Fill and Sign the Guardianship 497426828 Form

Guardianship Questionnaire PROPOSED GUARDIAN #1 Full name       Other Names/Maiden name       Date of Birth/Birth Place       State ID/Drivers License No.       Social Security No.       Housing: Rent Own Buying Amount Per Month       How Many Bedrooms/Baths       Is It A House? Or Apt.?       Do You Plan To Remain In This Residence, Or Are You Looking For Another Location? Yes No List Addresses for Past Five Years: 1.       Phone No.       From       to       Own Rent Rent/Mortgage $ /Month       2.       Phone No.       From       to       Own Rent Rent/Mortgage $ /Month       3.       Phone No.       From       to       Own Rent Rent/Mortgage $ /Month       High School Graduate?       If Not, Grade Last Attended       Place & Name Of High School       Age Left School       Reason       List College Or University Attended: Degree Or Units/Majors       List Any Previous Marriages, Including Name Of Spouse, Date, How Terminated, And Date Of Final Separation:             Your Health Good Fair Poor State Any Medical Conditions Currently Being Treated For       Medications – Name, Amount, Reason, How Often Taken:                   Attending Counseling? Yes No Type       Name of Counselor       Have You Ever Been Convicted Of An Offense Other Than A Minor Traffic Violation? Yes No If Yes, Please List Date: City: Outcome       Have You Ever Been On Or Are You On Probation/Parole? Yes No If yes, Officer/Agent’s Name: County/Phone No.       Do You Drink Alcoholic Beverages? Yes No If yes, how much/often?       What Drugs Do/Did You Use?       When Did You Last Use?       How Much/Often? Daily Weekly Monthly Cost?       Have You Ever Entered Or Completed An Alcohol Or Drug Treatment Program? Yes No If Yes, Give Details       Have You Ever Had Contact With A Child Protective Service Agency? Yes No If Yes, Give Details And County       Have You Ever Been Arrested For Domestic Violence? Yes No If Yes, Give Details       Name And Address of Employer       Phone       Title       How Long?       Days You Work       Hours       Gross Salary       Other Income: AFDC SOC. SEC. UNEMPLOYMENT CHILD SUPPORT Amount $       Mo For Whom Received       Total Gross Monthly Income       Total Gross Monthly Expenses       Have You Ever Filed Bankruptcy Yes No If Yes, Date       Place       Result       Have You, Your Spouse Or Either Parent Ever Been Involved In Any Of The Following?: Received Counseling For Domestic Violence? Yes No Domestic Dispute Where Law Enforcement Was Called Yes No Been The Subject Of A Domestic Or Civil Restraining Order? Yes No If Yes For Any, Give Date/Place/Case No./Court/Law Enforcement Agency/And Details For Each Incident:                   PROPOSED GUARDIAN #2 Full name       Other Names/Maiden name       Date of Birth/Birth Place       State ID/Drivers License No.       Social Security No.       Housing: Rent Own Buying Amount Per Month       How Many Bedrooms/Baths       Is It A House? Or Apt.?       Do You Plan To Remain In This Residence, Or Are You Looking For Another Location? Yes No List Addresses for Past Five Years: 1.       Phone No.       From       to       Own Rent Rent/Mortgage $ /Month       2.       Phone No.       From       to       Own Rent Rent/Mortgage $ /Month       3.       Phone No.       From       to       Own Rent Rent/Mortgage $ /Month       High School Graduate?       If Not, Grade Last Attended       Place & Name Of High School       Age Left School       Reason       List College Or University Attended: Degree Or Units/Majors       List Any Previous Marriages, Including Name Of Spouse, Date, How Terminated, And Date Of Final Separation:             Your Health Good Fair Poor State Any Medical Conditions Currently Being Treated For       Medications – Name, Amount, Reason, How Often Taken:                   Attending Counseling? Yes No Type       Name of Counselor       Have You Ever Been Convicted Of An Offense Other Than A Minor Traffic Violation? Yes No If Yes, Please List Date: City: Outcome       Have You Ever Been On Or Are You On Probation/Parole? Yes No If yes, Officer/Agent’s Name: County/Phone No.       Do You Drink Alcoholic Beverages? Yes No If yes, how much/often?       What Drugs Do/Did You Use?       When Did You Last Use?       How Much/Often? Daily Weekly Monthly Cost?       