Stanislaus — Conservatorship questionnaire

Source: https://www.stanislaus.courts.ca.gov/system/files/forms-and-filings/conservatorship_questionnaire.pdf

PLEASE FILL OUT THIS QUESTIONNAIRE AND RETURN TO THE FOLLOWING ADDRESS: STANISLAUS COUNTY SUPERIOR COURT INVESTIGATOR'S OFFICE PO BOX 3488, 800 11TH STREET RM 221 MODESTO, CA 95353 CONSERVATORSHIP QUESTIONNAIRE CASE NUMBER

CONSERVATEE

NAME: AGE: DOB: ADDRESS: EMAIL: OWN OR RENT? MONTHLY MORTGAGE PAYMENT OR RENT TELEPHONE # CARE GIVER/BOARD & CARE/FACILITY NAME: BIRTHPLACE PHYSICIAN: SSAN#: IS THE CONSERVATEE A CLIENT OF VMRC, OTHER REGIONAL CENTER? IF YES, PLEASE GIVE THE NAME OF THE CENTER, CASE MANAGER, ADDRESS, TELEPHONE #, ATTENDANCE SCHEDULE ETC.

IS THE CONSERVATEE ATTENDING ANY OTHER SCHOOL, WORK OR DAY PROGRAM? IF YES, PLEASE GIVE THE NAME OF THE CENTER, CASE MANAGER, ADDRESS TELEPHONE #, ATTENDANCE SCHEDULE, ETC.

CONSERVATEE’S MONTHLY INCOME: SOURCE(S) OF INCOME: CHECKING ACCT. BAL: SAVINGS ACCT. BAL.: OTHER ASSETS (BURIAL PLAN/TRUST, PLOT, ETC.):

CONSERVATOR(S): NAME: AGE: DOB:

ADDRESS:

HOME TELEPHONE: EMPLOYER: WORK TELEPHONE: ADDRESS:

HAVE YOU EVER BEEN CONVICTED OF A FELONY? IF YES, PROVIDE DATE, COUNTY & DETAILS.

HAVE YOU EVER FILED FOR BANKRUPTCY? IF YES, PROVIDE DATE, & DETAILS. I declare under the penalty of perjury the foregoing is true and correct.

DATED: By Conservator PLEASE ADD ANY ADDITIONAL INFORMATION YOU MAY FEEL IS PERTINENT. THANK YOU FOR YOUR ASSISTANCE. (Telephone calls to the Court Investigator's Office will be accepted between 10 a.m. and 3 p.m. at (209) 530-3189) CON02 (Mandatory Form) Rev 07/25