Santa Clara — PB-4076*

Source: https://santaclara.courts.ca.gov/system/files/forms/pb-4076_rem.pdf

ATTACHMENT PB- 4076

ATTORNEY OR PARTY WITHOUT ATTORNEY(Name, State Bar Number and Address): FOR COURT USE ONLY

Telephone: Fax Number:

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 Jose, CA 95113 BRANCH NAME:

IN RE: THE CONSERVATORSHIP OF:

CASE NUMBER

VERIFICATION OF VIEWING OF CONSERVATORSHIP VIDEO

INSTRUCTIONS

Before you may be appointed as a conservator, you must watch a video called With Heart: Understanding Conservatorships. This video discusses the duties and responsibilities of a conservator.

The video is available to you in two ways:

1. You may make an appointment with the Court Investigators Office to view it at the courthouse.
2. You may view the video online at https://www.youtube.com/watch?v=A-SX6YkFsP4

Once you have watched the video, you must fill out, sign, and file this form with the court.

I have petitioned the court to be appointed the conservator of the person and/or estate of (Name): I viewed the court's videotape presentation on the duties and responsibilities of the conservator on Date: at the following location: At the Courthouse by appointment with the Court Investigator Office. On-line viewing located at https://www.youtube.com/watch?v=A-SX6YkFsP4 I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

Print Name Signature

Reset Form Print Form

PB-4076 VERIFICATION OF CONSERVATORSHIP VIDEO VIEWING PAGE 1 OF 1 (PROBATE – SANTA CLARA COUNTY)