Stanislaus County Superior Court Investigator RELATIVE GUARDIANSHIP QUESTIONNAIRE Minor’s Name Case No. Proposed Guardian’s (Circle One) (Paternal or Maternal) relationship to minor This form must be completed and returned with the Petition for Guardianship (Relative). If you find there is not enough room to complete your answer, use the space on the reverse of this form, clearly identifying the question. Do not leave any question blank. State N/A if the question does not apply to you. FAILURE TO COMPLETE AND RETURN THIS FORM WITH THE PETITION WHEN SERVED ON THE INVESTIGATOR MAY RESULT IN DELAYS. ***ATTACH A COPY(IES) OF BIRTH CERTIFICATE(S) OF CHILD(REN) AND ANY DEATH CERTIFICATE(S) OF NATURAL PARENTS (if applicable). PERSONAL HISTORY OF PETITIONER(S) PROPOSED GUARDIAN #1 FULL NAME: OTHER NAMES/MAIDEN Date of Birth/Birth Place CA ID/DL NO. Social Security No. List Addresses for Past Five Years 1. Phone No. ( ) From Rent/Mortgage $ to ( ) Own ( ) Rent /Month to ( ) Own ( ) Rent /Month to ( ) Own ( ) Rent /Month 2. Phone No. ( ) From Rent/Mortgage $ 3. Phone No. ( ) From Rent/Mortgage $ GR001 Page 1 of 12 Rev 02/04 American LegalNet, Inc. www.FormsWorkFlow.com PROPOSED GUARDIAN #1 continued Your Health (Circle) Good Fair Poor State Any Medical Conditions Currently Being Treated For: Medications – Name, Amount, Reason, How Often Taken: Attending Counseling? (Circle) Type: Yes No Name of Counselor: Have You Ever Been Convicted Of An Offense Other Than A Minor Traffic Violation? (Circle) Yes No If Yes, Please List Date: City: Outcome: Have You Ever Been On Or Are You On Probation/Parole? (Circle) Yes Officer/Agent’s Name: No County/Phone No. Do You Drink Alcoholic Beverages? (Circle) Yes No How Much/Often? What Drugs Do/Did You Use? When Did You Last Use? How Much/Often? (Circle) Daily Weekly Monthly Cost? Have You Ever Entered Or Completed An Alcohol Or Drug Treatment Program? (Circle) Yes No If Yes, Give Details: Have You Ever Had Contact With A Child Protective Service Agency? (Circle) Yes No GR001 If Yes, Give Details And County: Page 2 of 12 Rev 02/04 American LegalNet, Inc. www.FormsWorkFlow.com PROPOSED GUARDIAN #1 continued Have You Ever Been Arrested For Domestic Violence? If Yes, Give Details: Name And Address of Employer: Phone ( Title: ) How Long? Days You Work: Hours: Gross Salary: Other Income (Circle) AFDC SOC. SEC. Amount $ UNEMPLOYMENT CHILD SUPPORT Mo/Wk For Whom Received: Have You Ever Filed Bankruptcy: (Circle) If So Date: MEDI-CAL ONLY Yes Place: No Result: Have You, Your Spouse Or Either Parent Ever Been Involved In Any Of The Following? Received Counseling For Domestic Violence? (Circle) Yes No Domestic Dispute Where Law Enforcement Was Called: (Circle) Yes No Been The Subject Of A Domestic Or Civil Restraining Order? (Circle) Yes No If Yes For Any, Give Date/Place/Case No./Court/Law Enforcement Agency/And Details For Each Incident: PROPOSED GUARDIAN #2 FULL NAME: Date of Birth/Birth Place GR001 OTHER NAMES/MAIDEN CA ID/DL NO. Page 3 of 12 Rev 02/04 American LegalNet, Inc. www.FormsWorkFlow.com PROPOSED GUARDIAN #2 continued Social Security No. List Addresses for Past Five Years 1. Phone No. ( ) From Rent/Mortgage $ to ( ) Own ( ) Rent /Month to ( ) Own ( ) Rent /Month to ( ) Own ( ) Rent /Month 2. Phone No. ( ) From Rent/Mortgage $ 3. Phone No. ( ) From Rent/Mortgage $ Your Health (Circle) Good Fair Poor State Any Medical Conditions Currently Being Treated For: Medications – Name, Amount, Reason, How Often Taken: Attending Counseling? (Circle) Type: Yes No Name of Counselor: