Fill and Sign the Conservatorship Form

Conservatorship Questionnaire Conservator of the Person Conservator of the Estate Both Date:       Name:       Date Letters of Conservatorship were issued (if applicable):       Limited: Yes No County for filing:       Conservator Proposed conservator(s): Name:       Home address:       Work address:       Telephone: (Home)       (Work)       E-Mail address:       Date of birth:       Social Security Number:       Drivers license number:       Expiration date:       Relationship of proposed conservator of person, of person and estate, or of estate:       What are your qualifications to act as conservator?       Does proposed conservatee consent to conservatorship? Yes No Have you ever filed a bankruptcy petition for relief under Chapter 7 or Chapter 11 of the Federal Bankruptcy Act? Yes No Have you ever been convicted of a felony or any other crime involving bodily injury, elder abuse, theft, fraud, or embezzlement? Yes No For each offense, give the date of conviction and the offense charged:                   Have you had a restraining order or protective order filed against you in the last 10 years? Yes No Are you required to register as a sex offender? Yes No Have you been removed or asked to resign as a conservator, guardian, executor, or fiduciary in any other case? Yes No 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? Yes No Conservatee Name:       Home address:       Work address:       Type of residence (home, relative’s home, care facility, etc.):       Telephone: (Home)       (Work)       E-Mail address:       Date of birth:       Social Security Number:       Is conservatee married? Yes No If yes, date of marriage:       Physical condition of proposed conservatee:       Health problems (if any):       Is proposed conservatee developmentally disabled? Yes No If yes, please describe:       If yes, give address of local regional center working with the proposed conservatee. Name of facility:       Address:       Telephone:       If proposed conservatee is petitioner, did petitioner waive bond? Yes No Has proposed conservatee nominated conservator? Yes No If so, give names, addresses, telephone numbers, and relationships of nominees in order of his or her preference. 1.       2.       3.       Is/was there any emergency that requires/required a temporary conservator of the person or estate until a permanent conservator is appointed? Yes No If yes, please describe:       Name of temporary conservator:       Address: Telephone:       Please list relatives of conservatee, including parents, grandparents, siblings, spouse, children, and grandchildren of the conservatee: 1) NAME:       ADDRESS:       RELATIONSHIP TO CONSERVATEE:       2) NAME:       ADDRESS:       RELATIONSHIP TO CONSERVATEE:       3) NAME:       ADDRESS:       RELATIONSHIP TO CONSERVATEE:       4) NAME:       ADDRESS:       RELATIONSHIP TO CONSERVATEE:       5) NAME:       ADDRESS:       RELATIONSHIP TO CONSERVATEE:       6) NAME:       ADDRESS:       RELATIONSHIP TO CONSERVATEE:       7) NAME:       ADDRESS:       RELATIONSHIP TO CONSERVATEE:       8) NAME:       ADDRESS:       RELATIONSHIP TO CONSERVATEE:       9) NAME:       ADDRESS:       RELATIONSHIP TO CONSERVATEE:       Financial advisors/services (please complete only if conservatorship of the estate is requested) Type of Service Performed:       Name of advisor:       Address:       Phone:       Fax:       Health services provided during the last year:(i.e. generally, dental, therapy, psychological pediatrics):       Physician of conservatee:       Address:       Phone:       Fax:       Social services provided during the last year (i.e. art classes, work training, outings)       Is conservatee employed? Yes No If yes please provide employer name and address:       Is the conservatee enrolled in school? Yes No Name of school/program:       Address:       Phone:       Fax:       Will proposed conservatee be able to attend hearing? Yes No Is proposed conservatee willing to attend? Yes No If not, please explain:       Is there a physical or emotional problem that will prevent proposed conservatee ’s attendance in court? Yes No Are there special circumstances requiring conservatee to be placed in a developmental center? Yes No Does conservatee have social/sexual relationships that require involvement of a conservator? Yes No Do you expect anyone to challenge the petition for limited conservatorship? Yes No If the answer to any of the previous questions is YES, please explain:       POWERS REQUESTED (for Limited Conservatorships of persons with developmental disabilities only): Please check: Residence; Confidential Records; Marriage; Contracts; Medical treatments; Social/Sexual relationships; Education Is the proposed conservatee capable of completing a voter registration form? Yes No Is proposed conservatee a patient in or on leave of absence from a state institution? Yes No If yes, please provide name and address of facility. Name of facility:       Address: Telephone:       Financial status Assets: Type Name/Type When Acquired How Titled Cost/Value Encumbrances Bank and savings and loan association accounts, name and address of institution or branch Real property Securities Tangible personal property (e.g., jewelry, paintings, cars, household furniture) Insurance policies (e.g., life, health, disability, auto) Business interests Property located outside state: Other property, e.g., royalties, mineral interests, accounts or notes receivable Jointly held property and totten trusts Trusts of which proposed conservatee is beneficiary Debts Name of Creditor Address of Creditor Amount of Debt Nature of Debt Is Debt Disputed? Yes No Yes No Yes No Yes No Yes No Standard of living Is the proposed conservatee currently receiving financial assistance under SSI and/or SSP? Yes No Is proposed conservatee receiving benefits from the Veterans Administration? Yes No If yes, please provide address of office handling claim and claim number. Name of office:       Address:       Telephone:       Claim number:       Source of Income Monthly Amount Living costs Expense Monthly Amount What assets may be sold to supplement living expenses if income is inadequate?:       What assets should be used first?:       Did proposed conservatee make regular gifts? Yes No If yes, to whom and in what amounts?:                   Please list any dependents of conservatee and amounts provided for support:                   Safe-deposit boxes: Name of institution:       Address:       Box number:       Describe contents:       Location of safety deposit keys:       Name and address of any other person having access to safety deposit box:       Claims By Others Name of Claimant Address Description of Claim Property Involved Is Claim Admitted? Yes No Yes No Yes No Is proposed conservatee a party to any contracts? Yes No Name and address of other parties to contract, nature of contract, and copy, if available Nature of Contract Other Party(s) Other Party Addreess(es) Has proposed conservatee made a will? Yes No Is a copy available? Yes No If yes, to whom and from whom?       What are proposed conservatee's testamentary plans?       Names and addresses of persons who assisted in planning: Name Address Is proposed conservatee the settlor or trustee of any trust? Yes No Supporting Documents: Please provide copies of any IEPs and Regional Center IPPs which have been developed for the proposed conservatee. In addition, if you have any documents that demonstrate the need for the conservatorship, such as evaluations that recommend a Conservatorship, please provide copies.