Court Investigations Guardianship Questionnaire {MSC-PR-001}

MERCED COUNTY SUPERIOR COURTCOURT INVESTIGATIONS GUARDIANSHIP QUESTIONNAIREMinor's NameCase 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 clearlyidentifying 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 FORMMUST BE COMPLETED FOR THAT PERSON.FAILURE TO SERVE THE COURT INVESTIGATOR WITH THIS FORM AND COPIES OF ALL DOCUMENTS FILEDIN 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) 725-4190Monday through Friday 8:00 a.m. to 4:00 p.m. COURT INVESTIGATIONS GUARDIANSHIP QUESTIONNAIREPage 1 of 7 American LegalNet, Inc. www.FormsWorkFlow.com PERSONAL HISTORY PROPOSED GUARDIAN FULL NAMEOTHER NAMES/MAIDEN DATE OF BIRTH/BIRTHPLACECA ID/DL NO.SOCIAL SECURITY NO. LIST ALL ADDRESSES FOR THE PAST 5 YEARS1. 2. 3. PHONE NO.PHONE NO.PHONE NO.FROMTOFROMTOFROMTOOWNRENTOWNRENTOWNRENTRENT/MORTGAGE $/MONTHRENT/MORTGAGE $/MONTHRENT/MORTGAGE $/MONTH LAST GRADE OF SCHOOL ATTENDED1-789101112SOME COLLEGECOLLEGE GRADUATEMASTERS FATHER'S NAMEMOTHER'S NAME YOUR HEALTHGOODFAIRPOORNAME OF YOUR PHYSICIAN: STATE ANY MEDICAL CONDITIONS YOU ARECURRENTLY BEING TREATED FOR: MEDICATIONS - NAME, AMOUNT, REASON,HOW OFTEN TAKEN: ATTENDING COUNSELING?YESNOTYPE:COUNSELOR: HAVE YOU EVER BEEN CONVICTED FOR ANIF YES, PLEASE LIST:OFFENSE OTHER THAN A MINOR TRAFFICDATECITYVIOLATIONOUTCOMEVIOLATION?YESNO HAVE YOU EVER BEEN OR ARE YOU ONIF YES, PLEASE LIST:PROBATION/PAROLE?YESNODATECITYOFFICER/AGENT/TELEPHONE NO. DO YOU DRINK ALCOHOLIC BEVERAGES?YESNOHOW MUCH/OFTEN? WHAT DRUGS DO/DID YOU USE?WHEN DID YOU LAST USE? HOW MUCH/OFTEN?DAILYWEEKLYMONTHLYCOST? HAVE YOU EVER ENTERED OR COMPLETEDIF YES, GIVE DETAILS: AN ALCOHOL OR DRUG TREATMENTPROGRAM?YESNO HAVE YOU EVER HAD CONTACT WITH A CHILDIF YES, GIVE DETAILS AND COUNTY:PROTECTIVE SERVICE AGENCY?YESNO ARE YOUMARRIEDDIVORCEDSEPARATEDWIDOWEDLIVING TOGETHER DATES AND PLACE OF ALL MARRIAGES:CHILDREN OF THE MARRIAGE:DATE/REASON FOR END OF MARRIAGE: COURT INVESTIGATIONS GUARDIANSHIP QUESTIONNAIREPage 2 of 7!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! American LegalNet, Inc. www.FormsWorkFlow.com PERSONAL HISTORY SPOUSE OR SIGNIFICANT OTHER FULL NAMEOTHER NAMES/MAIDEN DATE OF BIRTH/BIRTHPLACECA ID/DL NO.SOCIAL SECURITY NO. LIST ALL ADDRESSES FOR THE PAST 5 YEARS1.2.3.PHONE NO.PHONE NO.PHONE NO.FROMTOFROMTOFROMTOOWNRENTOWNRENTOWNRENTRENT/MORTGAGE $/MONTHRENT/MORTGAGE $/MONTHRENT/MORTGAGE $/MONTH LAST GRADE OF SCHOOL ATTENDED1-789101112SOME