San Bernardino — SB-18074

Source: https://sanbernardino.courts.ca.gov/system/files/sb-18074.pdf

ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address): FOR COURT USE ONLY

NAME:
STATE BAR NUMBER:
STREET ADDRESS:
MAILING ADDRESS:
CITY AND ZIP CODE:
TELEPHONE NO: FAX NO.(Optional)

ATTORNEY FOR (Name): SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN BERNARDINO

STREET ADDRESS:
CITY AND ZIP CODE:
BRANCH NAME:

GUARDIANSHIP OF THE PERSON ESTATE

(Minor’s Name)

CONFIDENTIAL GUARDIANSHIP QUESTIONNAIRE CASE NUMBER:
AND AUTHORIZATION FOR RELEASE OF INFORMATION

(Probate Code Section 1513)

NOTICE TO PROPOSED GUARDIAN OR APPLICANT AND RELEASE OF INFORMATION

Each proposed guardian must complete a separate questionnaire.

Please be advised, the information provided on this questionnaire will be used to
conduct a full and complete investigation of applicant’s background. The results of the
investigation and relationship histories will be fully reported to the court.

Re: Guardianship of (Minor’s name):

(Minor’s name):

(Minor’s name):

(Minor’s name):

(Minor’s name):

I give the Court Investigator’s Office authority to release any information in its files to
the Guardianship Court Investigator’s Office. Such information may include, but is not
limited to, school records, medical records, employment records, and psychological
records.

The Guardianship Court Investigator’s Office utilizes this information to complete its
required investigation in connection with my petition for guardianship of a minor child.

I have read and understand the above conditions and agree to them.

PRINT NAME OF PROPOSED GUARDIAN OR APPLICANT SIGNATURE OF PROPOSED GUARDIAN OR APPLICANT Date

Local Court Form (Rev. CONFIDENTIAL GUARDIANSHIP QUESTIONNAIRE AND Page 1 of 7 6-28-2016) SB18074 Mandatory AUTHORIZATION FOR RELEASE OF INFORMATION Probate Code § 1513

Relative (relationship) __________________________ Non-Relative

PROPOSED GUARDIAN INFORMATION

Proposed Guardian: Last First Middle Maiden Name

Phone numbers Home: Work: Cell: Address: City: Zip: Place of Birth: Date of Birth: Social Security Number: Driver’s License Number: Race or Ethnicity: Will you or anyone else in the home require an interpreter? Yes No Language:

DESCRIBE YOUR HOME

Single Family Home Apartment How long at present address? Rent Own Monthly mortgage payment or rent? $ No. of bedrooms: Will the minor(s) have their 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(s)? Where and how are they stored? Who cares for the minor(s) if adults are employed outside of the home?

OTHER CHILDREN LIVING IN YOUR HOME UNDER THE AGE OF 18 (ATTACH ADDITIONAL PAGE IF NECESSARY)

Name Relationship to Date of Birth Place of Birth Grade Level Developmental Disabilities
you

OTHER ADULTS LIVING IN YOUR HOME OVER THE AGE OF 18 (INCLUDING YOUR SPOUSE) Name Driver’s License Social Security Date of Birth Relationship Child Criminal Number to you Protective History Services History (Yes/No) (Yes/No)

Does any adult in the home have any problem(s) that could affect the minor(s), such as a history of child abuse/molestation, violent behavior, or an alcohol or drug problem? Yes No If yes, explain:

Local Court Form (Rev. CONFIDENTIAL GUARDIANSHIP QUESTIONNAIRE AND Page 2 of 7
6-28-2016) SB18074 Mandatory AUTHORIZATION FOR RELEASE OF INFORMATION Probate Code § 1513

Have the police ever been to your home? Yes No If yes, explain when and why (attach additional page if necessary):

EMPLOYMENT / INCOME

Are you employed? Yes No Name of Employer: Telephone Number: Address of Employer: Length of Employment: Job Title: Last Grade Completed and Special Training: Gross Monthly Income: Income from other sources (retirement, SSI, etc.):

YOUR HEALTH CONDITION (List any prior and/or current physical or mental health problems)

Present health status: Good Fair Poor If Fair or Poor, please explain:

Have you ever been treated for or do you now have a physical impairment (e.g. hearing loss)? Yes No If yes, explain in detail, including medications, hospitalizations, and therapy/counseling (when and where):

What, if any medications are you currently taking and what are they are for?

