Alameda — Guardianship Questionnaire

Source: https://www.alameda.courts.ca.gov/system/files/forms-and-filings/guardianship-confidential-questionnaire.pdf

Superior Court of California COUNTY OF ALAMEDA

Civil Division

Berkeley Courthouse 2120 Martin Luther King Jr. Way, Berkeley, CA 94704

PROBATE GUARDIANSHIP QUESTIONNAIRE INSTRUCTIONS

1. All proposed guardians (the person asking to be guardian) must answer all the questions in this Questionnaire. The Court Investigator uses the information to report to the Judge deciding the case. This questionnaire is also available on the court’s website at: https://www.alameda.courts.ca.gov/divisions/probate/probate-rules-forms

2. To avoid a delay in your case being heard by the Judge, you must file this completed Questionnaire AT THE SAME TIME that you file your Petition for Appointment as Guardian.

3. If you are not related by blood to the child, you must also mail the following: • A copy of Petition for Appointment of Guardian of Minor & • Notice of Hearing Send these to Director of Social Services, 744 P Street, M.S. 19-31, Sacramento, CA 95814

4. If the Petition asks the Court to appoint more than one person as guardian, each additional proposed guardian must complete Sections I & II of the questionnaire separately.

5. If you are asking to be appointed as the Guardian of the Estate only, the court investigator will interview you by telephone.

6. If you are asking to be appointed as the Guardian of the Person (or Person and Estate), the court investigator may conduct a home visit. After this questionnaire is received, the court investigator will contact you to schedule the home visit if necessary. The court investigation cannot begin until after a completed questionnaire is received.

7. The court investigator fee is $800. You may ask for a Fee Waiver if you are unable to pay. To ask for a Fee Waiver, file a Request to Waive Court Fee, Form FW-001-GC through the Probate Clerks Office. You may also be able to make monthly payments through Alameda County Central Collections.

8. You must sign your name on pages 4 and 11.

9. You must answer all the questions on the Questionnaire completely.

10. If you need help filling out this Questionnaire, contact the Court’s Self-Help Center at 510-272-1393.

• FOR YOU TO BE APPOINTED AS GUARDIAN, THE CHILD(REN) MUST CURRENTLY LIVE WITH YOU.

• THE CHILD(REN) MUST ALSO APPEAR WITH YOU AT THE FIRST COURT HEARING. • FILE THIS QUESTIONNAIRE WITH YOUR PETITION OR YOUR CASE WILL BE CONTINUED. • DO NOT FILE THIS COVERSHEET WITH YOUR QUESTIONNAIRE.

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Guardianship Questionnaire (rev 2.24)

COURT INVESTIGATORS OFFICE 2120 Martin Luther King Jr. Way Berkeley, California 94704

SUPERIOR COURT OF CALIFORNIA
COUNTY OF ALAMEDA

CONFIDENTIAL GUARDIANSHIP QUESTIONNAIRE

In the Guardianship of: ) PROBATE CASE NO:________________
)
) HEARING DATE:___________________
)
)
) (Hearing date should be at least 90 days
) from date of filing)
)
)
Minor(s) )

TO PREVENT ANY DELAY IN YOUR HEARING, YOU MUST FILL OUT THIS QUESTIONNAIRE COMPLETELY AND FILE IT AT THE SAME TIME THAT YOU FILE YOUR PETITION FOR APPOINTMENT OF GUARDIAN OF MINOR

COURT CLERK: File as a confidential document

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Guardianship Questionnaire (rev 2.24)

CONFIDENTIAL GUARDIANSHIP SCREENING (PROBATE CODE SECTION 1516)

GUARDIANSHIP OF: CASE NO.:

1. A COPY OF EACH CHILD’S BIRTH CERTIFICATE MUST BE ATTACHED TO THIS FORM.

2. INFORMATION ABOUT THE CHILD(REN) NEEDING GUARDIANSHIP: Name Sex Date of Birth Place of Birth Social Security #

Check here and list any additional children on an attached separate piece of paper.

3. Does the family have Native American/American Indian ancestry or heritage? YES NO

4. LIST THE PROPOSED GUARDIAN(S): THIS INFORMATION IS REQUIRED DATE OF RELATIONSHIP NAME BIRTH TO CHILD(REN) TELEPHONE

5. ARE YOU RELATED TO THE CHILD(REN)’S: MOTHER BY: BLOOD MARRIAGE FATHER BY: BLOOD MARRIAGE

6. HAVE YOU EVER BEEN ARRESTED, CHARGED WITH, OR CONVICTED OF ANY CRIME (REGARDLESS OF THE OUTCOME)? YES NO

NOTE: THE COURT INVESTIGATOR WILL CONDUCT A CRIMINAL BACKGROUND CHECK.

7. CHILD(REN)’S PARENTS:

   NAME ADDRESS/PHONE BIRTHDATE SSN DATE OF DEATH

Parent 1:

Parent 2: Check here and list any additional parents on an attached separate piece of paper.

