SUPERIOR COURT OF CALIFORNIA, COUNTY OF RIVERSIDE PALM SPRINGS 3255 E. Tahquitz Canyon Wy., Palm Springs, CA 92262 RIVERSIDE 4050 Main St., Riverside, CA 925 01 TEMECULA 41002 County Center Dr., #100, Temecula, CA 92591 RI - PR 092 ATTORNEY OR PARTY WITHOUT ATTORNEY ( Name, State Bar Number and Address) FOR COURT USE ONLY (CONFIDENTIAL) TELEPHONE NO.: FAX NO. (Optional): E - MAIL ADDRESS (Optional): ATTORNEY FOR (Name ): IN THE MATTER OF: CASE NUMBER: SOCIAL HISTORY OF GUARDIAN/PARENT I. IDENTIFYING INFORMATION 1. a. Your Full Name: FIRST MIDDLE LAST aka/and/or maiden name: Pr imary Language Spoken: Do you need an interpreter? Place of Employment: b. Name of Spouse or Significant Other: FIRST MIDDLE LAST aka/and/or maiden name: Phone number Home: Work: Place of Employment: Social Security Number: 2. How long at your present address? Own? Rent? 3. Do you drink alcohol, use drugs or take any k ind of medication? If so, please indicate how frequently and explain. You: No Yes (explain): Spouse/Significant Other: No Yes (explain): Page 1 of 3 Adopted for Mandatory Use Riverside Superior Court Form RI - PR 092 [Rev. 01/01/19 ] SOCIAL HISTORY OF GUARDIAN/PARENT Probate Code 1513 riverside.courts.ca.gov/localfrms/loc alfrms.shtml American LegalNet, Inc. www.FormsWorkFlow.com IN THE MATTER OF: CASE NUMBER: 4. List all adults living in your home: Name Date of Birth Social Security No. Relationship 5. Has any adult living in your home ever been convicted of an offense other than a minor traffic ticket? No Yes (If yes, in an attached sheet of paper give the name of the individual, the date, place, and detail o f each offense) 6. Has any person living in your home lived in another state or used an alias? No Yes (If yes, state each Name: State: Alias: Name: State: Alias: Name: State: Alias: Name: State: Alias: 7. Have you or your spouse/significant other been approved previously of guardianship, foster care and/or adoption? No Yes (If yes, state the name, address, phone number of the approving entity and date of approval) a. Name of Child(ren): b. Address: c. Name of Approving Entity: d . Address and County: e. Date of Approval: f. If the proceeding has been terminated, the Date Terminated: g. Reason for termination: I I . FINANCIAL INFORMATION 8. Your Monthly net income(s) (All Sources ): $ Monthly expenses: $ 9. Is medical insurance available to minor? No Yes If so, give name of Insurer: 10. Do you receive public assistance? No Yes If so, amount $ 11. Do you pay or receive Child Support (for your own children)? No Yes Paying: $ Receiving: $ Page 2 of 3 Adopted for Mandatory Use Riverside Superior C ourt Form RI - PR 092 [Rev. 01/01/19 ] SOCIAL HISTORY OF GUARDIAN/PARENT Probate Code 1513 riverside.courts.ca.gov/localfrms/localfrms.shtml American LegalNet, Inc. www.FormsWorkFlow.com IN THE MATTER OF: CASE NUMBER: I I . YOUR MARRIAGES 12. Are you currently: Married Divorced Separated Widowed Never Married 13. Date of Present Marriage: 14. Do you or your spouse/ significant other have any children from a current or previous relationship? No Yes 15. If yes, complete the information below: Name of Child Date of Birth 16. Do all of these children live with you? Yes No List Names of Children who live with you: I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date: (PRINT NAME) (SIGNATURE) Page 3 of 3 Adopted for Mandatory Use Rivers ide Superior Court Form RI - PR 092 [Rev. 01/01/19 ] SOCIAL HISTORY OF GUARDIAN/PARENT Probate Code 1513 riverside.courts.ca.gov/localfrms/localfrms.shtml American LegalNet, Inc. www.FormsWorkFlow.com