Ventura — Conservatorship Preliminary / Interim Financial Declaration

Source: https://ventura.courts.ca.gov/system/files/vn262.pdf

VN262

CONFIDENTIAL

ATTORNEY OR PARTY WITHOUT ATTORNEY (Name and Address) Telephone Number

E-MAIL ADDRESS (Mandatory):

ATTORNEY FOR (Name):

SUPERIOR COURT OF CALIFORNIA, COUNTY OF VENTURA Juvenile Courthouse 4353 Vineyard Ave Oxnard, CA 93036

IN THE MATTER OF:

CASE NUMBER:

CONSERVATORSHIP

PRELIMINARY/INTERIM FINANCIAL DECLARATION

Ventura Superior Court Local Rule 10.02(A)(4)

Note: If additional space is needed, please attach additional page(s).

1. General Information Regarding the Conservatorship and Conservatee/Proposed Conservatee

   a. Type of Conservatorship (Check all that apply): Person _____ Estate _____ General _____ Limited ______

   b. (Proposed) Conservatee’s Age _______ and DOB: _______________ c. In a 10-Year Plus Marriage (Y/N) ____

   d. Possible Major Neurocognitive Disorder (Y/N) ________

   e. Possible Developmental Disability (Y/N) f. Is a Regional Center Client (Y/N) _____

   g. Diagnoses: __________________________________________________________________________________

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   h. Shortened life expectancy (Y/N) ______ If YES, briefly explain __________________________________________

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   i. (Proposed) Conservatee has Advanced Health Care Directive (Y/N) ______ Approx. AHCD Date: _____________

   j. (Proposed) Conservatee has a Trust (Y/N) ____ Approx. Trust Date: ____________________

   k. Owns home living in now (Y/N) _____ l. Relationship of (Proposed) Conservator

2. Assessing Annual Personal/Conservatorship Income and Assets

Income Source Amount Where Petitioner Obtained Information

a. Pension $ ___________________ _____________________________________________

b. Social Security $ ___________________ _____________________________________________

c. Rents $ ___________________ _____________________________________________

d. Dividends $ ___________________ _____________________________________________

e. Other ( ______________ ) $ ___________________ _____________________________________________

f. TOTAL ANNUAL INCOME $ ____________________

Mandatory Form VN262 (01/2021) PRELIMINARY/INTERIM FINANCIAL DECLARATION Page 1 of 2

VN262

CONSERVATORSHIP OF (Name): Case number:

CONSERVATEE

Asset Types Value Where Petitioner Obtained Information

g. Home, less encumbrances $ ___________________ _____________________________________________

h. Real Estate (not home) $ ___________________ _____________________________________________

i. Cash/Bank/Savings/CDs $ ___________________ _____________________________________________

j. Stocks/Bonds/IRAs $ ___________________ _____________________________________________

k. Other ( ______________ ) $ ___________________ _____________________________________________

l. TOTAL ASSETS $ ____________________

3. Assessing Trust Assets and Annual Proceeds

   a. Types of Assets in Trust: _______________________________________________________________________

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   b. Estimated Value of Trust Assets: $ ________________

   c. Estimated Annual Receipts from Trust Assets: $__________________

4. Assessing Monthly Expenses Amount Where Petitioner Obtained Information

   a. Rent/Mortgage/Home Insurance $ ___________________ ______________________________________

   b. Medical/Dental Costs/Insurance $ ___________________ ______________________________________

   c. Food/Utilities/Transportation $ ___________________ ______________________________________

   d. Care Providers $ ___________________ ______________________________________

   e. Other ( ____________________ ) $ ___________________ ______________________________________

   f. TOTAL MONTHLY EXPENSES $ ____________________

5. Expected Changes to Expenses and/or Income in the next 9 months (housing, care, etc.): __________________

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I declare under penalty of perjury, under the laws of the State of California that, based upon information and belief, the foregoing is true and correct, and that I have retained a copy for my record.

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Dated Signature of Conservator/Proposed Conservator

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Type or Print Name

File the original of this form with the Court and mail copies to the Probate Investigations Office at: 800 S. Victoria Ave, Ventura, CA 93009 and Public Defender’s Office at: 800 S. Victoria Ave. Suite 207, Ventura, CA 93009.

Mandatory Form VN262 (01/2021) PRELIMINARY/INTERIM FINANCIAL DECLARATION Page 2 of 2