Name, Address, Phone # & State Bar # of Attorney or Party without Attorney FOR COURT USE ONLY Attorney for: SUPERIOR COURT OF CALIFORNIACOUNTY OF YOLO 1000 Main Street Woodland, CA. 95695 (530) 406-6704 Guardianship of: Case Number: DECLARATION IN SUPPORT OF EX PARTE REQUEST FOR TEMPORARY GUARDIANSHIP I, the undersigned, declare as follows: 1. Name of Child (Children) (1)___________________________________ (2)___________________________________ (3)___________________________________ (4)___________________________________ Date of birth: _________ Date of birth: _________ Date of birth: _________ Date of birth: _________ 2. Name of Child's (children's) School(s): ___________________________________________ 3. Relationship of proposed guardian to child: Grandparent Great-Grandparent Brother/Sister Cousin Other: (Describe relationship) ____________________________________________ 4. Current residence of the child (children): _________________________________________ 5. Current residence of the proposed guardian: _______________________________________ 6. How long has the child lived with the proposed guardian? (list dates) ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 7. Why do you believe the mother cannot now care for the child (children)? ________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 8. Why do you believe the father cannot now care for the child (children)? ________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 9. Source of income in proposed guardian's home. (List employment, government benefits or other income sources.) _______________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ Rev: 06/08/2016 YOCV 0125 Declaration in Support of Ex Parte Request for Temporary Guardianship Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com 10. My employment history for the past five years is described below (attach additional pages, if necessary). Position Employer Name & Address Date of Employment 11. Name and age of all individuals living in proposed guardian's home: __________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 12. Criminal record of any individual living in proposed guardian's home: _________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 13. List all related legal cases (involving the child or child's parents) including other guardianships, juvenile, family, family support, criminal or domestic violence, and list the county where filed: Other Guardianships: _________________________________________________________ ___________________________________________________________________________ Juvenile Cases: _____________________________________________________________ ___________________________________________________________________________ Family Law Cases: ___________________________________________________________ ___________________________________________________________________________ Family Support Cases: _______________________________________________________ ___________________________________________________________________________ Criminal Cases: _____________________________________________________________ ___________________________________________________________________________ Domestic Violence Cases: ____________________________________________________ ___________________________________________________________________________ 14. I will immediately notify the court if I learn of any custody proceedings concerning the proposed ward (child) in this or any other state not listed above. 15. Additional information provided to the court is attached. Number of pages attached: _____ I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Executed on ___________________ at _____________________, California. _______________________________________ Petitioner/Proposed Guardian Rev: 06/08/2016 YOCV 0125 Declaration in Support of Ex Parte Request for Temporary Guardianship Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com