San Mateo — Confidential Status Report

San Mateo — Confidential Status Report¶

Source: https://sanmateo.courts.ca.gov/system/files/local-forms/pr-19.pdf

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SUPERIOR COURT OF THE STATE OF CALIFORNIA COUNTY OF SAN MATEO PROBATE COURT INVESTIGATIONS 400 County Center, 8th Floor, SMC-127 PI Redwood City, CA 94063

CONFIDENTIAL STATUS REPORT Status Report of Conservatee Pursuant to Local Court Rule 4.81.18

NOTE: If there is more than one conservator, only one Status Report must be completed. Each co-conservator must sign the Status Report or attach a separate signature page that, when signed indicates agreement to the contents of the Confidential Status Report. The Confidential Status Report is also available online at www.sanmateo.courts.ca.gov.

Please type or print legibly when completing this document.

Conservatee’s Name:___________________________________________________________
Case Number: Date of Birth:___________________ Age:__________
Name of Facility (if applicable):__________________________________________________
Facility or Home Address:_______________________________________________________ Street

City Zip
Phone:______________________ Facility Contact:___________________________________
Type of Residence/Facility:______________________________________________________ (Nursing Home, Residential Care, Assisted Living, Private Home)
What is date of placement? Describe facility services and medical monitoring of conservatee?

Do you plan to continue placement or change placement?

______________________________________________________________________________

CONFIDENTIAL STATUS REPORT
Form adopted for Mandatory Use Local Court Rule 4.81.18
Local Court Form PR-19 [Rev. February 2013]

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Current health status/functional level: stable declined improved

Primary Diagnosis:_____________________________________________________________

Comments:_____________________________________________________________________
Hospitalizations during the review period? YesYes No If yes, list dates and reasons for
hospitalizations:
DAY PROGRAM - If the conservatee attends a day program such as a vocational program, sheltered work program, adult day health program or any other day program, please complete the following information:

Program Name:_________________________________________________________________

Address:_______________________________________________________________________

Phone:_________________________ Contact person:__________________________________

Days attended:__________________________________ Hours:__________________________

Program services and activities:____________________________________________________

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VISITATION - Dates of visits to the conservatee (not living with conservator):

Date:_______________ Date:_______________ Date:_______________ Date:_______________ Date:_______________ Date:_______________ Date:_______________ Date:_______________ Date:_______ ________ Date:_______________ Date:_______________ Date:_______________ Date:_______________ Date:_______________ Date:_______________ Date:_______________ Date:_______________ Date:_______________ Date:_______________ Date:_______________ Date:_______ ________ Date:_______________ Date:_______________ Date:_______________ Date:_______________ Date:_______________ Date:_______________ Date:_______________ Date:_______________ Date:_______________ Date:_______________ Date:_______________ Date:_______ ________ Date:_______________ Date:_______________ Date:_______________ Date:_______________ Date:_______________ Date:_______________ Date:_______________ Date:_______________ Date:_______________ Date:_______________ Date:_______________ Date:_______ ________ Date:_______________ Date:_______________ Date:_______________ Date:_______________ Date:_______________ Date:_______________ Date:_______________ Date:_______________ Date:_______________ Date:_______________ Date:_______________ Date:_______ ________ Date:_______________ Date:_______________ Date:_______________
FINANCIAL INFORMATION – MUST BE COMPLETED FOR ALL CONSERVATORSHIPS:

Does the conservatee have a trust? Yes No

If yes, Trustee: ______________________________ Current Market Value: _____________

Does the conservatee have a Special Needs Trust? Yes No

If yes, Trustee: _____________________________ Current Market Value: _____________

Does the conservatee have monthly income? Yes No

If yes, what is the source?____________________________________________________

Social Security/Supplemental Security Income (SSI)/Trust/Other

Total average monthly income:_______________________________________________

Average monthly expenses __________________________________________________

Does the conservatee have a Representative Payee? Yes No

Name of Representative Payee:________________________________________________

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For a Conservatorship of the Estate, an accounting is required unless waived by the Court pursuant to Section 2628 of the Probate Code. If waived, a Declaration in Support of Waiver of Accounting (Local Form Number PR-24) must be filed each review period.

If an accounting is being filed, complete the following information: (Use additional sheets of paper if necessary.)

Total current fair market value (FMV) of estate:__________________________________

Total average monthly income:________________________________________________

Total average monthly expenses:_______________________________________________

Explain any “internal accounting adjustments” not otherwise delineated in the accounting:

Describe any unusual receipts or disbursements, sales, purchases or changes in the form of assetsassets notnot otherwiseotherwise delineateddelineated inin thethe accounting.accounting. Address any unusual compensation paid to third parties, especially if they are relatives of the conservatee or the conservator. (For example, if the monthly phone bill averages $50.00, explain a phone bill of $250.00; or, if a rental property earns gross monthly rent of $2,500.00, explain why the listed net rent is $2,275.00.).).) Use additional sheets, if necessary.

Current Issues: Conservator’s personal observations and compliance with Court orders and recommendations; also include information regarding any criminal matters or civil litigation involving the conservatee or conservator.

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The conservator has a recent photograph of the conservatee taken and preserved by the conservator on an annual basis for the purpose of identifying the conservatee if he or she becomes missing.

Yes; Date of photograph: _________________
Name of person completing this document: ___
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

Executed on at Date Location SIGN

Conservator Signature:

Print Name:

I am a co-conservator in this matter and I have read the Confidential Status Report of

Conservatee and know the contents thereof. The report is true of my own knowledge and understanding.

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

Executed on at Date Location

Conservator Signature:

Print Name:

Please mail a completed form and one additional copy, at least thirty (30) days prior to the review hearing date, to:

Superior Court, County of San Mateo

Probate Clerk’s Office 400 County Center, 1 st Floor Redwood City, CA 94063-1655

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