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8. OTHER PEOPLE LIVING IN YOUR HOME, AGE 18 AND OVER:

   NAME DATE OF BIRTH SSN RELATIONSHIP TO CHILD(REN)

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A SCREENING OF PREVIOUS CONTACTS WITH CHILD PROTECTIVE SERVICES WILL BE CONDUCTED.

AGREEMENT TO RELEASE AND SHARE INFORMATION

By signing below, I agree that I am the proposed guardian in this matter. I consent to the release of any and

all records about me in possession of Child Protective Services, and to the delivery of those records to the Court Investigator and Court for use in determining my suitability as guardian. I consent to the release of any and all criminal records about me from the Court Investigator’s background check to Child Protective Services. I also consent to the Court Investigator and Court sharing all records with all counsel in the guardianship case. SIGN

Date: Signature(s) of Proposed Guardian(s) required SIGN

Date: Signature(s) of Proposed Guardian(s) required

DO NOT WRITE BELOW THIS LINE

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DEPARTMENT OF SOCIAL SERVICES USE ONLY

NO INFORMATION AVAILABLE INFORMATION AVAILABLE (see attached results form from CWW)

Screening by Worker #: Date: Phone No.:

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CONFIDENTIAL GUARDIANSHIP QUESTIONNAIRE

YOU MUST ANSWER ALL QUESTIONS. Write “N/A” if a question does not apply to you.

GUARDIANSHIP OF: _________________________________CASE NO. :

Will you or anyone else in the home require an interpreter? YES NO Language:___________

SECTION I

PROPOSED GUARDIAN’S INFORMATION (This information is about the person who wants to be guardian. Complete Sections I & II of this questionnaire for each proposed guardian):

Name: Date of Birth:

Phone numbers: Home Work Cell :

Home Address: ___________________________City: __________ Zip:

Email address: Place of Birth:

Social Security No.: Driver’s License No.:

Are you currently: Married Widowed Single Separated Divorced

If currently married or separated, what is your spouse’s name?

List your children, even if they are adults and not living with you. Provide their date of birth, address, and whether they have ever been arrested or charged with a crime.

NAME DATE OF BIRTH ADDRESS ARRESTED? YES NO YES NO YES NO YES NO Check here and list any additional children on a separate sheet of paper.

YOUR HEALTH CONDITION: List any physical or mental health problems.

List any medications you are taking and state what they are for

Have you ever been in counseling? YES NO

If yes, what was the reason? Drugs Alcohol Grief Domestic Violence Other

Explain:

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EDUCATIONAL HISTORY:

Did you receive a high school diploma or GED? YES NO

If yes, where & when:

Highest Degree(s) earned: Where & When:

EMPLOYMENT:

Are you employed? YES NO

Name of Employer Address:

Length of employment: Job Title:

Are you retired or have you been at your current employment for less than five years? YES NO

If yes, please list work history for the past 5 years:

Name of Employer Employed from_______________to_____________________

Name of Employer Employed from_______________to_____________________

PROPOSED GUARDIAN’S FINANCIAL INFORMATION:

Total Monthly Income: $ Total Monthly Expenses: $

Total Assets Total Liabilities

Does anyone else contribute money to the household or contribute money to support the child(ren) needing the

guardianship? YES NO

If yes, who? _____________________ How much? $__________How often? ____________

Are you financially able to support the child(ren)? YES NO If your expenses are greater than your income, how will you make up the difference?

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Have you applied for, or are you already receiving, benefits for the child(ren)? YES NO Welfare Amount $ Social Security Amount $ Medi-Cal Amount $_______________ Child Support Amount $_______________

Is someone else, such as a parent, receiving the above benefits for the child(ren)? YES NO UNKNOWN Who: Relationship to child:

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REFERENCES:

Please list three references who have known you, at least, five years and who are NOT relatives. You must provide the complete name, address, including zip codes and daytime phone numbers. Please notify each reference that we will be contacting them by letter or telephone.

PRINT NAME STREET ADDRESS, CITY, ZIP CODE DAYTIME TELEPHONE 1. 2. 3.

SECTION II

DESCRIBE YOUR HOME:

Single family home Apartment No. of bedrooms _____ No. of bathrooms _____ How long have you lived here?

Will child(ren) have own room YES NO If shared, with whom? Name: Age:

Do you have any guns or other weapons stored on the property? YES NO

If yes, what type of weapon? ___________________ Where and how are they stored? ___________________

Is there a swimming pool or hot tub? YES NO Is it fenced? YES NO

Are there pets in the home? __________________________________________

Does any adult in the home have any problem(s) that could affect the child, such as a history of child abuse/molest, criminal background, violent behavior, alcohol or drug problem? YES NO Explain:__________________________________________________________________________________

Have the police ever been to your home? YES NO

If yes, when and why? ______________________________________________________________________

Does anyone in the home object to the guardianship? YES NO If yes, who?

