Merced — MSC-PR-001

Source: https://www.merced.courts.ca.gov/system/files/msc-pr-001-court-investigations-guardianship-questionnaire-re-712018.pdf

MSC-PR-001

MERCED COUNTY SUPERIOR COURT

COURT INVESTIGATIONS GUARDIANSHIP QUESTIONNAIRE

Minor's Name

Case No. Hearing Date:

Petitioner's (paternal or maternal) relationship to the minor:

This questionnaire MUST be completed and served to the Court Investigator with the Petition for Appointment of Guardianship. If you find there is not enough room to complete your answer, use the reverse of the page or attach a separate sheet of paper clearly identifying the question. DO NOT leave any question blank. State N/A if the question does not apply to you.

IF THERE IS A PROPOSED CO-GUARDIAN WHO IS NOT LISTED AS SPOUSE OR SIGNIFICANT OTHER, AN ADDITIONAL FORM MUST BE COMPLETED FOR THAT PERSON.

FAILURE TO SERVE THE COURT INVESTIGATOR WITH THIS FORM AND COPIES OF ALL DOCUMENTS FILED IN THIS MATTER MAY RESULT IN DELAYS.

For clarification or questions regarding this questionnaire or the guardianship procedure please contact:

Merced County Superior Court Investigator (209) 725-4190 Monday through Friday 8:00 a.m. to 4:00 p.m.

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MSC-PR-001 PERSONAL HISTORY

PROPOSED GUARDIAN

FULL NAME OTHER NAMES/MAIDEN

DATE OF BIRTH/BIRTHPLACE CA ID/DL NO. SOCIAL SECURITY NO.

LIST ALL ADDRESSES FOR THE PAST 5 YEARS

1. 2. 3.

PHONE NO. PHONE NO. PHONE NO. FROM TO FROM TO FROM TO = OWN = RENT = OWN = RENT = OWN = RENT RENT/MORTGAGE $ /MONTH RENT/MORTGAGE $ /MONTH RENT/MORTGAGE $ /MONTH LAST GRADE OF SCHOOL ATTENDED = 1-7 = 8 = 9 = 10 = 11 = 12 = SOME COLLEGE= COLLEGE GRADUATE = MASTERS

FATHER'S NAME MOTHER'S NAME

YOUR HEALTH = GOOD = FAIR = POOR NAME OF YOUR PHYSICIAN:

STATE ANY MEDICAL CONDITIONS YOU ARE CURRENTLY BEING TREATED FOR:

MEDICATIONS - NAME, AMOUNT, REASON, HOW OFTEN TAKEN:

ATTENDING COUNSELING? = YES = NO TYPE: COUNSELOR:

HAVE YOU EVER BEEN CONVICTED FOR AN IF YES, PLEASE LIST: OFFENSE OTHER THAN A MINOR TRAFFIC DATE CITY VIOLATION OUTCOME VIOLATION? = YES = NO

HAVE YOU EVER BEEN OR ARE YOU ON IF YES, PLEASE LIST: PROBATION/PAROLE?= YES = NO DATE CITY OFFICER/AGENT/TELEPHONE NO.

DO YOU DRINK ALCOHOLIC BEVERAGES? = YES = NO HOW MUCH/OFTEN?

WHAT DRUGS DO/DID YOU USE? WHEN DID YOU LAST USE?

HOW MUCH/OFTEN? = DAILY = WEEKLY = MONTHLY COST?

HAVE YOU EVER ENTERED OR COMPLETED IF YES, GIVE DETAILS: AN ALCOHOL OR DRUG TREATMENT PROGRAM? = YES = NO

HAVE YOU EVER HAD CONTACT WITH A CHILD IF YES, GIVE DETAILS AND COUNTY: PROTECTIVE SERVICE AGENCY? = YES = NO

ARE YOU = MARRIED = DIVORCED = SEPARATED = WIDOWED = LIVING TOGETHER

DATES AND PLACE OF ALL MARRIAGES: CHILDREN OF THE MARRIAGE: DATE/REASON FOR END OF MARRIAGE:

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MSC-PR-001 PERSONAL HISTORY

SPOUSE OR SIGNIFICANT OTHER

FULL NAME OTHER NAMES/MAIDEN

DATE OF BIRTH/BIRTHPLACE CA ID/DL NO. SOCIAL SECURITY NO.

LIST ALL ADDRESSES FOR THE PAST 5 YEARS

1. 2. 3.

