Fillable CONFIDENTIAL (DO NOT ATTACH TO PETITION) (California)

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CONFIDENTIAL (DO NOT ATTACH TO PETITION) (California)

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CONFIDENTIAL (DO NOT ATTACH TO PETITION)
GC-212
Form Adopted for Mandatory Use
Judicial Council of California
GC-212 [Rev. July 1, 2009]
Probate Code, § 1516;
Family Code, § 3011;
Cal. Rules of Court, rule 7.1001
www.courts.ca.gov
CONFIDENTIAL GUARDIAN SCREENING FORM
(Probate—Guardianships and Conservatorships)
Page 1 of 2
The proposed guardian must complete and sign this form. The person requesting appointment of a
guardian must submit the completed and signed form to the court with the guardianship petition.
This form must remain confidential.
SUPERIOR COURT OF CALIFORNIA, COUNTY OF
STREET ADDRESS:
MAILING ADDRESS:
BRANCH NAME:
CITY AND ZIP CODE:
GUARDIANSHIP OF
(Name):
MINOR
FOR COURT USE ONLY
CASE NUMBER:
ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address):
TELEPHONE NO.:
FAX NO. (Optional):
E-MAIL ADDRESS (Optional):
ATTORNEY FOR (Name):
HEARING DATE AND TIME:
DEPT.:
CONFIDENTIAL GUARDIAN SCREENING FORM
Guardianship of
Person Estate
How This Form Will Be Used
This form is confidential and will not be a part of the public file in this case. Each proposed guardian must complete and sign a
separate copy of this form under rule 7.1001 of the California Rules of Court. The information provided will be used by the court
and by persons and agencies designated by the court to assist the court in determining whether to appoint the proposed
guardian as guardian. The proposed guardian must respond to each item.
1.
a.
Proposed guardian (name):
b.
Date of birth:
c.
Social security number:
d.
Driver's license number:
State:
e.
Telephone numbers: Home: Work: Other:
2.
I am
I am not
required to register as a sex offender under California Penal Code section 290.
(If you checked "I am," explain in Attachment 2.)
3.
I have
I have not
been charged with, arrested for, or convicted of a crime deemed to be a felony or a
misdemeanor. (If you checked "I have," explain in Attachment 3.)
(Check here if you have been arrested for drug or alcohol-related offenses.)
4.
I have
I have not
had a restraining order or protective order filed against me in the last 10 years.
(If you checked "I have," explain in Attachment 4.)
5.
I am
I am not
receiving services from a psychiatrist, psychologist, or therapist for a mental health–related
issue. (If you checked "I am," explain in Attachment 5.)
6.
Yes
No
(If you checked "Yes," explain in Attachment 6 and provide the name and address of each
social worker, parole officer, or probation officer.)
7.
Yes
No
(If you checked "Yes," explain in Attachment 7.)
8.
I am
I am not
Do you, or does any other person living in your home, have a social worker or parole or probation officer assigned to him or her?
Have you, or has any other person living in your home, been charged with, arrested for, or convicted of any form of child abuse,
neglect, or molestation?
9.
Yes
No
(If you checked "Yes," explain in Attachment 9.)
Have you, or has any other person living in your home, habitually used any illegal substances or abused alcohol?
aware of any reports alleging any form of child abuse, neglect, or molestation made to any
agency charged with protecting children (e.g., Child Protective Services) or any other law
enforcement agency regarding me or any other person living in my home. (If you checked "I am,"
explain in Attachment 8 and provide the name and address of each agency.)
GC-212 [Rev. July 1, 2009] Page 2 of 2
CONFIDENTIAL GUARDIAN SCREENING FORM
(Probate—Guardianships and Conservatorships)
GC-212
GUARDIANSHIP OF (Name):
MINOR
CASE NUMBER:
CONFIDENTIAL
10.
Have you, or has any other person living in your home, been charged with, arrested for, or convicted of a crime involving illegal
substances or alcohol?
Yes
No
(If you checked "Yes," explain in Attachment 10.)
11.
Do you or does any other person living in your home suffer from mental illness?
Yes
No
(If you checked "Yes," explain in Attachment 11.)
12.
Do you suffer from any physical disability that would impair your ability to perform the duties of guardian?
Yes
No
(If you checked "Yes," explain in Attachment 12.)
13.
I have or may have
I do not have
an adverse interest that the court may consider to be a risk to, or to have an
effect on, my ability to faithfully perform the duties of guardian.
(If you checked "I have or may have," explain in Attachment 13.)
14.
previously been appointed guardian, conservator, executor, or fiduciary in another proceeding.
I have
I have not
(If you checked "I have," explain in Attachment 14.)
15.
been removed as guardian, conservator, executor, or fiduciary in any other proceeding.
I have
I have not
(If you checked "I have," explain in Attachment 15.)
16.
a private professional fiduciary, as defined in Business and Professions Code section 6501(f).
I am
I am not
(If you checked "I am," respond to item 17. If you checked "I am not," go to item 18.)
17.
I am
I am not
currently licensed by the Professional Fiduciaries Bureau of the Department of Consumer
Affairs. My license status and information is stated in item 1 on page 1 of the Professional
Fiduciary Attachment signed by me and attached to the petition that proposes my appointment
as guardian in this matter. (Complete and sign the Professional Fiduciary Attachment and
attach it to the petition, or deliver it to the petitioner for attachment, before the petition is filed.
See item 4d of the petition. Use form GC-210(A-PF)/GC-310(A-PF) for this attachment.)
18.
I am
I am not
a responsible corporate officer authorized to act for (name of corporation):
19.
filed for bankruptcy protection within the last 10 years.
I have
I have not
(If you checked "I have," explain in Attachment 19.)
MINORS' CONTACT INFORMATION
20.
Minor's name:
Home telephone:
School (name):
School telephone:
Other telephone:
Minor's name:
Home telephone:
School (name):
School telephone:
Other telephone:
Minor's name:
Home telephone:
School (name):
School telephone:
Other telephone:
21.
22.
DECLARATION
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Date:
(TYPE OR PRINT NAME OF PROPOSED GUARDIAN)
(SIGNATURE OF PROPOSED GUARDIAN)*
* Each proposed guardian must fill out and file a separate screening form.
a California nonprofit charitable corporation that meets the requirements for appointment as
guardian of the proposed ward under Probate Code section 2104. I certify that the
corporation's articles of incorporation specifically authorize it to accept appointments as
guardian. (If you checked "I am," explain the circumstances of the corporation's care of,
counseling of, or financial assistance to the proposed ward in Attachment 18.)
Information on additional minors is attached.
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CONFIDENTIAL (DO NOT ATTACH TO PETITION) (California)

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Completed 3 January 2022

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