Do you have a history of mental health issues/impairments? Yes No If yes, explain:

Have you ever been in counseling? Yes No If yes, when? If yes, what was/is the reason? Drugs Alcohol Grief Domestic Violence Other Explain:

CRIMINAL BACKGROUND

Were you ever arrested for an offense other than a minor traffic violation? Yes No If yes, give date, place and details of offense (attach additional page if necessary):

Have you had previous involvement with Child Protective Services? Yes No If yes, explain the circumstances in detail and include dates and name of County or State where involvement occurred (attach an additional page if necessary):

Are you currently on Probation? Yes No Officer’s Name: If yes, explain: Are you currently on Parole? Yes No Officer’s Name: If yes, explain:

Local Court Form (Rev. CONFIDENTIAL GUARDIANSHIP QUESTIONNAIRE AND Page 3 of 7
6-28-2016) SB18074 Mandatory AUTHORIZATION FOR RELEASE OF INFORMATION Probate Code § 1513

MARRIAGES

Indicate if you are: Married Widowed Single Separated Divorced Registered Domestic Partner If currently married or separated, what is your spouse’s name? Date of most recent marriage: Number of children from this marriage: Ages of children: Previous marriages: Name of former spouses: How were previous marriages terminated (i.e., divorce or death)? Number of children from previous marriages: Ages of children:

SPOUSE INFORMATION (Complete only if spouse is not a proposed guardian and is, therefore, not required to complete a separate questionnaire) Full name: Maiden name (if applicable): Aliases: Language(s) spoken (including sign language): Race/Ethnicity: Age: Date of Birth: Place of Birth: Social Security Number: Driver’s License Number: Telephone Number ( TDD): Mobile Phone Number:

Employer Name: Employer Phone Number: Employer Address: Job Title:

Present health status: Good Fair Poor Does your spouse take any medication? Yes No Does your spouse have any special health problems? Yes No Does your spouse have any mental/emotional problems? Yes No Has your spouse ever used drugs or alcohol? Yes No

Have charges ever been filed against your spouse for crimes other than minor traffic citations? Yes No Is your spouse on parole or probation? Yes No If yes, parole or probation officer’s name: Phone Number: Has your spouse had previous involvement with Child Protective Services? Yes No

INFORMATION ABOUT THE MINOR(S) NEEDING GUARDIANSHIP (ATTACH ADDITIONAL PAGE IF NECESSARY) Minor 1 Name: Age: Ethnicity: Date of Birth: Place of Birth: Date placed with petitioner: Relationship to Petitioner: Name of school: Telephone: Grade Level: Teacher’s Name: Name of physician caring for minor: Telephone: Address of Physician: Describe known medical needs, mental health needs, and/or other special needs: Local Court Form (Rev. CONFIDENTIAL GUARDIANSHIP QUESTIONNAIRE AND Page 4 of 7 6-28-2016) SB18074 Mandatory AUTHORIZATION FOR RELEASE OF INFORMATION Probate Code § 1513

How do you plan to meet the minor’s medical, mental health, and/or special needs?

Does the minor have a social worker? Yes No If yes, who is the social worker? Telephone Number: Is there a custody or visitation order for the minor? Yes No Don’t Know Date of the order: Case Number: Where did the proceeding take place? County: State:

Minor 2 Not applicable Name: Age: Ethnicity: Date of Birth: Place of Birth: Date placed with petitioner: Relationship to Petitioner Name of school: Telephone: Grade Level: Teacher’s Name: Name of physician caring for minor: Telephone: Address of Physician: Describe known medical needs, mental health needs, and/or other special needs:

How do you plan to meet the minor’s medical, mental health, and/or special needs?

