SUPERIOR COURT OF THE STATE OF CALIFORNIA IN AND FOR THE COUNTY OF TULARE Guardianship Questionnaire: Request to Waive Pre-Guardianship Report IN THE GUARDIANSHIP OF: CASE NO: Date of Hearing Dept. Time name/s of minor/s PLEASE FILL OUT THE QUESTIONNAIRE FOR EACH PROSPECTIVE GUARDIAN AND THE UCCJEA DECLARATION FORM (GC-120/FL-105) COMPLETELY. FOR JUDGE'S USE ONLY: Based on the information contained herein: The guardianship report is waived, pursuant to California Probate Code Section 1513 (a). The matter is referred to Child Protective Services for report and recommendation of nonrelative petition for guardianship pursuant to PC1513(a). The matter is referred to Family Court Services for report and recommendation on the following issues: The necessity of further investigation is to be determined at the first hearing. Dated: Signed: Judge/Commissioner of the Superior Court 5/2006 Page 1 of 15 Guard. Packet Item #2 TU-9 American LegalNet, Inc. www.FormsWorkflow.com Attorney's/Conservator's Name: Attorney's/Conservator's Address: Attorney's/Conservator's Telephone #: Attorney for/Acting In Pro Per SUPERIOR COURT OF THE STATE OF CALIFORNIA IN AND FOR THE COUNTY OF TULARE Guardianship of: ) ) ) ) ) ) ) ) (Minor(s) last name) (Case number) GUARDIANSHIP QUESTIONNAIRE Because you may be making medical, educational, financial, and other life decisions for the Minor(s) (also may be referred to as Ward(s)), the Court, prior to granting Guardianship powers, would like to determine the stability, experience, and decision-making ability of the proposed Guardian(s). If you have questions, feel free to call the Court Investigator's office at (559) 733-6052. NAME(S) OF MINOR(S): DOB: S.S. # AGE: CURRENT ADDRESS: Provide the names of all proposed Minors who have Native American Ancestry: NAME(S) OF PROPOSED GUARDIAN(S): (Mandatory for each proposed Guardian) Name: Name: Address: Address: Home phone: Work phone: Relationship to Minor: DOB: SS#: CaDL#: Expiration: Sex: M F Height: Weight: Eye color: Hair color: Other names used: Home phone: Work phone: Relationship to Minor: DOB: SS#: CaDL#: Expiration: Sex: M F Height: Weight: Eye color: Hair color: Other names used: Education level completed: Age: When: Education level completed: Age: When: GUARDIANSHIP QUESTIONNAIRE 2 American LegalNet, Inc. www.FormsWorkflow.com MINOR #1: How long at current placement? Current School: Grade: Teacher: (Name) (Name) Days/Hours in school: Method of transportation: rides bus walks rides bike other After school programs/activities: After school child care provider's name, address, telephone number: Days/Hours attending after school program: Name of the doctor(s) who provide medical care for the Minor: (Include specialists) Date of last doctor visit: List all prescription and over-the-counter medications: Name of the dentist who provides dental care for the Minor: Name of the optometrist/ophthalmologist who provides eye care for the Minor: Name of the psychiatrist/psychologist/counselor: Child's hobbies/activities: Child's bedtime: School days Weekends/Holidays NOTE: Please provide the current and prior year school attendance records and grade reports. (Example: 2003-2004 and 2004-2005). If there are more than three Minors, please copy this page and complete the information for each additional Minor. GUARDIANSHIP QUESTIONNAIRE 3 American LegalNet, Inc. www.FormsWorkflow.com MINOR #2: How long at current placement? Current School: Grade: Teacher: (Name) (Name) Days/Hours in school: Method of transportation: rides bus walks rides bike other After school programs/activities: After school child care provider's name, address, telephone number: Days/Hours attending after school program: Name of the doctor(s) who provide medical care for the Minor: (Include specialists) List all prescription and over-the-counter medications: Name of the dentist who provides dental care for the Minor: Name of the optometrist/ophthalmologist who provides eye care for the Minor: Name of the psychiatrist/psychologist/counselor: Child's hobbies/activities: Child's bedtime: School days Weekends/Holidays NOTE: Please provide the current and prior year school attendance records and grade reports. (Example: 2003-2004 and 2004-2005). If there are more than three