WRITTEN STATEMENT OF BACKGROUND AND QUALIFICATIONS FOR PIERCE COUNTY SUPERIOR COURT P.I./G.A.L. CERTIFIED REGISTRY UNDER RCW 26.09.220 AND 26.12.175 THIS IS PUBLIC INFORMATION I, _____________________________, state the following as an outline of my background and qualifications to be eligible for the Pierce County Superior Court Parenting Investigator/Guardian Ad Litem certified registry under RCW 26.09.220 AND RCW 26.12.175. A. Level of formal education and year degree(s) obtained: B. Training related to Parenting Investigator/Guardian Ad Litem’s duties: Date Mentoring completed: _________________________________________________ Name(s) of mentor(s): _________________________________________________ Mentoring verification is on file in Pierce County Superior Court Administration? Yes___ No___ C. Number of years experience as a Guardian Ad Litem under RCW 26.09.220 and/or RCW 26.12.175: 1. Please also list each year and the county(ies) in which you were appointed to serve on a RCW 26.09.220 and/or RCW 26.12.175 Certified Registry. Also indicate the date you first served. For example: 7/1/1999 – Present, Pierce County, first served May, 2000 7/1/2000 – 7/1/2001, King County, never served RCW 26.09 Written Statement of Background and Qualifications Page 1 Revised 01/31/05 American LegalNet, Inc. www.USCourtForms.com D. Number of appointments you have received as a Parenting Investigator/Guardian ad Litem and the county or counties of appointment during the last year, 1/1/04 to 12/31/04 (if not a new applicant): E. Percentage of your total case load that RCW 26 Parenting Investigator/Guardian ad Litem work represents overall: F. Criminal history, as defined in RCW 9.94A.030: Completed Washington State Patrol Conviction Criminal History Record must be received by the Court. Expected date the Court will have this information if not attached to application. Date: __________ G. Have you ever been accused of, or been a victim of domestic violence or an antiharassment action? Yes _______ No _______ If yes, please explain. H. Evidence of my knowledge, training, and experience, in the following areas, pursuant to RCW 26.09.220 and /or RCW 26.12.175. You must complete in full the information requested below, in the space provided, in addition to attaching your resume or vitae. However, answers that only refer to a resume or vitae are not acceptable so do NOT just attach these documents: 1) Child development, child sexual abuse, and child physical abuse and neglect: 2) Clinical and forensic investigative and interviewing techniques: RCW 26.09 Written Statement of Background and Qualifications Page 2 Revised 01/31/05 American LegalNet, Inc. www.USCourtForms.com 3) 4) Knowledge of relevant statutory and legal requirements to determine the best interest of the minor child in the context of a dissolution or parentage proceeding: 5) A general understanding of ethnic and cultural diversity and their implications for working with youth of color and their families in the context of a dissolution or parentage proceeding: 6) I. Family reconciliation and mediation services: Legal procedure: The number of times I have been removed for failure to adequately perform duties as Parenting Investigator/Guardian Ad Litem, or for other cause. Give a brief explanation of each such removal, with the case name and cause number: I also certify the following: J. I have successfully completed the Parenting Investigator / Guardian Ad Litem training required by the Pierce County Superior Court and laws of the State of Washington. Please give date and place where original certificate was obtained. Please also give other trainings attended and the month/year attended. RCW 26.09 Written Statement of Background and Qualifications Page 3 Revised 01/31/05 American LegalNet, Inc. www.USCourtForms.com K. My normal hourly rate is $_________. My hourly rate to serve as Parenting Investigator/ Guardian Ad Litem by stipulation and agreement is $_________. On rotational draw cases my rates are $75.00 per hour. Retainer and further fees are by order of the Court obtained in advance of incurring fees, or county pay if a paternity case. AGREE _____ DISAGREE _____ L. I am presently not serving, nor have I recently applied to serve, as a Judge or Commissioner pro tempore in Pierce County Superior Court. AGREE _____ DISAGREE _____ M. I have no criminal history or license suspension or revocation. AGREE _____ DISAGREE _____ N. I am not the subject of any pending investigation or action by a government agency, professional organization or one that would result in a criminal conviction or a license revocation or suspension. AGREE _____ DISAGREE _____ If you disagree, please explain: O. I will not accept any appointment involving a conflict of interest, and in the event I discover a conflict in the course of an appointment/investigation, I will immediately advise the parties, counsel, and court. AGREE _____ DISAGREE _____ P. I have read, signed, returned, and agreed to be governed by the Pierce County Superior Court RCW 26 P.I./G.A.L. Code of Conduct as set out in the Pierce County Superior Court