San Joaquin — Confidential Guardianship Questionnaire

Source: https://www.sjcourts.org/sites/default/files/forms/2026-02/SJPR400-Confidential-Guardianship-Questionnaire_0.pdf

FOR COURT USE ONLY In the Superior Court of the State of California In and for the County of San Joaquin

CONFIDENTIAL GUARDIANSHIP QUESTIONNAIRE (DECLARATION BY PROPOSED GUARDIAN(S))

SAN JOAQUIN COUNTY SUPERIOR COURT 315 W. ELM STREET LODI, CA 95240

CASE NAME: CASE NUMBER: Is an interpreter needed? ☐ No ☐ Yes If yes, for whom and in what language: Instructions to Petitioner(s) / Proposed Guardian(s): This questionnaire MUST be completed with the Petition for Appointment of Guardianship. If there is not enough room to complete your answer, attach a separate sheet of paper clearly identifying the question. DO NOT leave any questions blank. State N/A if the question does not apply or “unknown” if you do not know the answer to a question.

This form is required and failure to complete it or to provide attachments may result in delays.

PAGE 1-2 OF THE GUARDIANSHIP QUESTIONNAIRE MUST BE COMPLETED FOR EACH MINOR LISTED ON THE PETITION; MAKE COPIES OF PAGE 1-2 FOR EACH ADDITIONAL CHILD AND ATTACH THEM TO THE QUESTIONNAIRE. MINOR CHILD(REN) LISTED ON GUARIANSHIP PETITION ATTACH a copy of the birth certificate for each child Full Legal Name: Date of Birth: (As on birth certificate) Pronoun of Preference: he/him/his she/her/hers they/them/theirs Person with Whom Residing: Social Security Number: Name of School/Daycare: Grade Level: Address of School/Daycare: Teacher’s/Provider’s Name: School/Daycare Phone: Are there special educational needs? No Yes (Describe): ______________________________________________________________________________________

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Has this child received Regional Center services (past or present)? No Yes If yes, answer items a-d below. a. Regional Center(s) they received or are receiving services from:

b. Diagnosis:
c. Service Coordinator (include name & phone number):
d. Has the Minor received any other resources or services for Developmental Disability?
No Yes (Describe): _____________________________________________________________________________
______________________________________________________________________________________________________
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CONFIDENTIAL GUARDIANSHIP QUESTIONNAIRE

Mandatory Page 1 of 8 SJPR-400 (Revised 07/2023) Local Rule 4-702

Is this child a member of or do you have reason to believe this child may be eligible for membership in an Indian tribe recognized by the federal government? No Not Sure Yes (Specify tribe):

Is this child subject to any legal custody orders? No Not Sure Yes DOES THE CHILD HAVE: If Yes, Provide Details MEDICAL PROBLEMS? No Yes BEHAVIORAL PROBLEMS? No Yes DIFFICULTIES IN SCHOOL? No Yes COUNSELOR? No Yes SOCIAL WORKER? No Yes LEGAL GUARDIAN? No Yes OPEN CPS CASE? No Yes Will the child’s school be changed? No Yes If Yes, Name and address of new school:

Does this child receive any individual or family counseling, therapy, or psychological services? No Yes Is this child prescribed any medications? No Yes If yes, please list medication(s) and reason for the medication: Medication Reason

Continued on attachment for this child

Additional children attached

CONFIDENTIAL GUARDIANSHIP QUESTIONNAIRE

Mandatory Page 2 of 8 SJPR-400 (Revised 07/2023) Local Rule 4-702

PAGES 3-5 OF THE GUARDIANSHIP QUESTIONNAIRE MUST BE COMPLETED BY EACH PETITIONER/PROPOSED GUARDIAN; MAKE COPIES OF PAGES 3-5 FOR EACH ADDITIONAL PETITIONER/PROPOSED GUARDIAN AND ATTACH THEM TO THE QUESTIONNAIRE.