PHONE NO. PHONE NO. PHONE NO. FROM TO FROM TO FROM TO = OWN = RENT = OWN = RENT = OWN = RENT RENT/MORTGAGE $ /MONTH RENT/MORTGAGE $ /MONTH RENT/MORTGAGE $ /MONTH LAST GRADE OF SCHOOL ATTENDED = 1-7 = 8 = 9 = 10 = 11 = 12 = SOME COLLEGE = COLLEGE GRADUATE = MASTERS

FATHER'S NAME MOTHER'S NAME

YOUR HEALTH = GOOD = FAIR = POOR NAME OF YOUR PHYSICIAN:

STATE ANY MEDICAL CONDITIONS YOU ARE CURRENTLY BEING TREATED FOR:

MEDICATIONS-NAME, AMOUNT, REASON, HOW OFTEN TAKEN:

ATTENDING COUNSELING?= YES = NO TYPE: COUNSELOR:

HAVE YOU EVER BEEN CONVICTED FOR AN IF YES, PLEASE LIST: OFFENSE OTHER THAN A MINOR TRAFFIC DATE CITY VIOLATION OUTCOME VIOLATION? = YES = NO

HAVE YOU EVER BEEN OR ARE YOU ON IF YES, PLEASE LIST: PROBATION/PAROLE? DATE CITY OFFICER/AGENT/TELEPHONE NO. = YES = NO

DO YOU DRINK ALCOHOLIC BEVERAGES? = YES = NO HOW MUCH/OFTEN?

WHAT DRUGS DO/DID YOU USE? WHEN DID YOU LAST USE?

HOW MUCH/OFTEN? = DAILY = WEEKLY = MONTHLY COST?

HAVE YOU EVER ENTERED OR COMPLETED AN IF YES, GIVE DETAILS: ALCOHOL OR DRUG TREATMENT PROGRAM? = YES = NO

HAVE YOU EVER HAD CONTACT WITH A CHILD IF YES, GIVE DETAILS AND COUNTY: PROTECTIVE SERVICE AGENCY? = YES = NO

ARE YOU = MARRIED = DIVORCED = SEPARATED = WIDOWED = LIVING TOGETHER

DATES AND PLACE OF ALL MARRIAGES: CHILDREN OF THE MARRIAGE: DATE/REASON FOR END OF MARRIAGE:

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MSC-PR-001

EMPLOYMENT / FINANCIAL

PROPOSED GUARDIAN

NAME/ADDRESS/PHONE OF EMPLOYER TITLE:

HOW LONG? DAYS/HOURS YOU WORK GROSS SALARY/MO.

OTHER INCOME = TANF = SOCIAL SECURITY = UNEMPLOYMENT = CHILD SUPPORT = MEDI-CAL

AMOUNT $ MO/WK RECEIVED FROM:

NAME/ADDRESS/PHONE OF PREVIOUS EMPLOYERS:

(GIVE DATES OF EMPLOYMENT AND REASON FOR TERMINATION)

WHERE DO YOU BANK? (COMPLETE ADDRESS) TYPES OF ACCOUNTS: ACCOUNT NUMBERS:

HAVE YOU EVER FILED FOR BANKRUPTCY? IF YES, GIVE DATE PLACE AND RESULT: = YES = NO

DO YOU SUPPORT ANYONE OUTSIDE OF IF YES GIVE NAME/RELATIONSHIP AND REASON: YOUR RESIDENCE? = YES = NO

SPOUSE/SIGNIFICANT OTHER

NAME/ADDRESS/PHONE OF EMPLOYER TITLE:

HOW LONG? DAYS/HOURS YOU WORK GROSS SALARY/MO.

OTHER INCOME = TANF = SOCIAL SECURITY = UNEMPLOYMENT = CHILD SUPPORT = MEDI-CAL

AMOUNT $ MO/WK RECEIVED FROM:

NAME/ADDRESS/PHONE OF PREVIOUS EMPLOYERS: (GIVE DATES OF EMPLOYMENT AND REASON FOR TERMINATION)

WHERE DO YOU BANK? (COMPLETE ADDRESS) TYPES OF ACCOUNTS: ACCOUNT NUMBERS:

HAVE YOU EVER FILED FOR BANKRUPTCY? IF YES, GIVE DATE PLACE AND RESULT: = YES = NO

DO YOU SUPPORT ANYONE OUTSIDE OF IF YES GIVE NAME/RELATIONSHIP AND REASON: YOUR RESIDENCE? = YES = NO

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MSC-PR-001

RESIDENCE

ARE THERE ANY OTHER ADULTS RESIDING IN THE HOME? = YES = NO

IF YES: NAME DOB CA ID/DL NO. SOCIAL SECURITY NO. RELATIONSHIP

ARE THERE ANY OTHER CHILDREN RESIDING IN THE HOME? = YES = NO

IF YES: NAME DOB RELATIONSHIP

GUARDIANSHIP CHILD

CHILD TO BE UNDER GUARDIANSHIP: NAME DOB RELATIONSHIP

ANY NATIVE AMERICAN BLOOD? PERCENTAGE? TRIBE?