OTHER CHILDREN IN THE HOME (under 18 years of age): Name Date of Birth School Attending Relation to Guardian

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SECTION III

INFORMATION ABOUT THE CHILD(REN) NEEDING GUARDIANSHIP:

1. Have any of the child(ren) been involved with the Juvenile Court? YES NO DON’T KNOW

2. Do any of the child(ren) have a Social Worker? YES NO DON’T KNOW

If, yes, what is the Social Worker’s name? _____________________ Phone number ____________

3. Why do you need the guardianship?

4. Has the child(ren) been subjected to abuse, neglect, or abandonment? YES NO DON’T KNOW

5. Please provide names and ages of the siblings (brothers and sisters) of the child(ren) and the person with whom they live: NAME OF SIBLING AGE WITH WHOM THEY LIVE

6. Does the child(ren) visit his/her brothers and/or sisters? YES NO How often?___________

7. Is there any specific religious or cultural heritage, such as Native American ancestry, that would affect the

child(ren)’s future plans? YES NO Explain:

8. Does the family have Native American ancestry or receive any medical or other services/benefits from a tribe?

YES NO UNKNOWN

If yes, please explain:__________________________________________________________________________

Name of Tribe:_______________________________________________________________________________

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SCHOOL AND/OR DAY CARE: (Please contact the child(ren)’s school or daycare and tell them that we may be contacting them. Please attach a copy of the child(ren)’s most recent report card to this questionnaire).

Name Director or Principal

Address

Teacher’s Name

Grade level If Daycare, is it licensed? ____________________

Does the child(ren) have any special educational needs? YES NO DON’T KNOW Describe________________________________________________________________________________ Is the child(ren) receiving services through the Regional Center? YES NO DON’T KNOW

Case Manager: Telephone:

MEDICAL/HEALTH CARE: Medical Insurance Provider: Medical Number: __________________________

Date of last medical appointment: _______________ Reason for visit: ________________________________

Date of last dental appointment:_________________ Reason for visit: _______________________________

Are all required immunizations current? YES NO DON’T KNOW

Does the child have any medical problems, physical or psychological? YES NO Does the child take any prescribed medications? YES NO

Has the child ever been hospitalized? YES NO Why, When?______________________

Has the child seen a counselor in the past? YES NO Why, When?______________________

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Is the child seeing a counselor now? YES NO If yes, how often?

Name of Counselor: Telephone:

SECTION IV

INFORMATION ABOUT THE NATURAL PARENTS OF CHILD(REN): (Please provide the most current information available).

Mother’s Name:___________________________________________ SSN: ____________________________

Date of Birth:_______________________ If deceased, date of death:__________________________________

Address:_____________________________________ Telephone:____________________________________

Father’s Name:___________________________________________ SSN: ____________________________

Date of Birth:_______________________ If deceased, date of death:__________________________________

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Address:_____________________________________ Telephone:____________________________________

Does the child(ren) have contact with the mother? YES NO Explain:

Does the mother agree to the guardianship? YES NO DON’T KNOW

Does the mother have Native American Ancestry? YES NO DON’T KNOW

Does the child(ren) have contact with the father? YES NO Explain:___________________________

Does the father agree to the guardianship? YES NO DON’T KNOW

Does the father have Native American Ancestry? YES NO DON’T KNOW

Complete this section only if you want to be Guardian of the Estate. If not, skip this section and continue to the next page.

SECTION V

GUARDIANSHIP OF THE ESTATE ONLY Where is the money or property coming from that the child(ren) will be receiving?

Inheritance - Attach a copy of the will or provide -

Name of the deceased person: __________________________ Date of death: Probate Case

No.______________ Estate administered in (County) (State)

Child will inherit:

Real estate - Address Value child(ren)’s share $

Cash, $ Location ________________________________________________________

Stock/Bonds $ Location_______________________________________________________

Other, describe ______________________________________________________________________________

Insurance benefit, Insured:_________________ Relation to child(ren)______________ Value

$_______________

Gift from (Name) (relation) Type of asset

(cash, real property, etc.) ______________________ Value $_____________

Personal Injury Settlement –

Case No. ________________, in (County) ___________, (State) where the case was

settled. Value $ __________________

Other source, describe Value $________________________________

What are your plans for managing the estate? (Place money in a blocked bank account? investments? rental of real

property? etc.)

Does the child(ren) already have money in an individual or joint account?

YES NO DON’T KNOW

Location: _____________, balance: $

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Name on individual and/or joint accounts:

Does the child(ren) already have any other investments or property?

YES NO DON’T KNOW

What ____________________________________________ Value $________________

Do you expect to request to use the child(ren)’s estate for any purpose (taxes, tax preparation, bond premiums,

court costs/fees and other expenses)? YES NO If yes, what expenses will you request the court to

approve?

Please provide the name, address and phone number of one person who will always know how to get in contact with you.

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(Name) (Address) (Telephone)

Name of person who helped you complete this form ________________________________________________

Address

Bar No. ___________ Telephone Fax Number

VERIFICATION

I/We the undersigned declare under the penalty of perjury that the preceding is true and correct.

Executed in California on . City Date

SIGN

Signatures __________________________ __________________________

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