Santa Clara — Form PB-4005

Source: https://santaclara.courts.ca.gov/system/files/forms/pb-4005_rem.pdf

ATTACHMENT PB-4005

For Court use only:

Temp hrg date: __________________

Perm hrg date: __________________

REFERRAL FOR COURT INVESTIGATOR & QUESTIONNAIRE - GUARDIANSHIP

Case number (if you have one): Guardianship of (name): Person Estate

▪ Do you think anyone will disagree with the guardianship? Yes No

If yes, who? Name: Telephone number:

▪ Has Child Protective Services (CPS) ever been called about the children in this case? Yes No

If yes, which County: Santa Clara Other (County name):

Are there any custody orders about the children in this case? Yes No

If yes, which County: Santa Clara Other (County name):

What is the primary language spoken in the home?____________________________________________

Information about the CHILDREN

▪ Child Name:

▪ Birth Date:

▪ Social Security Number:

▪ School, Grade, School Telephone Number:

▪ Child Name:

▪ Birth Date:

▪ Social Security number:

▪ School, Grade, School Telephone Number:

▪ Child Name:

▪ Birth Date:

▪ Social Security Number:

▪ School, Grade, School Telephone Number:

Check if there are more children in the case add information about them on another page.

CONFIDENTIAL – DO NOT PUT IN COURT FILE

REFERRAL FOR COURT INVESTIGATOR & QUESTIONNAIRE - GUARDIANSHIP (PROBATE)

PB-4005 REV 07/01/2022 Page 1 of 2 For Mandatory Use

ATTACHMENT PB-4005

Information about the PROPOSED GUARDIANS’S ATTORNEY

Proposed Guardian doesn’t have an attorney

Name:______________________________________ email______________________________________-

Address:

Phone Number: Fax Number:

Information about the PROPOSED GUARDIAN(S)

Proposed Guardian :

▪ Name:____________________________________ email_________________________________________ ▪ Relationship to child(ren): Grandparent Aunt/Uncle Other:

▪ Birth Date:

▪ Social Security Number:

▪ Driver’s License Number:

▪ Home Address:

▪ Home Phone Number: Cell Phone Number:

▪ Work Address:

▪ Work Phone Number: Fax Number:

Proposed Guardian :

▪ Name: ____________________________________ email_________________________________________ ▪ Relationship to child(ren): Grandparent Aunt/Uncle Other:

▪ Birth Date:

▪ Social Security Number:

▪ Driver’s License Number:

▪ Home Address:

▪ Home Phone Number: Cell Phone Number:

▪ Work Address:

▪ Work Phone Number: Fax Number:

All proposed Guardians must answer these questions:

1. Have you ever been convicted of a misdemeanor or felony offense? Yes No

If yes, what offense(s): Date: County:

2. Is there a social worker, probation or parole officer supervising you or ANY person who lives with you? Yes No

If yes, explain:

CONFIDENTIAL – DO NOT PUT IN COURT FILE

REFERRAL FOR COURT INVESTIGATOR & QUESTIONNAIRE - GUARDIANSHIP (Probate)

PB-4005 REV 07/01/2022 Page 2 of 3 For Mandatory Use

ATTACHMENT PB-4005

I/We declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. SIGN

Date: Proposed Guardian 1 signs here: SIGN

Date: Proposed Guardian 2 signs here:

Information about OTHER ADULTS (age 18 or older) WHO LIVE IN YOUR HOME

▪ Name: ____________________________________ email_________________________________________

▪ Birth Date:

▪ Social Security Number:

▪ Driver’s License Number: State:

▪ Name: ____________________________________ email_________________________________________

▪ Birth Date:

▪ Social Security Number:

▪ Driver’s License Number: State:

▪ Name: ____________________________________ email_________________________________________

▪ Birth Date:

▪ Social Security Number:

▪ Driver’s License Number: State:

▪ Name: ____________________________________ email_________________________________________

▪ Birth Date:

▪ Social Security Number:

▪ Driver’s License Number: State:

▪ Name: ____________________________________ email_________________________________________

▪ Birth Date:

▪ Social Security Number:

▪ Driver’s License Number: State:

More adults live in my home. I’ve attached information about them on a separate page.

CONFIDENTIAL – DO NOT PUT IN COURT FILE

REFERRAL FOR COURT INVESTIGATOR & QUESTIONNAIRE - GUARDIANSHIP (Probate)

PB-4005 REV 07/01/2022 Page 3 of 3 For Mandatory Use