Stanislaus — HAVE YOU EVER BEEN ON OR ARE YOU ON PROBATION/PAROLE? YES or NO

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

STANISLAUS COUNTY SUPERIOR COURT INVESTIGATOR GUARDIANSHIP QUESTIONNAIRE

Minor’s Name(s): DOB:

Proposed Guardian’s is the relative of the minor how? (circle one) MATERNAL or PATERNAL Relationship: (ex. Grandmother/father, aunt/uncle, cousin…) This form must be completed and returned with the Petition for Guardianship. If you find there is not Enough space to complete your answers, use the space provided on page 12, clearly identifying the question by number. DO NOT LEAVE ANY QUESTIONS BLANK, STATE N/A IF THE QUESTION DOES NOT APPLY TO YOU. FAILURE TO COMPLETE & RETURN THIS FORM WITH THE PETITION WHEN FILING, MAY RESULT IN DELAYS. ATTACH A COPY(IES) OF BIRTH CERTIFICATE(S) OF EACH CHILD AND ANY DEATH CERTIFICATE(S) OF NATURAL PARENTS (if applicable).

PERSONAL HISTORY OF PETITIONER(S)

PROPOSED GUARDIAN #1

FULL NAME: OTHER NAMES/MAIDEN: DATE OF BIRTH: ID OR DL#: SOCIAL SECURITY #: EMAIL:

LIST ADDRESSES FOR PAST 5 YEARS: PRESENT ADDRESS: DATES: TO RENT or OWN MONTHLY PAYMENT: $ PHONE NO. ( )

PRIOR ADDRESS: DATES: TO RENT or OWN MONTHLY PAYMENT: $ PHONE NO. ( )

YOUR HEALTH: (CIRCLE) GOOD FAIR POOR

STATE ANY MEDICAL CONDITIONS CURRENTLY BEING TREATED FOR:

MEDICATIONS – NAME AMOUNT, REASON AND HOW OFTEN TAKEN:

ATTENDING COUNSELING? YES or NO TYPE: NAME OF COUNSELOR: HAVE YOU EVER BEEN ON OR ARE YOU ON PROBATION/PAROLE? YES or NO OFFICER/AGENT’S NAME: PHONE #: ( )

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DO/DID YOU EVER USE ILLEGAL DRUGS? YES or NO IF YES, WHEN DID YOU LAST USE? HOW MUCH/OFTEN? (CIRCLE ONE) DAILY WEEKLY MONTHLY COST? $

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

HAVE YOU EVER HAD CONTACT WITH A CHILD PROTECTIVE SERVICES (CPS) AGENCY? YES or NO IF YES, GIVE DETAILS:

HAVE YOU EVER BEEN ARRESTED FOR DOMESTIC VIOLENCE OR ANY OTHER CRIMINAL OFFENSE? YES or NO IF YES, GIVE DETAILS:

EMPLOYMENT: NAME OF EMPLOYER: ADDRESS: PHONE #: ( ) TITLE: HOW LONG? DAYS YOU WORK: HOURS: GROSS SALARY : $ WEEKLY BIWEEKLY MONTHLY OTHER INCOME: (CIRCLE ONE) AFDC SOCIAL SECURITY UNEMPLOYMENT CHILD SUPPORT AMOUNT: $ WEEKLY or MONTHLY FOR WHOM RECEIVED: HAVE YOU EVER FILED BANKRUPTCY: YES or NO IF YES, DATE: PLACE: RESULT: HAS YOUR SPOUSE OR ANY OTHER ADULTS IN YOUR HOME BEEN ARRESTED FOR DOMESTIC VIOLENCE OR ANY OTHER CRIMINAL OFFENSES? IF YES, GIVE DETAILS BELOW:

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PROPOSED GUARDIAN #2

FULL NAME: OTHER NAMES/MAIDEN: DATE OF BIRTH: ID OR DL#: SOCIAL SECURITY #: EMAIL:

LIST ADDRESSES FOR PAST 5 YEARS: PRESENT ADDRESS: DATES: TO RENT orOWN MONTHLY PAYMENT: $ PHONE NO. ( )

PRIOR ADDRESS: DATES: TO RENT orOWN MONTHLY PAYMENT: $ PHONE NO. ( )

YOUR HEALTH: (CIRCLE) GOOD FAIR POOR

STATE ANY MEDICAL CONDITIONS CURRENTLY BEING TREATED FOR:

MEDICATIONS – NAME AMOUNT, REASON AND HOW OFTEN TAKEN:

ATTENDING COUNSELING? YES or NO TYPE: NAME OF COUNSELOR: HAVE YOU EVER BEEN ON OR ARE YOU ON PROBATION/PAROLE? YES or NO OFFICER/AGENT’S NAME: PHONE #: ( )

DO/DID YOU EVER USE ILLEGAL DRUGS? YES or NO IF YES, WHEN DID YOU LAST USE? HOW MUCH/OFTEN? (CIRCLE ONE) DAILY WEEKLY MONTHLY COST? $