Minors, please copy this page and complete the information for each additional Minor. GUARDIANSHIP QUESTIONNAIRE 4 American LegalNet, Inc. www.FormsWorkflow.com MINOR #3: How long at current placement? Current School: Grade: Teacher: (Name) (Name) Days/Hours in school: Method of transportation: rides bus walks rides bike other After school programs/activities: After school child care provider's name, address, telephone number: Days/Hours attending after school program: Name of the doctor(s) who provide medical care for the Minor: (Include specialists) List all prescription and over-the-counter medications: Name of the dentist who provides dental care for the Minor: Name of the optometrist/ophthalmologist who provides eye care for the Minor: Name of the psychiatrist/psychologist/counselor: Child's hobbies/activities: Child's bedtime: School days Weekends/Holidays NOTE: Please provide the current and prior year school attendance records and grade reports. (Example: 2003-2004 and 2004-2005). If there are more than three Minors, please copy this page and complete the information for each additional Minor. GUARDIANSHIP QUESTIONNAIRE 5 American LegalNet, Inc. www.FormsWorkflow.com CHILD'S MOTHER: CHILD'S FATHER: Address: Address: Home phone: Work phone: Relationship to proposed Guardian: Home phone: Work phone: Relationship to proposed Guardian: DOB: SS#: Other names used: DOB: SS#: Other names used: CaDL#: CaDL#: HOUSEHOLD COMPOSITION OF PROPOSED GUARDIAN(S): (List all adults and children, related or unrelated, temporary or permanent) 1. Name: DOB: Age: Sex: Height: Weight: Eye color: Name of school/place of employment: Address: Phone number: Other names used: Place of birth: Hair color: SS#: CaDL: 2. Name: DOB: Age: Sex: Height: Weight: Eye color: Name of school/place of employment: Address: Phone number: Other names used: Place of birth: Hair color: SS#: CaDL: 3. Name: DOB: Age: Sex: Height: Weight: Eye color: Name of school/place of employment: Address: Phone number: Other names used: Place of birth: Hair color: SS#: CaDL: 4. Name: DOB: Age: Sex: Height: Weight: Eye color: Name of school/place of employment: Address: Phone number: Other names used: Place of birth: Hair color: SS#: CaDL: GUARDIANSHIP QUESTIONNAIRE 6 American LegalNet, Inc. www.FormsWorkflow.com PROPOSED GUARDIANS: (For each person petitioning the Court for guardianship and are not married or living together as domestic partners and not living in the same household, please copy pages 7 through 11 and provide the requested information.) Current marital status of the proposed Guardian: Married Divorced Remarried Widowed Domestic partners Separated Currently living apart from spouse (please explain) List all previous marriages Name Date Married Date Separated List legal names of all children of proposed Guardian: Name DOB Age Residence: Do you Rent Lease Own Do you plan to remain in the residence? Yes List residences for the three previous years Date Divorced Place of Residence School your residence? Years lived at this address No Is your residence provided by your employer? Value of donated housing per month Is your residence a Mobile Home ? Apartment? House? Other? If other, please explain Is your residence in a rural setting? Residential neighborhood? Mobile home park? Apartment complex? Other? If other, please explain Number of bedrooms How much is your rent/mortgage payment per month? To whom are payments made? If you are buying your home, provide the following information: Purchase price Current estimated market value Balance owed Lending Institution (Name) (Address) (Name) (Address) GUARDIANSHIP QUESTIONNAIRE 7 American LegalNet, Inc. www.FormsWorkflow.com What are your monthly utility bills? Gas Electricity Sewer/Water Garbage Propane Telephone (home) (cell/pager) (other) Have you ever been served with a Three Day Notice to Pay Rent or Quit Possession of Real Property pursuant to an oral or written agreement for the rental of residential real property? Yes No . If so, provide the date, name, address, and telephone numbers of the lessor or landlord. Income: Monthly income from employment Monthly income from commissions No Do you have checking accounts? Yes Please list the balance of each account separately. No Do you have