Fill and Sign the Termination Guardianship San Diego Superior Court 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