San Francisco — Declaration of Proposed Guardian

Source: https://sf.courts.ca.gov/system/files/prb-pgn-001-confidential-declaration-proposed-guardian.pdf

CONFIDENTIAL Attorney Name(s) or Party without Attorney 1 Firm Name Mailing Address 2 City, State, Zip Code Phone Number(s) 3 Fax Number Email Address 4 Attorney for {INSERT NAME} or Self-Represented 5

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8 SUPERIOR COURT OF THE STATE OF CALIFORNIA 9 COUNTY OF SAN FRANCISCO 10

11 Guardianship of: Case Number: PGN-

12 {INSERT NAME(S) OF CHILD(REN)} CONFIDENTIAL DECLARATION OF 13 PROPOSED GUARDIAN

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17 Please complete one form for each person applying for guardianship and attach another piece of paper to this form if more space is needed to answer any of the questions. 18

19 1. Explain why the parents cannot care for the child/ren. 20

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23 2. Do the parents agree that you can be the guardian? ☐ Yes ☐ No ☐ Not Sure 24 If NO, or NOT SURE, please explain: 25

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28 CONFIDENTIAL DECLARATION OF PROPOSED GUARDIAN PRB-PGN-001 Rev. Jul-01-2020

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1 3. Provide the following information: Your full legal name: 2 Your email address: 3 Your Social Security #: 4 Your date of birth: MM-DD-YYYY

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4. Your education (last grade completed/degree earned): 6

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8 5. Your current job title:

9 Name, address, and phone number of current employer/s: 10

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12 6. Are you in good health? ☐ Yes ☐ No 13 If NO, please explain: 14

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17 7. Have you ever been appointed as the guardian of any other child/ren? 18 ☐ Yes ☐ No If YES, please state the County where you were appointed as a guardian, the date 19 you were appointed, and the name/s of the child/ren and the case number if known: 20

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28 CONFIDENTIAL DECLARATION OF PROPOSED GUARDIAN PRB-PGN-001 Rev. Jul-01-2020

CONFIDENTIAL 8. Please tell us about everyone who lives with the child/ren or has frequent contact with 1 the child/ren: 2 Complete Legal Name Date of Relationship Social Driver’s Birth to Child(ren) Security License/ID 3 (MM/DD/YYYY) Number Number

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8 9. Who did the child/ren live with previously? Name, address/es, relationship/s to the 9 child/ren, and date/s of residence:

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13 10. Does/Do the child/ren have any special emotional, psychological, educational, or 14 physical needs? ☐ Yes ☐ No 15 If YES, please explain what the needs are and what you would do to meet the needs:

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20 11. Will the child/ren need day care? ☐ Yes ☐ No

21 If YES, give information about the child/ren’s day care provider:

22 Name of Daycare Provider:

23 Daycare Address: Daycare Phone Number: 24 Name of Daycare Provider: 25 Daycare Address: 26 Daycare Phone Number:

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28 CONFIDENTIAL DECLARATION OF PROPOSED GUARDIAN PRB-PGN-001 Rev. Jul-01-2020

CONFIDENTIAL 12. Is/are the child/ren in school? ☐ Yes ☐ No 1 If YES, please provide information about the child/ren’s schooling: 2 Name of School: 3 School Address:

4 School Phone Number:

5 Name of School: 6 School Address: 7 School Phone Number: 8 If YES, please attach recent report card(s)/proof of enrollment in school

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10 13. Will the child/ren have their own bedroom in your house? ☐ Yes ☐ No

11 If NO, please state who shares a bedroom with the child/ren:

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14 14. Is there firearm in the home? ☐ Yes ☐ No 15 If YES, how is it stored?

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18 15. Are there any animals or pets in the home? ☐ Yes ☐ No 19 If YES, please describe: 20

21 16. Will you get or ask for financial support to help take care of the child(ren)? 22 ☐ Yes ☐ No

23 If YES, please explain type and amount of financial support:

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28 CONFIDENTIAL DECLARATION OF PROPOSED GUARDIAN PRB-PGN-001 Rev. Jul-01-2020

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2 17. Have you or has anyone living in the home ever been arrested? ☐ Yes ☐ No 3 If YES, please explain what the charges were, the date and place of offense/s, and

4 how the case/s ended, such as “guilty”, or “case dismissed.”

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10 18. Is/are the child/ren involved in any other Court case? This can be in Juvenile Court, 11 Family Court or any other Court. ☐ Yes ☐ No If YES, please state which Court, the case number, and why: 12

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15 19. Have you, or anyone who lives with you, ever had any contact with Child Protective 16 Services/Department of Human Services Agency? ☐ Yes ☐ No

17 If YES, please explain when and why:

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20 20. Where do/does the child/ren get health and dental care?

21 Name of the doctor or medical clinic: 22 Phone number: Approximate date of most recent medical appointment: 23 Name of the dentist or dental clinic: 24 Phone Number: 25 Approximate date of the most recent dental appointment:

26 Please attach a copy of the minor/s’ health insurance card and immunization record 27 as proof of routine and consistent medical care.

28 CONFIDENTIAL DECLARATION OF PROPOSED GUARDIAN PRB-PGN-001 Rev. Jul-01-2020

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1 21. Does everyone who lives in the home speak and understand English? ☐ Yes ☐ No 2 If NO, please identify the other language/s: 3

4 22. Please attach a copy of the child/ren’s birth certificate. If the birth certificate is in

5 another language, please provide an English-language translation of the birth certificate. 6

7 23. Please provide the name, telephone number, and email address of someone who will 8 always know how to contact you.

9 Name:

10 Phone Number:

Email Address:11

12 In-person interviews may be required. Please be advised a Court Investigator will be 13 contacting you to schedule a meeting in your home with you and the child(ren). Personal 14 interviews with additional residents of the minor’s household may be required.

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In signing below, I consent to a complete criminal and children’s services referral16 history background screening by the San Francisco Superior Court, Court

17 Investigator’s Office. 18

19 I declare under penalty of perjury under the laws of the State of California that the

20 above information is true and correct.

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22 Date:

23 Printed Name Signature 24

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28 CONFIDENTIAL DECLARATION OF PROPOSED GUARDIAN PRB-PGN-001 Rev. Jul-01-2020