PETITIONER / PROPOSED GUARDIAN

Full Legal Name: AKA or Maiden Name: Pronoun of Preference: he/him/his she/her/hers they/them/theirs Legal Relationship to Child: Mother Father Stepparent Other:

Age: Date of Birth: Place of Birth: Social Security Number: Driver’s License No.: Currently valid: No Yes Home Phone: Business Telephone: Cell Phone: e-mail address: Current Address: From: – to PRESENT City: State: Zip: Are you currently Single Married Divorced Separated Widowed Living Together If married or living together, How long have you been married/living Name of Spouse/Partner: together? Date of Birth of Spouse/Partner: LIST PREVIOUS ADDRESSES FOR THE PAST 5 YEARS Continued on Attachment

From: _____________ To: _______________ From: _____________ To: _______________

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Previous Street Address Previous Street Address

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City State Zip Code City State Zip Code

From: _____________ To: _______________ From: _____________ To: _______________

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Previous Street Address Previous Street Address

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City State Zip Code City State Zip Code

CURRENT EMPLOYMENT Your Position and/or Job Title:

Name of Company:_________________________________________________________ _______________________________________

Address:___________________________________________________________ Telephone: _______________________________________________________________ ______________ _____________ City State Zip Code

Length at this job: Days/Hours you work: Gross Salary/Monthly: $

Other Income TANF Social Security Unemployment Amount $ _______________ Child Support Medi-Cal Other _____________________ Received from:___________________

CONFIDENTIAL GUARDIANSHIP QUESTIONNAIRE

Mandatory Page 3 of 8 SJPR-400 (Revised 07/2023) Local Rule 4-702

CRIMINAL RECORDS Please note that a complete criminal background will be conducted. Disclose any arrests, even if the charges were later dismissed. Have charges ever been filed against you for crimes other than a minor traffic violation? No Yes If yes, please specify: Disposition Charge(s) City/State Date (pending, dismissed, convicted) 1.

Continued on attachment

Are you on Probation? No Yes If yes, provide information below:

Probation Officer: Phone Number:

Are you on Parole? No Yes If yes, provide information below:

Parole Agent: Phone Number:

Do you have any restraining orders or ever been a party to a request for a restraining order? No Yes If Yes, Explain: _____________________________________________________________________________

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Have you ever had contact with a Child Protective Service Agency? No Yes If Yes, which county? __________________________________________________________________________

Give Detail: __________________________________________________________________________________________________

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Have you or anyone living in your home ever been accused of or convicted for child abuse or child molestation? No Yes If Yes, Explain: _______________________________________________________________________________________________

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MEDICAL HISTORY

Your health is Good Fair Poor

If fair or poor, please explain: ____________________________________________________________________________________

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Are you currently taking any medications? No Yes If yes, complete the following: Continued on attachment Name Amount Reason How Often Taken

CONFIDENTIAL GUARDIANSHIP QUESTIONNAIRE

Mandatory Page 4 of 8 SJPR-400 (Revised 07/2023) Local Rule 4-702

Have you ever had a substance abuse problem with any of the following? Alcohol No Yes Drugs No Yes

If yes, to any of the above, please explain:

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If you have received psychiatric treatment or counseling, please complete the section below. Continued on attachment Name of Doctor/Hospital Address of Doctor/Hospital Date Last Treated Diagnosis

FINANCIAL INFORMATION

Your Monthly Net Income(s)(All Sources): $ Monthly Expenses: $ INCOME: Please list source(s) of income and amount(s): Income Source Amount

The home you live in is: owned rented Please ATTACH proof of residence, e.g. rental agreement. Monthly Rent or Mortgage: $ Value (if own): $ Approximate Size: Sq. ft. Number of Bedrooms: Number of Bathrooms: OTHER ASSETS: Please list other major assets or real property and the value: Asset Value 1.

