Free Microsoft Word - PROPOSED-Guard - Attachment 9 - Santa Cruz - California

Guardianship of (child/ren's name/s):

Case Number:

ATTACHMENT (Number): __________ 1

Page _____ of ______ (Add pages as required)
(Month/Day/Year)

I am the ___________________. I was born on _________________.
(Relationship to minor)

2

The current state of my health is (please describe below):

____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________
Continued on attached page 3

The specific reason the parents are unable to care for the minor is (please describe below):

Mother
is currently incarcerated, has passed away, is not mentally stable, is not financially stable, has never been in the child's life, wants me to have the child, Other: ________________________________ Please explain below:

Father
is currently incarcerated, has passed away, is not mentally stable, is not financially stable, hasn't seen the child in _____ years ____ months wants me to have the child, Other: ________________________________

____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________
Continued on attached page 4

Check the box that bests describes the minor's needs: Does the minor have special emotional, psychological, educational, or personal needs? No If yes, please list the needs and how are you able to provide for them (please describe below):

Yes

____________________________________________________________ ____________________________________________________________ ____________________________________________________________
5

Will the minor have his/her own room? Full Legal Name: Relation. to Minor (if any): Date of Birth:

Yes

No (if No, please list who he/she will be sharing with): Full Legal Name: Relation. to Minor (if any): Date of Birth:

6

I declare under penalty of perjury under California State law that the information in this form is true and correct, which means if I/we lie on this form I/we am guilty of a crime.
Date:

________ ___________________
(Petitioner) Print Name Here

____________________
(Petitioner) Sign Name Here

Santa Cruz Superior Court Adopted for Optional Use New January 1, 2009

Declaration In Support Of Guardianship
(Probate)
Page 1of 1 SUP CV 1077