Minor Guardianship Social History {PC 670}

USE NOTE: File this form with the petition for appointment of guardian. This information is confidential and will not be placed in the public court file.Parent and Minor Child Information: Name of minorMinor222s birth dateLast 4 digits of Minor222s SSNMinor222s present address City State ZipParent222s nameParent222s birth dateParent222s nameParent222s birth dateFather222s name on minor222s birth certificate Yes þ No Paternity established through court proceedings þ If yes, specify court and county where paternity was established Yes þ þ No þ þ Circuit þ þ Probate þ CountyMinor222s parents married to each other Yes þ No Minor222s parents divorced from each other þ If yes, specify county of divorce Yes þ þ No þ County Child þ Parent(s): þ Victim of domestic violence Child þ Parent(s): þ Had contact with the protective services unit of MDHHS Child þ Parent(s): þ Experienced a substance abuse problem Child þ Parent(s): þ Experienced a mental health problem þ Name of school child attends (specify if home schooled)Describe child222s school attendance, behavior, and gradesDescribe child222s relationship and extent of contact with parent(s)If the child is a member of an Indian tribe, or is eligible for membership in an Indian tribe and is a biological child of a member of an Indian tribe, list the child222s tribal affiliation. Victim of domestic violence Had contact with the protective services unit of MDHHS Experienced a substance abuse problem Experienced a mental health problemSpecify the date, place, and nature of any offense, other than a minor traffic violation, for which you were convicted; check if none None American LegalNet, Inc. www.FormsWorkFlow.com File No. Proposed Guardian Questionnaire: (the proposed guardian must complete all items below) 1. þ Describe the reasons for the guardianship. 2. þ Do the parents agree with this guardianship? þ Yes þ No þ If no, explain. 3. þ Describe the parents222 visiting schedule with the child after you are the guardian. If there is no understanding about this, check þ þ none. 4. þ Describe any physical and/or mental limitations you have that would affect your ability to raise this child. If there are none, þ þ check þ þ none. 5. þ Describe the type (visits, telephone calls, etc.) and frequency of contact (daily, weekly, etc.) you have had with the minor in þ the past. 6. þ Explain how you propose to handle the additional financial burden of this guardianship. List annual income of the household þ and the sources of that income. 7. þ Describe the sleeping space you have in your home for this child. 8. þ Indicate how many other children live in your home. 9. þ Describe the methods of discipline you would use to control this child. 10. þ Provide the full name and date of birth of every adult living in the home. 11. þ List two people the court may contact for references. Provide their names, addresses, and telephone numbers. 12. þ Specify any other information you believe would be helpful to the court. Date þ Signature American LegalNet, Inc. www.FormsWorkFlow.com