ࡱ> u@ @bjbj $~~8R"j#j#j#8#.$d"M($$:$$$$$$MMMMMMM$NRQ=M&$$&&=M$$RMY,Y,Y,&2$$MY,&MY,Y,o,H#K$$ zj#/)RJ6LLhM0MJZQ)Ql#K""Q#K$L$%6Y,Z%,%w$$$=M=M""d 1,("" QUESTIONNAIRE FOR CONSERVATORSHIP PETITION General Info for Petition Petitioner Name of Petitioner: __________________________________________________________ Address of Petitioner: __________________________________________________________ Phone of Petitioner: __________________________________________________________ Is petitioner a creditor / agent of a creditor of conservatee? Y N Is petitioner a debtor / agent of a debtor of conservatee? Y N Proposed Conservator(s) if different from Petitioner Name of Conservator: __________________________________________________________ Address: __________________________________________________________ Phone: __________________________________________________________ Social Security Number: __________________________________________________________ Drivers License Number: __________________________________________________________ Date of Birth: __________________________________________________________ Name of Co-Conservator (if any):____________________________________________________ Address of Co-C: __________________________________________________________ Phone of Co-C: __________________________________________________________ Social Security # of Co-C: __________________________________________________________ Drivers License # of Co-C:_________________________________________________________ Date of Birth of Co-C: __________________________________________________________ Proposed Conservatee Name of Conservatee: __________________________________________________________ Present Address (current location):______ _____________________________________________ Phone: __________________________________________________________ Residence (If different from current location):___________________________________________ Social Security Number: __________________________________________________________ Date of Birth: __________________________________________________________ Relationship to petitioner __________________________________________________________ Relationship to conservator_________________________________________________________ California resident? Y N San Diego County resident? Y N Will proposed conservatee continue to live in his home? Y N If N, will conservatee be moved after cship is approved? Y N If proposed conservatee does not live at home, will s/he return to her/his home? Y N If Y, give date of return to home or reason why not returning: _________________________ __________________________________________________________________________ Is conservatee a patient or on leave from a state institution or mental health? Y N Is conservatee receiving MediCal benefits? Y N Does conservatee adhere to a religion that relies on prayer alone for healing? Y N Is conservatee receiving or entitled to receive VA benefits? Y N If Y, how qualified (e.g., parent, spouse, self) ______________________________________ Name: __________________________________________________________ Claim/Serial #:________________________________________________________ Branch/Rank:_________________________________________________________ Dates of Service:______________________________________________________ Estimated monthly benefit playable: $ _________ Is conservatee able to complete affidavit of voter registration? Y N Proposed Conservatees incapacity Proposed conservatees DX_________________________________________________________ Date of Dx:______________________________________________________________________ Severity of condition: __________________________________________________________ Describe the following: Inability to tend to physical health:__________________________________________ Inability to care for food: _________________________________________________ Inability to care for clothing: ___________________________________________________ Inability to secure shelter _______________________________________________________ Is Conservatee under an LPS conservatorship? Y N If Y, case number: ________________________ Is petnr or conservator the Spouse or Domestic Partner of conservatee? Y N If Y, indicate which one __________________________________________ If Y, are they legally separated, divorced, OR is marriage annulled OR is there a pending proceeding? Y N If Y, does spouse (petnr or consrvtr) want a conservator be appointed? Y N If Y, does spouse (petnr or consrvtr) wish to be appointed as conservator? Y N Attendance of Proposed conservatee at the hearing Willing to attend? Y N Was proposed conservator nominated? Y N Able but unwilling to attend? Y N Contest conservatorship? Y N Prefers another person to act as conservator? Y N Unable to attend due to medical reasons? Y N If Y, doctor must so indicate in Capacity Declaration Out of state? Y N Is proposed conservatee Developmentally Disabled? Y N If Y, specify nature and degree of disability Regional Center Client, Mental Age (Attachment 5f) ____________________________________________________________________________ Limited Powers and Duties (Attachment 1h & 1j) Circle powers requesting and indicate reason Fix residence / dwelling ___________________________________________________ Access to confidential records ___________________________________________________ Give / Withhold consent to marriage________________________________________________ Right to contract __________________________________________________ Give / Withhold medical consent___________________________________________________ Social / Sexual contact ___________________________________________________ Decision re. education ___________________________________________________ Does Proposed Conservatee have Dementia? Y N If Y: Are you seeking to place Conservatee in a secured facility? Y N If Y, give name and address of facility:___________________________________ Does conservatee need/would benefit from dementia medications and lack the capacity to give informed consent? Y N If Y, give list of medications, dosage, and exact purpose _____________________ ___________________________________________________________________ ___________________________________________________________________ Conservatorship of Estate: Y N If Y: Character and estimated value of property in estate: Personal Property: $________________ Real property Yes* No *If yes, state: Location ______________________________________________ Value $ _________________ (estimated or per appraisal?) Annual gross income from: Real property $_______________ Personal property $ _____________ Pensions $ _____________ Wages: $__________ Public assistance benefits: $___________ Other: $ ______________ Describe a specific incident of the Proposed Conservatees substantial inability to manage his/her financial resources or resist fraud or