savings accounts? Yes Please list the balance of each account separately. Monthly income from investments Name and address of investment broker Monthly income from other sources: Sources of income Amount Monthly income from public assistance (To whom each is paid) Social Security Disability payments Veteran's benefits Monthly/annual income from insurance settlement(s) Debts: Describe all long term debt other than mortgage listed above (include second, third, and fourth mortgages, vehicles, business property, rental property, etc.) List all short term debt including each credit card debt, debt to private parties or family members, etc. (do not include bankruptcy debt) GUARDIANSHIP QUESTIONNAIRE 8 American LegalNet, Inc. www.FormsWorkflow.com Have you ever filed for bankruptcy? Yes No Please provide the following information for each time Type of petition Date filed Court in which filed Outcome Date debts discharged Have you ever been sued? Yes Please explain No Have you ever sued another person or entity, individually or on behalf of an entity? Yes Please explain Employment: Current Employer Employer's Address No Employer's telephone number Job Description Length of employment (List your previous employers for the last 5 years) 1. Name Telephone Job Description Address Date began Date left Reason for leaving 2. Name Address Telephone Job Description Date began Date left Reason for leaving 3. Name Address Telephone Job Description Date began Date left Reason for leaving Education: Highest level completed Reason for leaving Last school attended Degree(s) achieved Age left School Last year attended GUARDIANSHIP QUESTIONNAIRE 9 American LegalNet, Inc. www.FormsWorkflow.com Health: Do you have health insurance? Yes No Name of company and type of coverage Dental Vision Health Status: Good Fair Poor Fair or poor, please explain Are you taking any medication, prescription or over-the-counter? Yes If yes, list types and for what reasons No List any special health problems Have you ever had a problem with any of the following: Drugs: Prescription or Illegal Alcohol Mental/Emotional problems Please explain Vehicles: For each vehicle you own provide the make, model, year, and license number, as well as the name(s) on the registration. Make Model Year License Number 1. 2. 3. 4. For each vehicle you own, list whether or not insured and the amount of public liability coverage. Make/Year Insured or not Type/Amount of coverage 1. 2. 3. 4. Criminal History: Have you ever been arrested or had charges filed against you for any crime other than a traffic infraction? (This question must be answered even if you were only arrested and not convicted, or if convicted, the charges were thereafter dismissed and the record ordered No sealed.) Yes Please indicate the reason for arrests, charges, years, county, and state. Have you ever been arrested for driving under the influence of alcohol or a controlled substance? Yes No If so, please indicate date(s), year, county, and state GUARDIANSHIP QUESTIONNAIRE 10 American LegalNet, Inc. www.FormsWorkflow.com Have you ever been tried for any crime in any court? Please indicate the crime, year, county, and state. Yes No If so, please explain Have you ever been convicted, pled guilty or pled no contest to charges other than a traffic infraction? Indicate the type of conviction, year, county, and state. Yes No If so, please explain What was the sentence? Was the sentence completed? Yes No Release date Are you currently or have you ever been on probation or parole? Yes If so, please explain Name of Probation or Parole Officer No Telephone No. Are you the plaintiff or defendant in any current or pending criminal or civil matter? Yes No If so, please explain Have you ever applied for a domestic violence restraining order or had one issued against you? Yes No If so, please explain Have you ever been the victim or perpetrator of physical, verbal, emotional, psychological, or sexual abuse? Yes No If so, please explain Additional Information: Proposed Minor(s) length of residency at the present address. Will it be necessary to change residence of the proposed Minor(s) now? Yes If yes, please explain No Will the proposed Guardian(s) be available to transport the Minor(s) to school, medical, dental, No