NAME/ADDRESS OF SCHOOL GRADE: TEACHER:

NAME/ADDRESS OF PHYSICIAN

DID MOTHER RECEIVE PRENATAL CARE? = YES = NO FULL TERM BIRTH? = YES = NO DOES CHILD HAVE MEDICAL PROBLEMS? = YES = NO IF YES, EXPLAIN:

WAS THERE A DRUG TEST AT BIRTH? = YES = NO IF YES, RESULTS:

DOES CHILD HAVE BEHAVIORAL PROBLEMS? = YES = NO IF YES, EXPLAIN:

DIFFICULTIES IN SCHOOL? = YES = NO IF YES, EXPLAIN:

SPECIAL EDUCATION NEEDS? = YES = NO IF YES, EXPLAIN:

CRIMINAL INVOLVEMENT? = YES = NO IF YES, EXPLAIN:

CURRENT SOCIAL WORKER? = YES = NO IF YES, NAME: IS CHILD IN A DAYCARE PROGRAM? = YES = NO IF YES, PROVIDER: GIVE ALL OF THE ABOVE INFORMATION ON ALL CHILDREN PROPOSED TO BE UNDER GUARDIANSHIP. YOU CAN USE THE REVERSE OF THIS PAGE OR A SEPARATE SHEET. ATTACH COPIES OF BIRTH CERTIFICATES FOR EACH CHILD PROPOSED TO BE UNDER GUARDIANSHIP.

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MSC-PR-001

BIRTH PARENTS

MOTHER'S FULL NAME OTHER NAMES/MAIDEN

DATE OF BIRTH/BIRTHPLACE CA ID/DL NO. SOCIAL SECURITY NO.

ADDRESS TELEPHONE NO.

NAME/ADDRESS OF EMPLOYER TELEPHONE NO.

IS MOTHER IN AGREEMENT WITH DOES MOTHER CONTRIBUTE TO THE DOES MOTHER VISIT WITH CHILD? GUARDIANSHIP? = YES = NO SUPPORT OF CHILD? = YES = NO = YES = NO

DOES MOTHER HAVE ANY OTHER CHILDREN IF YES: NOT A PARTY TO THIS ACTION?= YES = NO NAME AGE

HAS THE MOTHER EVER BEEN ARRESTED AND/OR CONVICTED? = YES = NO IF YES, GIVE DETAILS:

HAS CPS EVER INVESTIGATED THE MOTHER? = YES = NO IF YES, GIVE DETAILS:

FATHER'S FULL NAME OTHER NAMES

DATE OF BIRTH/BIRTHPLACE CA ID/DL NO. SOCIAL SECURITY NO.

ADDRESS TELEPHONE NO.

NAME/ADDRESS OF EMPLOYER TELEPHONE NO.

IS FATHER IN AGREEMENT WITH DOES FATHER CONTRIBUTE TO THE DOES FATHER VISIT WITH CHILD? GUARDIANSHIP? = YES = NO SUPPORT OF CHILD?= YES = NO = YES = NO

DOES FATHER HAVE ANY OTHER CHILDREN IF YES: NOT A PARTY TO THIS ACTION?= YES = NO NAME AGE

HAS THE FATHER EVER BEEN ARRESTED = YES = NO IF YES, GIVE DETAILS: AND/OR CONVICTED?

HAS CPS EVER INVESTIGATED THE FATHER? = YES = NO IF YES, GIVE DETAILS:

GENERAL INFORMATION

WERE THE PARENTS EVER MARRIED? = YES = NO IF YES, STATUS? IF NO, WAS PATERNITY EVER ESTABLISHED? = YES = NO IF YES, CASE NO. COUNTY/STATE IS THERE AN ORDER FOR SUPPORT? = YES = NO IF YES, HOW MUCH? PAID TO? IS THERE A CUSTODY ORDER BETWEEN THE = YES = NO IF YES, CASE NO. PARENTS FOR THE CHILD?

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MSC-PR-001

GENERAL INFORMATION CONT'D

HAVE YOU, YOUR SPOUSE, ANOTHER ADULT IN THE HOME, OR THE PARENTS BEEN INVOLVED IN ANY OF THE FOLLOWING?

RECEIVED COUNSELING FOR DOMESTIC VIOLENCE? = YES = NO IF YES, WHO/WHY?

DOMESTIC DISPUTE WHERE LAW ENFORCEMENT WAS CALLED? = YES = NO IF YES, WHO/WHY?

BEEN THE SUBJECT OF A DOMESTIC OR CIVIL RESTRAINING ORDER? = YES = NO IF YES, WHO/WHY?

ADDITIONAL INFORMATION

LIST ANY OTHER INFORMATION YOU FEEL MAY BE HELPFUL TO THE INVESTIGATION.

I DECLARE UNDER THE PENALTY OF PERJURY THAT THE INFORMATION ON THIS FORM IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. DATED:

NAME OF PETITIONER SIGNATURE

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