Fill and Sign the Medical Records Request Ampamp Authorization Phoenix Childrens Hospital 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 for each case, give the date of removal or resignation: has your proposed conservator of person or guardian made a written attestation stating that the person has never been convicted of a felony, any crime involving bodily injury, elder abuse, theft, fraud, or embezzlement, or has been removed or asked to resign as a conservator, guardian, executor, or fiduciary in any other case? [yes/no, if yes: list dates of convictions only (including misdemeanor conviction) and why have they been never convicted of a felony, any crime involving bodily injury, elder abuse, theft, fraud, or embezzlement.] [I am not including misdemeanor convictions if none resulted in a conviction, or if a misdemeanor conviction was dismissed without a finding on appeal.] [this part is optional, so feel free to do it or leave it blank, but I would be more inclined to have you fill this out if you've been in the conservatorship of a person or are conservator of the person's estate.] have you ever participated in any legal proceedings as a special administrator of a decedent's estate? (other than those for purposes of applying for a certificate of appointment) [no/yes, for each case, give dates of participation in legal proceedings, how many cases, what did your participation consist of, and why. Do the attorneys for the estate or for the conservator have similar records? Are there documents that show your participation?] [I am not including participation in legal proceedings because the information on the website is incomplete. Also, i'm not including participation in legal proceedings because attorneys can be found in the names of the deceased people. I want to make sure you are providing truthful information, so fill out each part if appropriate.] have you ever served as a legal advocate in any matter relating to the estate of a decedent? (other than those for purposes of applying for a certificate of appointment) [no/yes, for each case, give dates of service, what your role was, how long you served in the role, and why you became involved.] [I'm assuming that each case has a different legal status and function from the other cases listed below. Therefore, I do not include attorneys or special advocates as legal advocates.]  if you have been retained as a special advocate or attorney in any matter relating to the estate of a decedent, describe your role and the nature of your legal work and any other legal work that you have done in the last.