optical, audiological, psychiatric, or other appointments? Yes If no, please explain how these needs will be met Which of the proposed Minor(s) is receiving Medi-Cal? List all income, by source and amount, for each proposed minor. List all expenses, by type and amount, for each proposed minor. Who will actually manage the Minor(s) money? Pay the bills? GUARDIANSHIP QUESTIONNAIRE 11 American LegalNet, Inc. www.FormsWorkflow.com Does a Durable Power of Attorney or a Durable Power of Attorney for Health Care exist for the Minor(s) or proposed Guardian(s)? If so, which person(s)? Where is it located? When was it signed? Who is named with powers? Does the Minor(s) have a Trust(s)? Yes No If so, please list (A) Preparer of the Trust (B) Date of Trust (C) Name of Trustee(s) Revocable Irrevocable Value of assets Is the Minor(s) the beneficiary of a Trust? Yes No Revocable If so, please list (A) Preparer of the Trust (B) Date of Trust (C) Named Trustee (D) Nature of beneficial interest for the Minor Irrevocable Reasons for guardianship: Briefly summarize the events which resulted in your seeking a guardianship at this time. If there is a conflict between you and the minor's parent(s), please state the nature of the conflict and with which parent(s) the conflict exists. GUARDIANSHIP QUESTIONNAIRE 12 American LegalNet, Inc. www.FormsWorkflow.com Describe the nature of your relationship, prior to the events which led to your petition for guardianship, with the minor's parent(s) including frequency and nature of the contact. Describe the nature of your previous relationship with the minor(s) including frequency and nature of the contact. What harm is currently occurring to the minor(s) which makes the guardianship necessary? What advantages can you give the Minor(s) that s/he is not presently receiving? What disadvantages will occur for the Minor(s) if you are granted guardianship? What special needs does the Minor(s) have? Please describe. How will you provide for housing, schooling, child care, supervision, socialization, spiritual needs, and financial support for the Minor(s)? GUARDIANSHIP QUESTIONNAIRE 13 American LegalNet, Inc. www.FormsWorkflow.com How will you provide guidance and what type of discipline will you use with the minor(s)? Please provide any information you can about the mother or father's involvement in past or pending criminal cases in any county or state. Provide case numbers and dates if possible. Child Welfare Services Involvement: Have you or anyone in your current household ever been the recipient of social services from the Department of Health and Human Services, other than financial aide? Yes No . If yes, please explain: Have you or anyone in your current household ever been reported to Child Welfare Services for child abuse or neglect? Yes No If yes, please explain: Name of county report was made: Year(s) in which services were provided: Describe the services provided: THIS QUESTIONNAIRE IS CONFIDENTIAL. IT WILL BE PLACED IN A SEALED ENVELOPE IN THE COURT FILE TO PROTECT YOUR PRIVACY. GUARDIANSHIP QUESTIONNAIRE 14 American LegalNet, Inc. www.FormsWorkflow.com AFFIDAVIT OF PROPOSED GUARDIANS I, , (first proposed guardian) and (second proposed guardian) of the minor(s) in question, as (please state your relationship to the referenced minor/s), hereby state under penalty of perjury under the laws of the State of California, that the aforementioned facts are true and correct to the best of my/our knowledge. I/We additionally request, upon the Court's discretion and review of this information, waiver of the Pre-guardianship Report as it pertains to my/our Petition for Appointment as Guardian(s) of: Name of Minor: Name of Minor: Name of Minor: CHECK ONE, DATE, AND SIGN To my knowledge, there is no one who objects to the establishment of this Guardianship or my appointment as Guardian. To my knowledge, the following person(s) object to this Guardianship or my appointment as Guardian: (Name) (Relationship to the child) (Name) (Relationship to the child) Date Type or print Proposed Guardian Signature of Proposed Guardian Date Type or print Proposed Guardian Signature of Proposed Guardian 5/2006 GUARDIANSHIP QUESTIONNAIRE 15 OF 15 American LegalNet, Inc. www.FormsWorkflow.com