Does the minor have a social worker? Yes No If yes, who is the social worker? Telephone Number: Is there a custody or visitation order for the minor? Yes No Don’t Know Date of the order: Case Number: Where did the proceeding take place? County: State:

Minor 3 Not applicable Name: Age: Ethnicity: Date of Birth: Place of Birth: Date placed with petitioner: Relationship to Petitioner Name of school: Telephone: Grade Level: Teacher’s Name: Name of physician caring for minor: Telephone: Address of Physician: Describe known medical needs, mental health needs, and/or other special needs:

How do you plan to meet the minor’s medical, mental health, and/or special needs?

Does the minor have a social worker? Yes No If yes, who is the social worker? Telephone Number: Is there a custody or visitation order for the minor? Yes No Don’t Know Date of the order: Case Number: Where did the proceeding take place? (County) (State)

Local Court Form (Rev. CONFIDENTIAL GUARDIANSHIP QUESTIONNAIRE AND Page 5 of 7 6-28-2016) SB18074 Mandatory AUTHORIZATION FOR RELEASE OF INFORMATION Probate Code § 1513

Minor 4 Not applicable Name: Age: Ethnicity: Date of Birth: Place of Birth: Date placed with petitioner: Relationship to Petitioner Name of school: Telephone: Grade Level: Teacher’s Name: Name of physician caring for minor: Telephone: Address of Physician: Describe known medical needs, mental health needs, and/or other special needs:

How do you plan to meet the minor’s medical, mental health, and/or special needs?

Does the minor have a social worker? Yes No If yes, who is the social worker? Telephone Number: Is there a custody or visitation order for the minor? Yes No Don’t Know Date of the order: Case Number: Where did the proceeding take place? County: State:

Minor 5 Not applicable Name: Age: Ethnicity: Date of Birth: Place of Birth: Date placed with petitioner: Relationship to Petitioner Name of school: Telephone: Grade Level: Teacher’s Name: Name of physician caring for minor: Telephone: Address of Physician: Describe known medical needs, mental health needs, and/or other special needs:

How do you plan to meet the minor’s medical, mental health, and/or special needs?

Does the minor have a social worker? Yes No If yes, who is the social worker? Telephone Number: Is there a custody or visitation order for the minor? Yes No Don’t Know Date of the order: Case Number: Where did the proceeding take place? County: State:

REFERENCES

Provide (2) non-related references who have knowledge of your home life and standing in the community. TELEPHONE NAME ADDRESS OCCUPATION NUMBER

Local Court Form (Rev. CONFIDENTIAL GUARDIANSHIP QUESTIONNAIRE AND Page 6 of 7 6-28-2016) SB18074 Mandatory AUTHORIZATION FOR RELEASE OF INFORMATION Probate Code § 1513

BIRTH PARENTS Mother’s Name: Date of Birth: Telephone: Address: Last contact with minor(s):

Father’s Name: Date of Birth: Telephone: Address: Last contact with minor(s):

What is the relationship between Petitioner and birth parents? (visitation schedule, areas of conflict or disagreement)?

How long do you expect this guardianship to last?

What are the long term plans for the minor(s)?

Is the birth mother in agreement with guardianship? Yes No Unknown Comments:

Is the birth father in agreement with guardianship? Yes No Unknown Comments:

Have the birth parents made you aware of their plans for the minor(s)? Yes No If yes, describe known plans:

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

Date:

____________________________________________________ ________________________________________________
TYPE OR PRINT NAME OF PROPOSED GUARDIAN OR APPLICANT SIGNATURE OF PROPOSED GUARDIAN OR APPLICANT

Local Court Form (Rev. CONFIDENTIAL GUARDIANSHIP QUESTIONNAIRE AND Page 7 of 7 6-28-2016) SB18074 Mandatory AUTHORIZATION FOR RELEASE OF INFORMATION Probate Code § 1513