Is medical insurance available to the Minor? No Yes If Yes, name of Insurer: Do you receive public assistance? No Yes If Yes, amount: $ Do you pay or receive child support (for your own children, if any)? No Yes If Yes, Paying: $ Receiving: $

Continued on attachment

CONFIDENTIAL GUARDIANSHIP QUESTIONNAIRE

Mandatory Page 5 of 8 SJPR-400 (Revised 07/2023) Local Rule 4-702

HOUSEHOLD COMPOSITION NAMES OF ANY OTHER ADULTS, 18 YEARS OR OLDER, LIVING IN THE HOME

1. Full Legal Name: AKA or Maiden Name: Sex: Age: Date of Birth: Place of Birth: Social Security Number: Driver’s License No.: Home Phone: Business Telephone: Cell Phone: E-mail Address: Relationship to Petitioner: Relationship to Child(ren):

2. Full Legal Name: AKA or Maiden Name: Sex: Age: Date of Birth: Place of Birth: Social Security Number: Driver’s License No.: Home Phone: Business Telephone: Cell Phone: E-mail Address: Relationship to Petitioner: Relationship to Child(ren):

3. Full Legal Name: AKA or Maiden Name: Sex: Age: Date of Birth: Place of Birth: Social Security Number: Driver’s License No.: Home Phone: Business Telephone: Cell Phone: E-mail Address: Relationship to Petitioner: Relationship to Child(ren):

4. Full Legal Name: AKA or Maiden Name: Sex: Age: Date of Birth: Place of Birth: Social Security Number: Driver’s License No.: Home Phone: Business Telephone: Cell Phone: E-mail Address: Relationship to Petitioner: Relationship to Child(ren): Continued on attachment

   NAMES OF ANY OTHER CHILDREN, UNDER 18, LIVING IN YOUR HOME

   Name Relation DOB School or Daycare

   Continued on attachment

   CONFIDENTIAL GUARDIANSHIP QUESTIONNAIRE

Mandatory Page 6 of 8 SJPR-400 (Revised 07/2023) Local Rule 4-702

IF THERE ARE ADDITIONAL PARENTS OF THE CHILD(REN) LISTED IN THE PETITION FOR GUARDIANSHIP, MAKE COPIES OF PAGE 7 OF THE GUARDIANSHIP QUESTIONNAIRE AND ATTACH THE ADDITIONAL PAGES TO THE QUESTIONNAIRE

PARENTS OF MINOR(S)

If a parent is deceased, please check “deceased” for that person’s and include death of death (DOD). ATTACH a copy of the death certificate or obituary.

1. Full Legal Name: AKA or Maiden Name: Deceased, DOD:

Age: Date of Birth: Place of Birth: Social Security Number: Driver’s License No.: Currently valid: No Yes Home Phone: Business Telephone: Cell Phone: e-mail address: Current Address: City: State: Zip: Last Date of Contact With Child(ren): 2. Full Legal Name: AKA or Maiden Name: Deceased, DOD:

Age: Date of Birth: Place of Birth: Social Security Number: Driver’s License No.: Currently valid: No Yes Home Phone: Business Telephone: Cell Phone: e-mail address: Current Address: City: State: Zip: Last Date of Contact With Child(ren):

OTHER CHILDREN OF PARENTS

Name Age Birth date Name(s) of Parent(s)

Continued on attachment

CONFIDENTIAL GUARDIANSHIP QUESTIONNAIRE

Mandatory Page 7 of 8 SJPR-400 (Revised 07/2023) Local Rule 4-702

PROPOSED VISITATION Provide specific details (days and times) For Father:

For Father’s Parents:

For Mother:

For Mother’s Parents:

For the Brothers & Sisters of the minor(s):

Before filing your documents with the court, confirm that you have attached all required documents to this packet

(Each Proposed Guardian must sign the acknowledgement under penalty of perjury.)

I declare under penalty of perjury under the laws of the State of California that all of the information I have submitted in this Guardianship Questionnaire is true and correct.

Date:

Type or print name Signature of Proposed Guardian

Date:

Type or print name Signature of Proposed Guardian

Note: If another person filed out this document for you, that person must also sign the acknowledgement under penalty of perjury.

Date:

Type or print name Signature

CONFIDENTIAL GUARDIANSHIP QUESTIONNAIRE

Mandatory Page 8 of 8 SJPR-400 (Revised 07/2023) Local Rule 4-702