. 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 CA ID/DL NO. SOCIAL SECURITY NO. 2. 3. LIST ALL ADDRESSES FOR THE PAST 5 YEARS 1. PHONE NO. FROM PHONE NO. FROM TO OWN RENT RENT/MORTGAGE $ /MONTH LAST GRADE OF SCHOOL ATTENDED OWN RENT RENT/MORTGAGE $ 1-7 8 10 11 COLLEGE GRADUATE FATHER'S NAME TO OWN RENT RENT/MORTGAGE $ /MONTH 9 SOME COLLEGE YOUR HEALTH PHONE NO. FROM TO /MONTH 12 MASTERS MOTHER'S NAME 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 IF YES, PLEASE LIST: OFFENSE OTHER THAN A MINOR TRAFFIC VIOLATION? YES NO DATE HAVE YOU EVER BEEN OR ARE YOU ON IF YES, PLEASE LIST: PROBATION/PAROLE? NO DATE DO YOU DRINK ALCOHOLIC BEVERAGES? YES YES CITY CITY OUTCOME OFFICER/AGENT/TELEPHONE NO. NO HOW MUCH/OFTEN? WHAT DRUGS DO/DID YOU USE? HOW MUCH/OFTEN? VIOLATION WHEN DID YOU LAST USE? DAILY WEEKLY HAVE YOU EVER ENTERED OR COMPLETED MONTHLY COST? IF YES, GIVE DETAILS: AN ALCOHOL OR DRUG TREATMENT PROGRAM? YES NO HAVE YOU EVER HAD CONTACT WITH A CHILD IF YES, GIVE DETAILS AND COUNTY: PROTECTIVE SERVICE AGENCY? YES NO ARE YOU MARRIED DIVORCED DATES AND PLACE OF ALL MARRIAGES: MER-0014 (Rev. 02/2008) SEPARATED WIDOWED CHILDREN OF THE MARRIAGE: LIVING TOGETHER DATE/REASON FOR END OF MARRIAGE: COURT INVESTIGATIONS GUARDIANSHIP QUESTIONNAIRE Page 2 of 7 American LegalNet, Inc. www.FormsWorkFlow.com PERSONAL HISTORY SPOUSE OR SIGNIFICANT OTHER FULL NAME OTHER NAMES/MAIDEN DATE OF BIRTH/BIRTHPLACE CA ID/DL NO. SOCIAL SECURITY NO. 2. 3. LIST ALL ADDRESSES FOR THE PAST 5 YEARS 1. PHONE NO. FROM PHONE NO. FROM TO OWN RENT RENT/MORTGAGE $ OWN RENT RENT/MORTGAGE $ /MONTH LAST GRADE OF SCHOOL ATTENDED 1-7 8 10 11 COLLEGE GRADUATE FATHER'S NAME TO OWN RENT /MONTH RENT/MORTGAGE $ 9 SOME COLLEGE YOUR HEALTH PHONE NO. FROM TO /MONTH 12 MASTERS MOTHER'S NAME 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 IF YES, PLEASE LIST: OFFENSE OTHER THAN A MINOR TRAFFIC VIOLATION? YES NO DATE CITY HAVE YOU EVER BEEN OR ARE YOU ON DATE OUTCOME IF YES, PLEASE LIST: PROBATION/PAROLE? YES NO VIOLATION DO YOU DRINK ALCOHOLIC BEVERAGES? YES WHAT DRUGS DO/DID YOU USE? HOW MUCH/OFTEN? CITY NO OFFICER/AGENT/TELEPHONE NO. HOW MUCH/OFTEN? WHEN DID YOU LAST USE? DAILY WEEKLY HAVE YOU EVER ENTERED OR COMPLETED AN MONTHLY COST? IF YES, GIVE DETAILS: ALCOHOL OR DRUG TREATMENT PROGRAM? YES NO HAVE YOU EVER HAD CONTACT WITH A CHILD IF YES, GIVE DETAILS AND COUNTY: PROTECTIVE SERVICE AGENCY? YES NO ARE YOU MARRIED DIVORCED DATES AND PLACE OF ALL MARRIAGES: MER-0014 (Rev. 02/2008) SEPARATED CHILDREN OF THE MARRIAGE: WIDOWED LIVING TOGETHER DATE/REASON FOR END OF MARRIAGE: 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? TITLE: DAYS/HOURS YOU WORK OTHER INCOME TANF AMOUNT $ SOCIAL SECURITY MO/WK UNEMPLOYMENT 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: HAVE YOU EVER FILED FOR BANKRUPTCY? YES ACCOUNT NUMBERS: IF YES, GIVE DATE PLACE AND RESULT: NO DO YOU SUPPORT ANYONE OUTSIDE OF YOUR RESIDENCE? YES IF YES GIVE NAME/RELATIONSHIP AND REASON: NO SPOUSE/SIGNIFICANT OTHER NAME/ADDRESS/PHONE OF EMPLOYER HOW LONG? TITLE: DAYS/HOURS YOU WORK OTHER INCOME TANF AMOUNT $ SOCIAL SECURITY MO/WK UNEMPLOYMENT 