undue influence. Also describe any variations from prior spending patterns: ______________________________________________________________ ___________________________________________________________________________ Need any of the following Independent Powers: If yes, state reasons for IMMEDIATE NEED: Contract Operate at the risk of the estate a business, farm, enterprise Grant or take options Sell real or personal property Create easements or servitudes Borrow money and give security for repayment thereof Purchase real or personal property Alter, improve, repair or raze replace and rebuild property of the estate Let or lease property of the estate Sell property of the estate on credit, if unpaid portion of the selling price is adequately secured Commence and maintain an action for partition Exercise stock rights and stock options Participate in and become subject to and to consent to the provisions of a voting trust and or a reorganization, consolidation, merger, dissolution, liquidation or other modification or adjustment affecting estate property Pay, collect, compromise, arbitrate, adjust claims, debts, or demands Employ attorneys, accountants, investment counsel, agents, depositaries and employees and pay the expense Second Degree Relatives (Attachment 11) List: Name, DOB or Age, Address, or if deceased, Date or Year of Death Spouse _______________________________________________________________________ Children: _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Grandchildren: _______________________________________________________________________ ______________________________________________________________________________________________________________________________________________ Mother: _______________________________________________________________________ Father: _______________________________________________________________________ Brothers: _______________________________________________________________________ ______________________________________________________________________________________________________________________________________________ Sisters: _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Paternal Grandmother: ________________________________________________________________ Paternal Grandfather: ________________________________________________________________ Maternal Grandmother: ________________________________________________________________ Maternal Grandfather: ________________________________________________________________ Confidential Conservator Screening Form Must be completed for each conservator How long has conservator known conservatee _____ Yrs _____ Mos Was conservator nominated? Y N If Y, by whom (conservatee / spouse or parent by of conservatee) If Y, how and provide document ___________________________________________________ Does the conservator owe conservatee money or has a financial obligation to conservatee? Y N If Y, explain ____________________________________________________________________ Does conservatee owe conservator money or has a financial obligation to conservator? Y N If Y, explain ____________________________________________________________________ Is conservator an agent for a creditor of conservatee? Y N If Y, explain ____________________________________________________________________ Has conservator filed for bankruptcy in last 10 years? Y N If Y, explain ____________________________________________________________________ Has conservator been convicted of a felony, even if expunged from record? Y N If Y, explain ____________________________________________________________________ Has conservator been charged with, arrested for, or convicted of embezzlement, theft or any crime involving taking of property? Y N If Y, explain ____________________________________________________________________ Has conservator been charged with, arrested for, or convicted of, a crime involving fraud, conspiracy or misrepresentation of info? Y N If Y, explain ____________________________________________________________________ Has conservator been charged with, arrested for, or convicted of any form of elder abuse or neglect? Y N If Y, explain ____________________________________________________________________ Has a restraining order or protective order been filed vs. conservator in the last 10 years? Y N If Y, explain ____________________________________________________________________ Does conservator have to register as a sex offender? Y N If Y, explain ____________________________________________________________________ Has conservator been appointed conservator, executor, or fiduciary in another proceeding? Y N If Y, explain ____________________________________________________________________ Has conservator been removed or asked to resign as a conservator, guardian, executor, or fiduciary in any case? Y N If Y, explain ____________________________________________________________________ Does conservator have an adverse interest considered to be a risk or have an effect on conservators ability to perform duties? Y N If Y, explain ____________________________________________________________________ Does conservator have any other person living in the house who has a social worker or parole or probation officer assigned? Y N If Y, explain ____________________________________________________________________ Confidential Supplemental Information Alternatives to Conservatorship Voluntary acceptance of inf or formal assistance ______________________________________ Special or limited POA ______________________________________ General POA ______________________________________ Durable POA ______________________________________ Trust ______________________________________ Other alternatives considered ______________________________________ Services Provided to proposed conservatee: Did conservatee receive health services during the past year? Y N If Y, explain ________________________________________________________________ Did conservatee receive social services during the past year? Y N If Y, explain ________________________________________________________________ Referral for Investigators Report Are there any of the following at the conservatees location? Firearms Y N ___________________________________________________ Dogs Y N ___________________________________________________ Restraining Order Y N ___________________________________________________ Other hazards Y N ___________________________________________________ Has there a previous investigation within the last 6 months? Y N Duties of Conservator > ASK PROPOSED CONSERVATOR to read and return signed forms at next meeting. Fee Waiver Forms Package > Inform petitioner abt fee and provide package to be filled out by petitioner and returned at next meeting (Note: if public benefit, should also bring proof of that benefit). 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