Administrative Policy # 1. AGREE _____ DISAGREE _____ Q. I have read and understand the applicability to me of the Pierce County Superior Court Administrative Policy # 2 for the RCW 26 PI/GAL Registry, as amended 9/1/04. AGREE _____ DISAGREE _____ I further certify that I have thoroughly studied the provisions and requirements of RCW 26.09.220 and RCW 26.12.175 and believe I am qualified to be appointed as a Parenting Investigator/ Guardian Ad Litem in Pierce County, Washington. ____________________________________ (Signature) ____________________________________ (Print Name) Date of signing: _____________________ Place of signing: _____________________ RCW 26.09 Written Statement of Background and Qualifications Page 4 Revised 01/31/05 American LegalNet, Inc. www.USCourtForms.com WRITTEN STATEMENT OF BACKGROUND AND QUALIFICATIONS FOR PIERCE COUNTY SUPERIOR COURT P.I./G.A.L. CERTIFIED REGISTRY UNDER RCW 26.09.220 AND RCW 26.12.175 (CONTINUED) THIS PORTION OF THE APPLICATION IS CONFIDENTIAL INFORMATION AND NOT FOR PUBLIC VIEWING Print Name: _________________________________________________________________ E-Mail Address: ______________________________________________________________ Contact Number for Court Use Only: __________________ Fax Number:_______________ R. Indicate number of cases resulting from stipulated agreements; number of cases accepted from rotational draw; and reasons for rejections as follows: 1. Since 1/1/2004 – how many of your Pierce County cases have been the direct result of an agreement between both parties? (This is different than those accepted from the rotational draw process. See 2 below.) Also please give the case number of each such case. 2. Since 1/1/2004 – how many cases have you accepted as a result of the rotational draw process in Pierce County? Answer with specific numbers, please. Also please give the case number of each such case. On these cases accepted as a result of the rotational draw process, did you ever require as a condition of accepting or continuing with the case, an agreement with fee terms different from an initial retainer of $500 or an hourly rate that exceeded $75 per hour? Yes___ No___ If yes, please explain. RCW 26.09 Written Statement of Background and Qualifications Page 5 Revised 01/31/05 American LegalNet, Inc. www.USCourtForms.com 3. Since 1/1/2004 – how many Pierce County rotational draw cases have you rejected for any reason? Please explain. 4. If appointed in a county(ies) other than Pierce, for each county list for the period beginning 1/1/2004: a. Number of cases that have been the direct result of an agreement between both sides. b. Number of cases accepted as a result of any rotational draw process. c. For cases accepted as a result of the rotational draw process, did you ever require as a condition of accepting or continuing with the case an agreement with fee terms different from those required under the rules of the certified registry? Please explain. d. How many rotational draw cases from non-Pierce County Certified Registries have you rejected for any reason? Please explain. RCW 26.09 Written Statement of Background and Qualifications Page 6 Revised 01/31/05 American LegalNet, Inc. www.USCourtForms.com 5. For each GAL/PI appointment in Pierce County from January 1, 2004 to present, list from most recent case to oldest case the following information: County 6. Case Name/No. R or S Active Work Performed Payment Issues For each still active appointment in Pierce County beginning before January 1, 2004, list from most recent case to oldest case the following information: County Case Name/No. R or S Active Work Performed Payment Issues R or S: Stipulation. The case was assigned through the Rotational Draw or by Active: Are you still actively working on this case? Answer Yes or No. Work Performed: Refers to the last or latest stage of work product you performed, e.g. preliminary report, final report, testify-trial/hearing, settlement/judgment. If you testified at the trial, or signed a parenting plan that resulted from settlement or a judgment of the court, you need not also indicate that you wrote a preliminary and/or final report. Payment Issues: Allows us to gather information generally regarding payment of GAL’s. Some likely comments would be: H or W paid in full (pd/f); W or H not paying (n/pd); receiving payments from H or W ($/mo); or court did not authorize full payment of fees charged (ct n/auth-full). RCW 26.09 Written Statement of Background and Qualifications Page 7 Revised 01/31/05 American LegalNet, Inc. www.USCourtForms.com I further certify that I have thoroughly studied the provisions and requirements of RCW 26.09.220 and RCW 26.12.175 and believe I am qualified to be appointed as a Parenting Investigator/ Guardian Ad Litem in Pierce County, Washington. ____________________________________ (Signature) ____________________________________ (Print Name) Date of signing: _____________________ Place of signing: _____________________ RCW 26.09 Written Statement of Background and Qualifications Page 8 Revised 01/31/05 American LegalNet, Inc. www.USCourtForms.com