COLLEGECOLLEGE GRADUATEMASTERS FATHER'S NAMEMOTHER'S NAME YOUR HEALTHGOODFAIRPOORNAME OF YOUR PHYSICIAN: STATE ANY MEDICAL CONDITIONS YOU ARE CURRENTLY BEING TREATED FOR: MEDICATIONS-NAME, AMOUNT, REASON, HOW OFTEN TAKEN: ATTENDING COUNSELING?YESNOTYPE:COUNSELOR: HAVE YOU EVER BEEN CONVICTED FOR ANIF YES, PLEASE LIST:OFFENSE OTHER THAN A MINOR TRAFFICDATECITYVIOLATIONOUTCOMEVIOLATION?YESNO HAVE YOU EVER BEEN OR ARE YOU ONIF YES, PLEASE LIST:PROBATION/PAROLE?DATECITYOFFICER/AGENT/TELEPHONE NO.YESNO DO YOU DRINK ALCOHOLIC BEVERAGES?YESNOHOW MUCH/OFTEN? WHAT DRUGS DO/DID YOU USE?WHEN DID YOU LAST USE? HOW MUCH/OFTEN?DAILYWEEKLYMONTHLYCOST? HAVE YOU EVER ENTERED OR COMPLETED ANIF YES, GIVE DETAILS:ALCOHOL OR DRUG TREATMENT PROGRAM?YESNO HAVE YOU EVER HAD CONTACT WITH A CHILDIF YES, GIVE DETAILS AND COUNTY:PROTECTIVE SERVICE AGENCY?YESNO ARE YOUMARRIEDDIVORCEDSEPARATEDWIDOWEDLIVING TOGETHER DATES AND PLACE OF ALL MARRIAGES:CHILDREN OF THE MARRIAGE:DATE/REASON FOR END OF MARRIAGE: COURT INVESTIGATIONS GUARDIANSHIP QUESTIONNAIREPage 3 of 7!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! American LegalNet, Inc. www.FormsWorkFlow.com EMPLOYMENT / FINANCIAL PROPOSED GUARDIAN NAME/ADDRESS/PHONE OF EMPLOYERTITLE: HOW LONG?DAYS/HOURS YOU WORKGROSS SALARY/MO. OTHER INCOMETANFSOCIAL SECURITYUNEMPLOYMENTCHILD SUPPORTMEDI-CAL AMOUNT $MO/WKRECEIVED 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:YESNO DO YOU SUPPORT ANYONE OUTSIDE OFIF YES GIVE NAME/RELATIONSHIP AND REASON:YOUR RESIDENCE?YESNO SPOUSE/SIGNIFICANT OTHER NAME/ADDRESS/PHONE OF EMPLOYERTITLE: HOW LONG?DAYS/HOURS YOU WORKGROSS SALARY/MO. OTHER INCOMETANFSOCIAL SECURITYUNEMPLOYMENTCHILD SUPPORTMEDI-CAL AMOUNT $MO/WKRECEIVED 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:YESNO DO YOU SUPPORT ANYONE OUTSIDE OFIF YES GIVE NAME/RELATIONSHIP AND REASON:YOUR RESIDENCE?YESNO COURT INVESTIGATIONS GUARDIANSHIP QUESTIONNAIREPage 4 of 7!!!!!!!!!!!!!!!!!! American LegalNet, Inc. www.FormsWorkFlow.com RESIDENCE ARE THERE ANY OTHER ADULTS RESIDING IN THEHOME?YESNO IF YES:NAMEDOBCA ID/DL NO.SOCIAL SECURITY NO.RELATIONSHIP ARE THERE ANY OTHER CHILDREN RESIDING INTHE HOME?YESNO IF YES:NAMEDOBRELATIONSHIP GUARDIANSHIP CHILD CHILD TO BE UNDER GUARDIANSHIP:NAMEDOBRELATIONSHIP ANY NATIVE AMERICAN BLOOD?PERCENTAGE?TRIBE? NAME/ADDRESS OF SCHOOLGRADE:TEACHER: NAME/ADDRESS OF PHYSICIAN DID MOTHER RECEIVE PRENATAL CARE?YESNOFULL TERM BIRTH?YESNO DOES CHILD HAVE MEDICAL PROBLEMS?YESNOIF