Santa Cruz — SUPPR-1077

Source: https://www.santacruz.courts.ca.gov/sites/default/files/pdfs/POST%20%28WEB%29SUPPR%201077%20Attachment%2C%20Declaration%20in%20Support%20of%20Guardianship.pdf

GUARDIANSHIP OF (NAME): CASE NUMBER:

ATTACHMENT (Number): Page ___ of ___
(add pages as required)

1 I am the ___________________. I was born on _________________. (Relationship to minor) (Month/Day/Year) 2 The current state of my health is (please describe below):

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__________________________________________________ Continued on attached page 3 The specific reason the parents are unable to care for the minor is (please describe below): Mother Father is currently incarcerated, is currently incarcerated, has passed away, has passed away, is not mentally stable, is not mentally stable, is not financially stable, is not financially stable, has never been in the child’s life, hasn’t seen the child in _____ years ____ months wants me to have the child, wants me to have the child, Other: ________________________________ Other: ________________________________ Please explain below:

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Continued on attached page

4 Check the box that best describes the minor’s needs: Does the minor have special emotional, psychological, educational, or personal needs? No Yes If yes, please list the needs and how you are able to provide for them (please describe below):

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5 Will the minor have his/her own room? Yes No (if No, please list who he/she will be sharing with): Full Legal Name: Full Legal Name: Relation. to Minor (if any): Relation. to Minor (if any): Date of Birth: Date of Birth:

6 I declare under penalty of perjury under California State law that the information in this form is true and correct, which means if I/we lie on this form I/we am guilty of a crime. Date:

(Petitioner) Print Name Here (Petitioner) Sign Name Here

Form Adopted for OPTIONAL USE DECLARATION IN SUPPORT OF Page 1 of 1 Superior Court of Santa Cruz County GUARDIANSHIP - ATTACHMENT SUPPR 1077 01/01/20