Santa Clara — PB-4002 Referral for Court Investigator – Conservatorship

Source: https://santaclara.courts.ca.gov/system/files/forms/pb-4002_rem.pdf

ATTACHMENT PB-4002 ATTORNEY OR PARTY WITHOUT ATTORNEY (Name and Address): TELEPHONE NUMBER: FOR COURT USE ONLY

EMAIL ADDRESS (Optional):

ATTORNEY FOR (Name):

SUPERIOR COURT OF CALIFORNIA, COUNTY OF SANTA CLARA

STREET ADDRESS: 191 North First Street

MAILING ADDRESS: 191 North First Street

CITY AND ZIP CODE: San José, California 95113

BRANCH NAME: Downtown Courthouse - Probate Division

Conservatorship of (Name): Temp Hrg Date:

Person Estate Limited Perm Hrg. Date:

CASE NUMBER:

REFERRAL FOR COURT INVESTIGATOR - CONSERVATORSHIP

Note: A fee may be assessed for Court Investigator Services – See Probate Code § 1851.5

This Referral is being sent to the Probate Investigator’s Office for an investigation regarding (check all that apply): Appointment Accounting/Review Termination Medical Powers Dementia Powers Other: (specify): Sale of (former) Residence Substituted Judgment

Information about the (Proposed) CONSERVATEE

▪ (Proposed) Conservatee’s CURRENT address:

Address:

Phone number: Email: _____________________________

▪ (Proposed) Conservatee’s HOME address:

Address:

Phone number: ___________________________________ ___ Email: _____________________________

▪ Birth Date: _____________________________ Social Security #: _____________________________

▪ Marital Status: Single/Divorced Widowed Married Registered Domestic Partner

▪ Language needs / Special needs

▪ If Limited Conservatorship , SARC Service Coordinator Name:______________________ _

▪ email: __________________________SARC Service Coordinator Phone Number:

▪ History of: APS Dependency CPS Family Court Case No: _____________________

If any box is checked, please provide brief history in separate attachment.

▪ Is (proposed) conservatee under an LPS Conservatorship now? Yes No

If yes, LPS #

▪ (Proposed) Conservatee’s Attorney (name):

Address:

Phone number: Fax number:

E-mail: ________________________________________

PB-4002 REV 07/01/2022 REFERRAL FOR COURT INVESTIGATOR - CONSERVATORSHIP Page 1 of 5 For Mandatory Use www.courtinfo.ca.gov (PROBATE – SANTA CLARA COUNTY)

ATTACHMENT PB-4002 Conservatorship of (Name): Case Number:

General Hearing Date:

CONFIDENTIAL – DO NOT PUT IN COURT FILE

Information about the (Proposed) CONSERVATOR

All proposed Conservators must complete the information on this page. If there is more than one proposed Conservator, attach a copy of this page for each person.

▪ Name:

▪ Relationship to Conservatee: Spouse Son/Daughter Registered Domestic Partner

Other (describe):

▪ Home Address:

▪ Home phone: Fax number:

▪ Birth Date: Email: _________________________________

▪ Social Security number:

▪ Driver’s License number:

▪ Work phone: Cell phone:

▪ (Proposed) Conservator’s Attorney (name):

Address:

Phone number: Fax number:

Email: __________________________________

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

SIGN

Date: Signature of Proposed Conservator

Information sheet(s) for (number) of (proposed) co-conservators is attached.

Information about (Proposed) Conservatee’s Relatives & Friends

PB-4002 REV 07/01/2022 REFERRAL FOR COURT INVESTIGATOR - CONSERVATORSHIP Page 2 of 5 For Mandatory Use www.courtinfo.ca.gov (PROBATE – SANTA CLARA COUNTY)

ATTACHMENT PB-4002 Conservatorship of (Name): Case Number:

General Hearing Date:

List the spouse or registered domestic partner, 1 st and 2 nd degree relatives (these are parents, children, brothers/sisters, grandparents and grandchildren), neighbors and close friends of the (proposed) conservatee.

