COUNTY OF SAN BERNARDINO GUARDIANSHIP QUESTIONNAIRE (Probate Code Section 1513) Non-Relative Relative (Relationship) NOTICE PLEASE BE ADVISED THE INFORMATION PROVIDED ON THIS QUESTIONNAIRE WILL BE USED TO CONDUCT A FULL AND COMPLETE INVESTIGATION OF APPLICANT'S BACKGROUND. THE RESULTS OF THE INVESTIGATION AND RELATIONSHIP HISTORIES WILL BE FULLY REPORTED TO THE COURT. I HAVE READ AND UNDERSTAND THE ABOVE CONDITIONS AND AGREE TO THEM. SIGNATURE: COMPLETE AND RETURN WITH THE PETITION. Minor's Name Case Number I. IDENTIFYING INFORMATION: PROPOSED GUARDIAN Full Name Last First Middle Race/Ethnicity Language) Address Language(s) spoken (Includes sign Street Apt. # City How long at present address? payment or rent? $ Telephone Number Age Maiden Name Own Indicate if TDD Date of Birth Zip Code Rent Monthly mortgage Driver's License # Place of Birth Social Security Number Religion Last Grade completed and special training Were you ever arrested for an offense other than a minor traffic violation? Yes No. If yes, give date, place and details of offense (All information will be verified with the Department of Justice) PAGE 1 OF 9 SB18074 2002 © American LegalNet, Inc. Have you had previous involvement with Child Protective Services? Yes No. If yes, explain the circumstances in detail and include dates and name of County or State where involvement occurred. Have you ever been treated for or do you now have a physical impairment (e.g. hearing loss)? Yes No. If yes, explain in detail. History of mental health impairment? Yes No. If yes, explain in detail including medications, hospitalizations (when and where), and therapy/counseling (when and where). How has the addition of this child to your family impacted your family's money situation. (e.g. increased child care expenses)? SPOUSE Full Name Last Race/Ethnicity Language) Age First Middle Language(s) spoken (Includes sign Place of Birth Date of Birth Social Security No. Maiden Name Religion DL # Last Grade completed and special training Were you ever arrested for an offense other than a minor traffic violation? Yes No. If yes, give date, place and details of offense Have you had previous involvement with Child Protective Services? Yes No. If yes, explain the circumstances in detail and include dates and name of County or State where involvement occurred. PAGE 2 OF 9 2002 © American LegalNet, Inc. Have you ever been treated for or do you now have a physical impairment (e.g. hearing loss)? Yes No. If yes, explain in detail. History of mental health impairment? Yes No. If yes, explain in detail including medications, hospitalizations (when and where), and therapy/counseling (when and where). II. MARRIAGES: PROPOSED GUARDIAN Married Divorced Separated Widowed Date and place of most recent marriage Ages of Children Number of children Previous marriages (Use additional paper if necessary) Name of former spouse Date and place of marriage How terminated? Divorce Month/Year Death Date City/State Place: City and State Number children from this marriage? Ages of children Who is financially supporting your minor children (include AFDC and/or Social Security benefits). If your minor children do not currently live in your home, describe your involvement with your kids, i.e. visitations. (List each child by name.) SPOUSE Previous marriages (Use additional paper if necessary) Name of former spouse PAGE 3 OF 9 2002 © American LegalNet, Inc. Date and place of marriage How terminated? State Divorce Month/Year Death City/State Date Place: Number children from this marriage? children City and Ages of With whom do your children from previous relationships live? Who is financially supporting your minor children (include AFDC and/or Social Security benefits). If your minor children do not currently live in your home, describe your involvement with your kids, i.e. visitations. (List each child by name.) III. EMPLOYMENT/INCOME: PROPOSED GUARDIAN Name of employer/Financial support source: Address of employer: Telephone number Title Length of service Gross monthly income: $ SPOUSE Name of employer/Financial support source: Address of employer: Telephone number Title Length of service Gross monthly income: $ Who cares for children if adults are employed outside of the home? PAGE 4 OF 9 2002 © American LegalNet, Inc. IV. CHILDREN AT HOME: Use additional sheets if necessary. Relationship Name V. OTHER MEMBERS OF HOUSEHOLD: DL # Name DOB Place of Birth Grade Level Special Needs Use additional sheets if necessary. SS # Sex DOB RelationShip Criminal History Occupation VI. REFERENCES: Give name, address and telephone number of three (3) non-related references who have knowledge of your home life and standing in the community. It is preferred if one (1) is a business associate other than your employer. Occupation Full name Telephone number 1. ( Address Number Full name Street City Occupation Zip Code Telephone number 2. ( Address Number Full name Street Occupation Zip Code Telephone number ( Number Street ) City 3. Address ) City ) Zip Code VII. CHILD OR CHILDREN BEING PLACED UNDER GUARDIANSHIP: 1. a. Name Ethnicity Place of birth petitioner Month/Day/Year Other names Age Date of Birth Date placed with Relationship to petitioner Page 5 of 9 2002 © American LegalNet, Inc. Name of school Grade Phone # Teacher's name Name of physician caring for child Address of physician Phone # b. Describe known medical problems, e.g. hearing or vision impairments. Describe special needs of child and services required to meet these needs, e.g. medication - hearing aids - eyeglasses. What is your understanding of the child's mental or physical impairments. How do you plan to meet the child's mental or health problems? 2. a. Name Other names Ethnicity Age Date of Birth Place of birth Date placed with petitioner Relationship to petitioner Month/Day/Year Name of school Phone # Grade Teacher's name Name of physician caring for child Address of physician Phone # b. Describe known impairments. medical problems, e.g. hearing or vision Describe special needs of child and services required to meet these needs, e.g. medication - hearing aids - eyeglasses. PAGE 6 OF 9 2002 © American LegalNet, Inc. Describe history of mental or physical impairments. VIII. BIRTH PARENTS Mother's name Telephone number Date of birth Address (if known) Mother's last contact with child. Father's name Telephone number Date of birth Address (if known) Father's last contact with child. 1. What is the relationship between Petitioner and birth parents, e.g. visitation between birth parents and child, include specific conditions - areas of conflict or disagreement. (Use back of page if necessary.) 2. How long do you expect this guardianship to last? 3. What are the long term plans for this child? 4. Is the birth mother in agreement with guardianship? Unknown Comments: Yes No 5. Is the birth father in agreement with guardianship? Unknown Comments: Yes No 6. Have the birth parents made you aware of their plans for this child? Yes No If yes, describe known plans: PAGE 7 OF 9 2002 © American LegalNet, Inc. I declare, under penalty of perjury, that the foregoing facts are true and correct. Date: (Petitioner's Signature) COUNTY USE ONLY DOJ Check PETITIONER Date Results: Negative Positive Results: Negative Positive Results: Negative Positive Action taken, if any SPOUSE Date Action taken, if any OTHER Date Action taken, if any PAGE 8 OF 9 2002 © American LegalNet, Inc. County of San Bernardino COURT INVESTIGATOR'S OFFICE Conservatorships - Guardianships Courthouse, Room 200 351 North Arrowhead Avenue San Bernardino, CA 92415-0240 AUTHORIZATION FOR RELEASE OF INFORMATION RE: Guardianship of I give your office authority to release any information in your files to the Guardianship Court Investigator's Office. This information may include school records, medical records, employment records or psychological records. This information is necessary in an investigation being made by the Guardianship Court Investigator's Office in connection with my petition for guardianship of a minor child. Signature Date: PAGE 9 OF 9 2002 © American LegalNet, Inc.