USE NOTE: File this form with the petition for appointment of guardian. This information is confidential and will not be placed in the public court file.Parent and Minor Child Information: Name of minorMinor222s birth dateLast 4 digits of Minor222s SSNMinor222s present address City State ZipParent222s nameParent222s birth dateParent222s nameParent222s birth dateFather222s name on minor222s birth certificate Yes � No Paternity established through court proceedings � If yes, specify court and county where paternity was established Yes � � No � � Circuit � � Probate � CountyMinor222s parents married to each other Yes � No Minor222s parents divorced from each other � If yes, specify county of divorce Yes � � No � County Child � Parent(s): � Victim of domestic violence Child � Parent(s): � Had contact with the protective services unit of MDHHS Child � Parent(s): � Experienced a substance abuse problem Child � Parent(s): � Experienced a mental health problem � Name of school child attends (specify if home schooled)Describe child222s school attendance, behavior, and gradesDescribe child222s relationship and extent of contact with parent(s)If the child is a member of an Indian tribe, or is eligible for membership in an Indian tribe and is a biological child of a member of an Indian tribe, list the child222s tribal affiliation. Victim of domestic violence Had contact with the protective services unit of MDHHS Experienced a substance abuse problem Experienced a mental health problemSpecify the date, place, and nature of any offense, other than a minor traffic violation, for which you were convicted; check if none None American LegalNet, Inc. www.FormsWorkFlow.com File No. Proposed Guardian Questionnaire: (the proposed guardian must complete all items below) 1. � Describe the reasons for the guardianship. 2. � Do the parents agree with this guardianship? � Yes � No � If no, explain. 3. � Describe the parents222 visiting schedule with the child after you are the guardian. If there is no understanding about this, check � � none. 4. � Describe any physical and/or mental limitations you have that would affect your ability to raise this child. If there are none, � � check � � none. 5. � Describe the type (visits, telephone calls, etc.) and frequency of contact (daily, weekly, etc.) you have had with the minor in � the past. 6. � Explain how you propose to handle the additional financial burden of this guardianship. List annual income of the household � and the sources of that income. 7. � Describe the sleeping space you have in your home for this child. 8. � Indicate how many other children live in your home. 9. � Describe the methods of discipline you would use to control this child. 10. � Provide the full name and date of birth of every adult living in the home. 11. � List two people the court may contact for references. Provide their names, addresses, and telephone numbers. 12. � Specify any other information you believe would be helpful to the court. Date � Signature American LegalNet, Inc. www.FormsWorkFlow.com