▪ Name: ___________________________ _____ Email: ______________________________________

▪ Relationship to (proposed) conservatee:

▪ Home Address:

▪ Home phone: Work phone: Cell phone:

▪ Name: ___________________________ _____ Email: ______________________________________

▪ Relationship to (proposed) conservatee:

▪ Home Address:

▪ Home phone: Work phone: Cell phone:

▪ Name: ___________________________ _____ Email: ______________________________________

▪ Relationship to (proposed) conservatee:

▪ Home Address:

▪ Home phone: Work phone: Cell phone:

▪ Name: ___________________________ _____ Email: ______________________________________

▪ Relationship to (proposed) conservatee:

▪ Home Address:

▪ Home phone: Work phone: Cell phone:

▪ Name: ___________________________ _____ Email: ______________________________________

▪ Relationship to (proposed) conservatee:

▪ Home Address:

▪ Home phone: Work phone: Cell phone:

▪ Name: ___________________________ _____ Email: ______________________________________

▪ Relationship to (proposed) conservatee:

▪ Home Address:

▪ Home phone: Work phone: Cell phone:

CONFIDENTIAL – DO NOT PUT IN COURT FILE

PB-4002 REV 07/01/2022 REFERRAL FOR COURT INVESTIGATOR - CONSERVATORSHIP Page 3 of 5 For Mandatory Use www.courtinfo.ca.gov (PROBATE – SANTA CLARA COUNTY)

ATTACHMENT PB-4002 Conservatorship of (Name): Case Number:

General Hearing Date:

Information about (Proposed) Conservatee’s Relatives & Friends

▪ Name: ___________________________ _____ Email: ______________________________________

▪ Relationship to (proposed) conservatee:

▪ Home Address:

▪ Home phone: Work phone: Cell phone:

▪ Name: ___________________________ _____ Email: ______________________________________

▪ Relationship to (proposed) conservatee:

▪ Home Address:

▪ Home phone: Work phone: Cell phone:

▪ Name: ___________________________ _____ Email: ______________________________________

▪ Relationship to (proposed) conservatee:

▪ Home Address:

▪ Home phone: Work phone: Cell phone:

▪ Name: ___________________________ _____ Email: ______________________________________

▪ Relationship to (proposed) conservatee:

▪ Home Address:

▪ Home phone: Work phone: Cell phone:

▪ Name: ___________________________ _____ Email: ______________________________________

▪ Relationship to (proposed) conservatee:

▪ Home Address:

▪ Home phone: Work phone: Cell phone:

▪ Name: ___________________________ _____ Email: ______________________________________

▪ Relationship to (proposed) conservatee:

▪ Home Address:

▪ Home phone: Work phone: Cell phone:

CONFIDENTIAL – DO NOT PUT IN COURT FILE

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ATTACHMENT PB-4002 Conservatorship of (Name): Case Number:

General Hearing Date:

Information about OTHER ADULTS (age18 or older) who reside with the proposed Conservatee

▪ Name: ___________________________ _____ Email: ______________________________________

▪ Relationship to (proposed) conservatee:

▪ Home Address:

▪ Home phone: Work phone: Cell phone:

▪ Name: ___________________________ _____ Email: ______________________________________

▪ Relationship to (proposed) conservatee:

▪ Home Address:

▪ Home phone: Work phone: Cell phone:

▪ Name: ___________________________ _____ Email: ______________________________________

▪ Relationship to (proposed) conservatee:

▪ Home Address:

▪ Home phone: Work phone: Cell phone:

▪ Name: ___________________________ _____ Email: ______________________________________

▪ Relationship to (proposed) conservatee:

▪ Home Address:

▪ Home phone: Work phone: Cell phone:

▪ Name: ___________________________ _____ Email: ______________________________________

▪ Relationship to (proposed) conservatee:

▪ Home Address:

▪ Home phone: Work phone: Cell phone:

▪ Name: ___________________________ _____ Email: ______________________________________

▪ Relationship to (proposed) conservatee:

▪ Home Address:

▪ Home phone: Work phone: Cell phone:

CONFIDENTIAL – DO NOT PUT IN COURT FILE

PB-4002 REV 07/01/2022 REFERRAL FOR COURT INVESTIGATOR - CONSERVATORSHIP Page 5 of 5 For Mandatory Use www.courtinfo.ca.gov (PROBATE – SANTA CLARA COUNTY)