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: HAVE YOU EVER FILED FOR BANKRUPTCY? YES IF YES, GIVE DATE PLACE AND RESULT: NO DO YOU SUPPORT ANYONE OUTSIDE OF YOUR RESIDENCE? YES NO MER-0014 (Rev. 02/2008) ACCOUNT NUMBERS: IF YES GIVE NAME/RELATIONSHIP AND REASON: 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? YES NO FULL TERM BIRTH? DOES CHILD HAVE MEDICAL PROBLEMS? YES NO IF YES, EXPLAIN: 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? YES NO IF YES, NAME: IS CHILD IN A DAYCARE PROGRAM? YES NO YES NO IF YES, PROVIDER: GIVE ALL OF THE ABOVE INFORMATION ON ALL CHILDREN PROPOSED TO BE UNDER GUARDIANSHIP. YOU CAN USE THE REVERSE OF THIS PAGE OR A SEPARATE SHEET. ATTACH COPIES OF BIRTH CERTIFICATES FOR EACH CHILD PROPOSED TO BE UNDER GUARDIANSHIP. MER-0014 (Rev. 02/2008) COURT INVESTIGATIONS GUARDIANSHIP QUESTIONNAIRE Page 5 of 7 American LegalNet, Inc. www.FormsWorkFlow.com BIRTH PARENTS MOTHER'S FULL NAME OTHER NAMES/MAIDEN DATE OF BIRTH/BIRTHPLACE CA ID/DL NO. SOCIAL SECURITY NO. ADDRESS TELEPHONE NO. NAME/ADDRESS OF EMPLOYER TELEPHONE NO. IS MOTHER IN AGREEMENT WITH GUARDIANSHIP? YES DOES MOTHER CONTRIBUTE TO THE NO SUPPORT OF CHILD? DOES MOTHER HAVE ANY OTHER CHILDREN NOT A PARTY TO THIS ACTION? YES DOES MOTHER VISIT WITH CHILD? YES NO YES NO IF YES: NO NAME AGE HAS THE MOTHER EVER BEEN ARRESTED AND/OR CONVICTED? YES NO IF YES, GIVE DETAILS: HAS CPS EVER INVESTIGATED THE MOTHER? YES NO IF YES, GIVE DETAILS: FATHER'S FULL NAME OTHER NAMES DATE OF BIRTH/BIRTHPLACE CA ID/DL NO. SOCIAL SECURITY NO. ADDRESS TELEPHONE NO. NAME/ADDRESS OF EMPLOYER TELEPHONE NO. IS FATHER IN AGREEMENT WITH GUARDIANSHIP? YES DOES FATHER CONTRIBUTE TO THE NO SUPPORT OF CHILD? DOES FATHER HAVE ANY OTHER CHILDREN NOT A PARTY TO THIS ACTION? YES YES DOES FATHER VISIT WITH CHILD? NO YES NO IF YES: NO NAME AGE HAS THE FATHER EVER BEEN ARRESTED AND/OR CONVICTED? YES NO IF YES, GIVE DETAILS: HAS CPS EVER INVESTIGATED THE FATHER? YES NO IF YES, GIVE DETAILS: GENERAL INFORMATION WERE THE PARENTS EVER MARRIED? YES NO IF YES, STATUS? IF NO, WAS PATERNITY EVER ESTABLISHED? YES NO IF YES, CASE NO. COUNTY/STATE IS THERE AN ORDER FOR SUPPORT? YES NO IF YES, HOW MUCH? PAID TO? IS THERE A CUSTODY ORDER BETWEEN THE PARENTS FOR THE CHILD? YES NO IF YES, CASE NO. MER-0014 (Rev. 02/2008) COURT INVESTIGATIONS GUARDIANSHIP QUESTIONNAIRE Page 6 of 7 American LegalNet, Inc. www.FormsWorkFlow.com GENERAL INFORMATION CONT'D HAVE YOU, YOUR SPOUSE, ANOTHER ADULT IN THE HOME, OR THE PARENTS BEEN INVOLVED IN ANY OF THE FOLLOWING? RECEIVED COUNSELING FOR DOMESTIC VIOLENCE? YES NO IF YES, WHO/WHY? DOMESTIC DISPUTE WHERE LAW ENFORCEMENT WAS CALLED? YES NO IF YES, WHO/WHY? BEEN THE SUBJECT OF A DOMESTIC OR CIVIL RESTRAINING ORDER? YES NO IF YES, WHO/WHY? ADDITIONAL INFORMATION LIST ANY OTHER INFORMATION YOU FEEL MAY BE HELPFUL TO THE INVESTIGATION. I DECLARE UNDER THE PENALTY OF PERJURY THAT THE INFORMATION ON THIS FORM IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. DATED: NAME OF PETITIONER MER-0014 (Rev. 02/2008) COURT INVESTIGATIONS GUARDIANSHIP QUESTIONNAIRE SIGNATURE Page 7 of 7 American LegalNet, Inc. www.FormsWorkFlow.com