Have You Ever Been Convicted Of An Offense Other Than A Minor Traffic Violation? (Circle) Yes No If Yes, Please List Date: City: Outcome: Have You Ever Been On Or Are You On Probation/Parole? (Circle) Yes GR001 Page 4 of 12 No Rev 02/04 American LegalNet, Inc. www.FormsWorkFlow.com PROPOSED GUARDIAN #2 continued Officer/Agent’s Name: County/Phone No. Do You Drink Alcoholic Beverages? (Circle) Yes No How Much/Often? What Drugs Do/Did You Use? When Did You Last Use? How Much/Often? (Circle) Daily Weekly Monthly Cost? Have You Ever Entered Or Completed An Alcohol Or Drug Treatment Program? (Circle) Yes No If Yes, Give Details: Have You Ever Had Contact With A Child Protective Service Agency? (Circle) Yes No If Yes, Give Details And County: Have You Ever Been Arrested For Domestic Violence? If Yes, Give Details: Name And Address of Employer: Phone ( Title: ) How Long? Days You Work: Hours: Gross Salary: Other Income (Circle) AFDC Amount $ SOC. SEC. UNEMPLOYMENT CHILD SUPPORT Mo/Wk For Whom Received: Have You Ever Filed Bankruptcy: (Circle) If So Date: GR001 MEDI-CAL ONLY Yes Place: No Result: Page 5 of 12 Rev 02/04 American LegalNet, Inc. www.FormsWorkFlow.com PROPOSED GUARDIAN #2 continued Have You, Your Spouse Or Either Parent Ever Been Involved In Any Of The Following? Received Counseling For Domestic Violence? (Circle) Yes No Domestic Dispute Where Law Enforcement Was Called: (Circle) Yes No Been The Subject Of A Domestic Or Civil Restraining Order? (Circle) Yes No If Yes For Any, Give Date/Place/Case No./Court/Law Enforcement Agency/And Details For Each Incident: OTHER ADULTS RESIDING IN THE HOME OF PROPOSED GUARDIAN(S) Full Name: Relationship: Other Names/Maiden: Date of Birth: Does This Person Have Any Criminal Record: (Circle) Yes Occupation: No If Yes, Where/When? Charges: Full Name: Other Names/Maiden: Relationship: Date of Birth: Does This Person Have Any Criminal Record: (Circle) Yes Occupation: No If Yes, Where/When? Charges: Full Name: Other Names/Maiden: Relationship: Date of Birth: Does This Person Have Any Criminal Record: (Circle) Yes If Yes, Where/When? GR001 Occupation: No Charges: Page 6 of 12 Rev 02/04 American LegalNet, Inc. www.FormsWorkFlow.com OTHER CHILDREN RESIDING IN THE HOME OF PROPOSED GUARDIAN(S) Full Name: Date Of Birth: Name And Address of School: Relationship: Date Of Birth: Full Name: Name And Address of School: Relationship: Date Of Birth: Full Name: Name And Address of School: Relationship: BIRTH PARENTS Natural Mother Full Name: Date of Birth: Other Names/Maiden CA ID/DL No. Social Security No. Last Known Address/Dates Lived There Name And Address Of Employer Telephone No. Is Mother In Agreement With Guardianship? (Circle) Yes No Does Mother Contribute To Support Of Child? (Circle) Yes No If Yes, How? Does Mother Visit With The Child? (Circle) Yes No If Yes, How Often? GR001 Page 7 of 12 Rev 02/04 American LegalNet, Inc. www.FormsWorkFlow.com BIRTH PARENTS – Natural Mother Continued Does The Mother Visit The Child Outside Of Your Home? (Circle) Yes No Does The Mother Send Cards, Gifts Or Call For Holidays? (Circle) Yes No Does The Mother Express An Interest In School Issues? (Circle) Yes No Does Mother Express An Interest In Health Issues? (Circle) Yes No Does The Mother Have Any Other Children? (Circle) Yes No Yes No If Yes Name: Date Of Birth: If Yes Name: Date Of Birth: If Yes Name: Date Of Birth: Has The Mother Ever Been Arrested And/Or Convicted? (Circle) If Yes, Give Date/Place/Charges: Has The Mother Ever Been Investigated By Child Protective