Have You Ever Entered Or Completed An Alcohol Or Drug Treatment Program? Yes No If Yes, Give Details       Have You Ever Had Contact With A Child Protective Service Agency? Yes No If Yes, Give Details And County       Have You Ever Been Arrested For Domestic Violence? Yes No If Yes, Give Details       Name And Address of Employer       Phone       Title       How Long?       Days You Work       Hours       Gross Salary       Other Income: AFDC SOC. SEC. UNEMPLOYMENT CHILD SUPPORT Amount $       Mo For Whom Received       Total Gross Monthly Income       Total Gross Monthly Expenses       Have You Ever Filed Bankruptcy Yes No If Yes, Date       Place       Result       Have You, Your Spouse Or Either Parent Ever Been Involved In Any Of The Following?: Received Counseling For Domestic Violence? Yes No Domestic Dispute Where Law Enforcement Was Called Yes No Been The Subject Of A Domestic Or Civil Restraining Order? Yes No If Yes For Any, Give Date/Place/Case No./Court/Law Enforcement Agency/And Details For Each Incident:                   OTHER ADULTS RESIDING IN THE HOME OF PROPOSED GUARDIAN(S) Full Name       Other Names/Maiden Name       Relationship       Date of Birth       Occupation       Does This Person Have Any Criminal Record? Yes No If Yes, Where/When?       Charges       Full Name       Other Names/Maiden Name       Relationship       Date of Birth       Occupation       Does This Person Have Any Criminal Record? Yes No If Yes, Where/When?       Charges       Full Name       Other Names/Maiden Name       Relationship       Date of Birth       Occupation       Does This Person Have Any Criminal Record? Yes No If Yes, Where/When?       Charges       OTHER CHILDREN RESIDING IN THE HOME OF PROPOSED GUARDIAN(S) Full Name       Date Of Birth       Name And Address of School       Relationship       Full Name       Date Of Birth       Name And Address of School       Relationship       Full Name       Date Of Birth       Name And Address of School       Relationship       BIRTH PARENTS Natural Mother: Full Name       Other Names/Maiden Name       Date of Birth       Drivers License/State ID No.       Social Security No.       Last Known Address/Dates Lived There       Name And Address Of Employer       Telephone No.       Is Mother In Agreement With Guardianship? Yes No Does Mother Contribute To Support Of Child? Yes No If Yes, How?       Does Mother Visit With The Child? Yes No If Yes, How Often?       Does The Mother Visit The Child Outside Of Your Home? Yes No Does The Mother Send Cards, Gifts Or Call For Holidays? Yes No Does The Mother Express An Interest In School Issues? Yes No Does Mother Express An Interest In Health Issues? Yes No Does The Mother Have Any Other Children? Yes No If Yes Name: Date Of Birth       If Yes Name: Date Of Birth       If Yes Name: Date Of Birth       Has The Mother Ever Been Arrested And/Or Convicted? Yes No If Yes, Give Date/Place/Charges       Has The Mother Ever Been Investigated By Child Protective Services? Yes No If Yes, Give Date/Place/Charges       Is There A Custody Order (From Divorce, Separation, Paternity) For This Child In Any County? Yes No If Yes, Give County/Case No. And Any Details       Natural Father Full Name       Other Names       Date of Birth       Drivers License/State ID No.       Social Security No.       Last Known Address/Dates Lived There       Name And Address Of Employer       Telephone No.       Is Father In Agreement With Guardianship? Yes No Does Father Contribute To Support Of Child? Yes No If Yes, How?       Does Father Visit With The Child? Yes No If Yes, How Often?       Does The Father Visit The Child Outside Of Your Home? Yes No Does The Father Send Cards, Gifts Or Call For Holidays? Yes No Does The Father Express An Interest In School Issues? Yes No Does Father Express An Interest In Health Issues? Yes No Does The Father Have Any Other Children? Yes No If Yes Name: Date Of Birth       If Yes Name: Date Of Birth       If Yes Name: Date Of Birth       Has The Father Ever Been Arrested And/Or Convicted? Yes No If Yes, Give Date/Place/Charges       Has The Father Ever Been Investigated By Child Protective Services? Yes No If Yes, Give Date/Place/Charges       Is There A Custody Order (From Divorce, Separation, Paternity) For This Child In Any County? Yes No. If Yes, Give County/Case No. And Any Details       GENERAL INFORMATION Were The Birth Parents Ever Married? Yes No If Yes, Status       If No, Was Paternity Ever Established Yes No If Yes, Case No. Name/County Of Court House       Is There An Order For Support? Yes No If Yes, How Much: Paid To Whom?       