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

HAVE YOU EVER HAD CONTACT WITH A CHILD PROTECTIVE SERVICES (CPS) AGENCY? YES or NO IF YES, GIVE DETAILS:

HAVE YOU EVER BEEN ARRESTED FOR DOMESTIC VIOLENCE OR ANY OTHER CRIMINAL OFFENSE? YES or NO IF YES, GIVE DETAILS:

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EMPLOYMENT: NAME OF EMPLOYER: ADDRESS: PHONE #: ( ) TITLE: HOW LONG? DAYS YOU WORK: HOURS: GROSS SALARY : $ WEEKLY BIWEEKLY MONTHLY OTHER INCOME: (CIRCLE ONE) AFDC SOCIAL SECURITY UNEMPLOYMENT CHILD SUPPORT AMOUNT: $ WEEKLY or MONTHLY FOR WHOM RECEIVED: HAVE YOU EVER FILED BANKRUPTCY: YES or NO IF YES, DATE: PLACE: RESULT: HAS YOUR SPOUSE OR ANY OTHER ADULTS IN YOUR HOME BEEN ARRESTED FOR DOMESTIC VIOLENCE

OR ANY OTHER CRIMINAL OFFENSES? IF YES, GIVE DETAILS BELOW:

OTHER ADULTS RESIDING IN THE HOME OF PROPOSED GUARDIAN(S)

FULL NAME: OTHER NAMES/MAIDEN: DOB: RELATIONSHIP: OCCUPATION: DOES THIS PERSON HAVE A CRIMINAL RECORD? YES or NO IF YES, GIVE DETAILS:

FULL NAME: OTHER NAMES/MAIDEN: DOB: RELATIONSHIP: OCCUPATION: DOES THIS PERSON HAVE A CRIMINAL RECORD? YES or NO IF YES, GIVE DETAILS:

FULL NAME: OTHER NAMES/MAIDEN: DOB: RELATIONSHIP: OCCUPATION: DOES THIS PERSON HAVE A CRIMINAL RECORD? YES or NO IF YES, GIVE DETAILS:

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OTHER CHILDREN RESIDING IN THE HOME OF THE GUARDIAN(S)

FULL NAME: DATE OF BIRTH: RELATIONSHIP TO CHILD: NAME & ADDRESS OF SCHOOL ATTENDING:

FULL NAME: DATE OF BIRTH: RELATIONSHIP TO CHILD: NAME & ADDRESS OF SCHOOL ATTENDING:

FULL NAME: DATE OF BIRTH: RELATIONSHIP TO CHILD: NAME & ADDRESS OF SCHOOL ATTENDING:

BIRTH PARENTS INFO

NATURAL MOTHER FULL NAME: OTHER NAMES/MAIDEN: DOB: CA ID/DL #: SOCIAL SECURITY #: LAST KNOWN ADDRESS/DATES LIVED THERE:

NAME & ADDRESS & PHONE # OF EMPLOYER:

IS MOTHER IN AGREEMENT WITH GUARDIANSHIP? YES or NO DOES MOTHER VISIT WITH CHILD? YES or NO IF YES, HOW OFTEN: DOES MOTHER VISIT THE CHILD OUTSIDE YOUR HOME? YES or NO DOES MOTHER EXPRESS AN INTEREST IN SCHOOL ISSUES? YES or NO DOES MOTHER EXPRESS AN INTEREST IN HEALTH ISSUES? YES or NO DOES MOTHER HAVE ANY OTHER CHILDREN? YES or NO IF YES COMPLETE NAME(S) AND DATE OF BIRTH(S) BELOW: FULL NAME: DATE OF BIRTH: FULL NAME: DATE OF BIRTH: FULL NAME: DATE OF BIRTH:

HAS MOTHER EVER BEEN INVESTIGATED BY CHILD PROTECTIVE SERVICES YES or NO IF YES, GIVE DETAILS:

HAS MOTHER EVER BEEN ARRESTED AND/OR CONVITED OF A CRIMINAL OFFENSE? IF YES, GIVE DETAILS:

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IS THERE A CUSTODY ORDER (FROM DIVORCE, SEPERATION, PATERNITY) FOR THIS CHILD IN ANY COUNTY? YES or NO IF YES, GIVE DETAILS:

NATURAL FATHER FULL NAME: OTHER NAMES/MAIDEN: DOB: CA ID/DL #: SOCIAL SECURITY #: LAST KNOWN ADDRESS/DATES LIVED THERE:

NAME & ADDRESS & PHONE # OF EMPLOYER:

IS FATHER IN AGREEMENT WITH GUARDIANSHIP? YES or NO DOES FATHER VISIT WITH CHILD? YES or NO IF YES, HOW OFTEN: DOES FATHER VISIT THE CHILD OUTSIDE YOUR HOME? YES or NO DOES FATHER EXPRESS AN INTEREST IN SCHOOL ISSUES? YES or NO DOES FATHER EXPRESS AN INTEREST IN HEALTH ISSUES? YES or NO DOES FATHER HAVE ANY OTHER CHILDREN? YES or NO IF YES COMPLETE NAME(S) AND DATE OF BIRTH(S) BELOW:

FULL NAME: DATE OF BIRTH: FULL NAME: DATE OF BIRTH: FULL NAME: DATE OF BIRTH:

HAS FATHER EVER BEEN INVESTIGATED BY CHILD PROTECTIVE SERVICES YES or NO IF YES, GIVE DETAILS:

HAS FATHER EVER BEEN ARRESTED AND/OR CONVITED OF A CRIMINAL OFFENSE? IF YES, GIVE DETAILS:

IS THERE A CUSTODY ORDER (FROM DIVORCE, SEPERATION, PATERNITY) FOR THIS CHILD IN ANY COUNTY? YES or NO IF YES, GIVE DETAILS:

GENERAL INFORMATION

WHERE THE BIRTH PARENTS EVER MARRIED? YES or NO IF YES: (circle one) STILL MARRIED DIVORCED SEPERATED UNKNOWN IF NO, WAS PATERNITY EVER ESTABLISHED: YES or NO IF YES, CASE #: NAME/COUNTY OF COURT HOUSE: IS THERE A CHILD SUPPORT ORDER? YES or NO DOES THE CHILDREN HAVE NATIVE AMERICAN BLOOD? YES or NO

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NAME OF TRIBE: INDIAN PERCENTAGE: IS THE CHILD(REN) A REGISTERED TRIBAL MEMBER? YES or NO

CHILDREN YOU ARE REQUESTING GUARDIANSHIP OF

CHILD NAME: DATE/PLACE OF BIRTH: RELATIONSHIP TO MINOR: DATE PLACED WITH GUARDIAN: CURRENT SCHOOL ATTENDING: ADDRESS OF SCHOOL: DIFFICULTIES IN SCHOOL: YES or NO SPECIAL NEEDS: YES or NO NAME & ADDRESS OF PHYSICIAN: DO YOU SUSPECT MOTHER USED DRUGS WHEN PREGNANT: RESULTS OF DRUG TEST AT BIRTH: DOES THE CHILD HAVE ANY BEHAVIORAL PROBLEMS AND/OR NEEDS: YES or NO IF YES, EXPLAIN: ANY CRIMINAL INVOLVEMENT? YES or NO IF YES, GIVE DETAILS:

CHILD NAME: DATE/PLACE OF BIRTH: RELATIONSHIP TO MINOR: DATE PLACED WITH GUARDIAN: CURRENT SCHOOL ATTENDING: ADDRESS OF SCHOOL: DIFFICULTIES IN SCHOOL: YES or NO SPECIAL NEEDS: YES or NO NAME & ADDRESS OF PHYSICIAN: DO YOU SUSPECT MOTHER USED DRUGS WHEN PREGNANT: RESULTS OF DRUG TEST AT BIRTH: DOES THE CHILD HAVE ANY BEHAVIORAL PROBLEMS AND/OR NEEDS: YES or NO IF YES, EXPLAIN: ANY CRIMINAL INVOLVEMENT? YES or NO IF YES, GIVE DETAILS:

CHILD NAME: DATE/PLACE OF BIRTH: RELATIONSHIP TO MINOR: DATE PLACED WITH GUARDIAN: CURRENT SCHOOL ATTENDING: ADDRESS OF SCHOOL: DIFFICULTIES IN SCHOOL: YES or NO SPECIAL NEEDS: YES or NO NAME & ADDRESS OF PHYSICIAN: DO YOU SUSPECT MOTHER USED DRUGS WHEN PREGNANT: RESULTS OF DRUG TEST AT BIRTH:

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DOES THE CHILD HAVE ANY BEHAVIORAL PROBLEMS AND/OR NEEDS: YES or NO IF YES, EXPLAIN: ANY CRIMINAL INVOLVEMENT? YES or NO IF YES, GIVE DETAILS: REMINDER YOU MUST ATTACH A COPY OF EACH CHILDS BIRTH CERTIFICATE AND/OR ANY DEATH CERTIFICATE(S) FOR THE NATURAL PARENTS

ADDITIONAL INFORMATION

LIST ANY OTHER INFORMATION BELOW YOU FEEL MAY BE HELPFUL TO THE COURT INVESTIGATOR APPOINTED TO YOUR CASE.

I, DECLARE UNDER PENALTY OF PERJURY THAT THE INFORMATION ON THIS FORM IS TRUE AND

CORRECT TO THE BEST OF MY KNOWLEDGE.

DATE:

PRINTED NAME OF PETITIONER SIGNATURE OF PETITIONER

PRINTED NAME OF PETITIONER SIGNATURE OF PETITIONER

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