Services? (Circle)Yes No If Yes, Give Date/Place/Charges: Is There A Custody Order (From Divorce, Separation, Paternity) For This Child In Any County? (Circle) Yes No. If Yes, Give County/Case No. And Any Details: Natural Father Other Names Full Name: Date of Birth: GR001 CA ID/DL No. Page 8 of 12 Social Security No. Rev 02/04 American LegalNet, Inc. www.FormsWorkFlow.com BIRTH PARENTS – Natural Father Continued Last Known Address/Dates Lived There Name And Address Of Employer Telephone No. Is Father In Agreement With Guardianship? (Circle) Yes No Does Father Contribute To Support Of Child? (Circle) Yes No If Yes, How? Does Father Visit With The Child? (Circle) Yes No If Yes, How Often? Does The Father Visit The Child Outside Of Your Home? (Circle) Yes No Does The Father Send Cards, Gifts Or Call For Holidays? (Circle) Yes No Does The Father Express An Interest In School Issues? (Circle) Yes No Does Father Express An Interest In Health Issues? (Circle) Yes No Does The Father Have Any Other Children? (Circle) Yes No Yes No If Yes Name: Date Of Birth: If Yes Name: Date Of Birth: If Yes Name: Date Of Birth: Has The Father Ever Been Arrested And/Or Convicted? (Circle) If Yes, Give Date/Place/Charges: GR001 Page 9 of 12 Rev 02/04 American LegalNet, Inc. www.FormsWorkFlow.com BIRTH PARENTS - Natural Father Continued Has The Father Ever Been Investigated By Child Protective Services? (Circle)Yes No If Yes, Give Date/Place/Charges: Is There A Custody Order (From Divorce, Separation, Paternity) For This Child In Any County? (Circle) Yes No. If Yes, Give County/Case No. And Any Details: GENERAL INFORMATION Were The Birth Parents Ever Married? (Circle) Yes No Yes No If Yes, Status: If No, Was Paternity Ever Established (Circle) If Yes, Case No. Name/County Of Court House: Is There An Order For Support? (Circle) If Yes, How Much: Yes No Paid To Whom? Does The Child(ren) Have Native American Blood? (Circle) Yes No Yes No Name of Tribe: Indian Percentage: Is Child(ren) A Registered Tribal Member? (Circle) GR001 Page 10 of 12 Rev 02/04 American LegalNet, Inc. www.FormsWorkFlow.com CHILDREN Child(ren) Under Guardianship First Child/Name: Date/Place Of Birth: Relationship: Date Placed With Guardian: Previous Schools: Name Address Name/Address Of Child’s Physician: Results of Drug Test At Birth: Do You Suspect Mother Used Drugs When Pregnant? Does The Child Have Any Behavioral Problems And/Or Needs: (Circle) Yes No Yes No If Yes, Explain: Difficulties In School? (Circle) Yes No Special Needs? (Circle) Yes No Criminal Involvement? (Circle) Yes No Date/Place Of Birth: Second Child/Name: Date Placed With Guardian: Relationship: Previous Schools: Name Address Name/Address Of Child’s Physician: Results of Drug Test At Birth: Do You Suspect Mother Used Drugs When Pregnant? Does The Child Have Any Behavioral Problems And/Or Needs: (Circle) If Yes, Explain: GR001 Page 11 of 12 Rev 02/04 American LegalNet, Inc. www.FormsWorkFlow.com CHILDREN CONTINUED Difficulties In School? (Circle) Yes No Special Needs? (Circle) Yes No Criminal Involvement? (Circle) Yes No REMINDER YOU MUST ATTACH A COPY OF EACH CHILD’S BIRTH CERTIFICATE AND/OR ANY DEATH CERTIFICATE FOR A NATURAL PARENT TO THIS FORM Additional Information List Any Other Information You Feel May Be Helpful To The Investigation I DECLARE UNDER PENALTY OF PERJURY THAT THE INFORMATION ON THIS FORM IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE DATED: PRINTED NAME OF PETITIONER: SIGNATURE GR001 SIGNATURE Page 12 of 12 Rev 02/04 American LegalNet, Inc. www.FormsWorkFlow.com