Does The Child(ren) Have Native American Blood? Yes No Name of Tribe       Indian Percentage       IsAre Child(ren) Registered Tribal Member(s)? Yes No CHILDREN Child(ren) Under Guardianship First Child: Name       Date/Place Of Birth       Social Security No.       Relationship       Date Placed With Guardian       Previous Schools: Name       Address       Name       Address       Name       Address       Name/Address Of Child’s Physician       Results of Drug Test At Birth       Do You Suspect Mother Used Drugs When Pregnant? Yes No Does The Child Have Any Behavioral Problems And/Or Needs Yes No If Yes, Explain Yes No Difficulties In School? Yes No Special Needs? Yes No Criminal Involvement? Yes No Does The Child Have Any Assets To Be Protected Is The Child A Beneficiary Under Any Insurance/Investment/Annuity/Trust, Etc.? Yes No If Yes, Describe Asset       Is The Child A Beneficiary Under Any Insurance/Investment/Annuity/Trust, Etc.? Yes No If Yes, Provide Name of Instrument in Which Named As Beneficiary, Owner’s Name, And Account Number:             Second Child Name       Date/Place Of Birth       Social Security No.       Relationship       Date Placed With Guardian       Previous Schools: Name       Address       Name       Address       Name       Address       Name/Address Of Child’s Physician       Results of Drug Test At Birth       Do You Suspect Mother Used Drugs When Pregnant? Yes No Does The Child Have Any Behavioral Problems And/Or Needs Yes No If Yes, Explain       Difficulties In School? Yes No Special Needs? Yes No Criminal Involvement? Yes No Does The Child Have Any Assets To Be Protected Is The Child A Beneficiary Under Any Insurance/Investment/Annuity/Trust, Etc.? Yes No If Yes, Describe Asset       Is The Child A Beneficiary Under Any Insurance/Investment/Annuity/Trust, Etc.? Yes No If Yes, Provide Name of Instrument in Which Named As Beneficiary, Owner’s Name, And Account Number:                   Name Of Social Worker       Business Phone No.       Fax No.       E-Mail Address       Has Anyone Pursued Guardianship Or Conservatorship Of The Proposed Ward(s) Before? Yes No Does The Proposed Ward(s) Have Any Children? Yes No Please List The Next Of Kin Of The Proposed Ward(s), Including Their Addresses And Their Relationship To The Proposed Ward:                   Are Any Of The Next Of Kin Currently In The United States Armed Service? Yes No If The Child(ren) Live(s) With You, When Did You Get Custody And How?       Do The Child(ren)’s Parents Agree With The Guardianship? Yes No Is There Anyone Who Opposes Your Guardianship? Yes No If Yes, Explain       How Do You Plan To Care For The Needs Of The Child(ren) With Regard To Housing, Finances, Schooling, Child Care And Supervision, Discipline And Guidance?       Do(es) The Child(ren) Have Any Special Problems? Yes No If Yes, How Are You Qualified To Help With These Problems?       Do You Expect The Proposed Ward(s) To Contest The Guardianship? Yes No Is This An Emergency Requiring Pursuit Of A Temporary Guardianship? Yes No Does The Proposed Ward(s)’s Psychiatrist Or Physician Support The Guardianship? Yes No What Types Of Health Insurance, If Any, Does The Proposed Ward(s) Have Available? Yes No Please Describe Your Contacts With The Child(ren), Including Whether The Child(ren) Has Ever Lived In Your Home Previously, The Extent Or Your Contacts With Him/Her/Them, And The Extent Of The Child(ren)'s Contacts       With Other Members Of Your Household, If Any       Please State, In Detail, The Reasons That The Child(ren)'s Mother And/Or Father Are Unfit To Serve As The Child's Legal Guardian: Yes No Please State, In Detail, Why You Believe That Your Obtaining Guardianship Is In The Best Interest Of The Child(ren), Including The Reasons Why Guardianship Is Appropriate And Why You Are The Best Person To Be The Guardian       Please Describe The Contact Your Child(ren) Would Have With His/Her/Their Parents If Guardianship Is Granted To You, Including How Such Contacts Will Be Scheduled, Their Frequency And Duration       PLANS FOR CHILD CARE IF NEEDED If Child Care Provider Is Licensed: Name       Address       Phone       If Child Care Provider Is Unlicensed: Name       Address       Date Of Birth       Social Security No.       Phone       Relationship To Child