YES, EXPLAIN: WAS THERE A DRUG TEST AT BIRTH?YESNOIF YES, RESULTS: DOES CHILD HAVE BEHAVIORAL PROBLEMS?YESNOIF YES, EXPLAIN: DIFFICULTIES IN SCHOOL?YESNOIF YES, EXPLAIN: SPECIAL EDUCATION NEEDS?YESNOIF YES, EXPLAIN: CRIMINAL INVOLVEMENT?YESNOIF YES, EXPLAIN: CURRENT SOCIAL WORKER?YESNOIF YES, NAME: IS CHILD IN A DAYCARE PROGRAM?YESNOIF YES, PROVIDER: GIVE ALL OF THE ABOVE INFORMATION ON ALL CHILDREN PROPOSED TO BE UNDER GUARDIANSHIP. YOU CANUSE THE REVERSE OF THIS PAGE OR A SEPARATE SHEET.ATTACH COPIES OF BIRTH CERTIFICATES FOR EACH CHILD PROPOSED TO BE UNDER GUARDIANSHIP. COURT INVESTIGATIONS GUARDIANSHIP QUESTIONNAIREPage 5 of 7!!!!!!!!!!!!!!!!!!!!!!!! American LegalNet, Inc. www.FormsWorkFlow.com BIRTH PARENTS MOTHER'S FULL NAMEOTHER NAMES/MAIDEN DATE OF BIRTH/BIRTHPLACECA ID/DL NO.SOCIAL SECURITY NO. ADDRESSTELEPHONE NO. NAME/ADDRESS OF EMPLOYERTELEPHONE NO. IS MOTHER IN AGREEMENT WITHDOES MOTHER CONTRIBUTE TO THEDOES MOTHER VISIT WITH CHILD?GUARDIANSHIP?YESNOSUPPORT OF CHILD?YESNOYESNO DOES MOTHER HAVE ANY OTHER CHILDRENIF YES:NOT A PARTY TO THIS ACTION?YESNONAMEAGE HAS THE MOTHER EVER BEEN ARRESTED AND/OR CONVICTED?YESNOIF YES, GIVE DETAILS: HAS CPS EVER INVESTIGATED THE MOTHER?YESNOIF YES, GIVE DETAILS: FATHER'S FULL NAMEOTHER NAMES DATE OF BIRTH/BIRTHPLACECA ID/DL NO.SOCIAL SECURITY NO. ADDRESSTELEPHONE NO. NAME/ADDRESS OF EMPLOYERTELEPHONE NO. IS FATHER IN AGREEMENT WITHDOES FATHER CONTRIBUTE TO THEDOES FATHER VISIT WITH CHILD?GUARDIANSHIP?YESNOSUPPORT OF CHILD?YESNOYESNO DOES FATHER HAVE ANY OTHER CHILDRENIF YES:NOT A PARTY TO THIS ACTION?YESNONAMEAGE HAS THE FATHER EVER BEEN ARRESTEDYESNOIF YES, GIVE DETAILS:AND/OR CONVICTED? HAS CPS EVER INVESTIGATED THE FATHER?YESNOIF YES, GIVE DETAILS: GENERAL INFORMATION WERE THE PARENTS EVER MARRIED?YESNOIF YES, STATUS? IF NO, WAS PATERNITY EVER ESTABLISHED?YESNOIF YES, CASE NO.COUNTY/STATE IS THERE AN ORDER FOR SUPPORT?YESNOIF YES, HOW MUCH?PAID TO? IS THERE A CUSTODY ORDER BETWEEN THEYESNOIF YES, CASE NO.PARENTS FOR THE CHILD? COURT INVESTIGATIONS GUARDIANSHIP QUESTIONNAIRE Page 6 of 7!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! American LegalNet, Inc. www.FormsWorkFlow.com GENERAL INFORMATION CONT'D HAVE YOU, YOUR SPOUSE, ANOTHER ADULTIN THE HOME, OR THE PARENTS BEENINVOLVED IN ANY OF THE FOLLOWING? RECEIVED COUNSELING FOR DOMESTIC VIOLENCE?YESNOIF YES, WHO/WHY? DOMESTIC DISPUTE WHERE LAW ENFORCEMENT WAS CALLED?YESNOIF YES, WHO/WHY? BEEN THE SUBJECT OF