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NAME, ADDRESS, AND TELEPHONE NUMBER OF ATTORNEY OR PARTY WITHOUT ATTORNEY: STATE BAR NUMBER Reserved for Clerk’s File Stamp

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COURTHOUSE ADDRESS: finished. Click on the button to select the appropriate court address. IN THE CONSERVATORSHIP OF: HEARING DATE:

CASE NUMBER:

PROBATE COURT APPOINTED COUNSEL'S REPORT JUDICIAL OFFICER/DEPT
FOR DEVELOPMENTALLY DISABLED ADULTS

I, , having been appointed by the Superior Court

of Los Angeles County as Probate Appointed Counsel for , the proposed conservatee pursuant to Probate Code section 1471, present my report as follows:

Appointed Counsel’s Disclosures
I declare that:

A. I am an active member of the State Bar. (Initial)
There are no disciplinary actions pending and none were filed against me during the past twelve months.
(Initial)
B. I have professional liability insurance coverage in effect. (Initial)
C. I do not and have not in the past represented any party to this proceeding other than this present appointment.
(Initial)
OR
As explained below, I do or have in the past represented the following party(ies) in this or another proceeding:

1. Describe the proposed conservatee’s diagnosis:

2. I personally interviewed the proposed conservatee on Location:

3. I informed the proposed conservatee that I am required to report to the court the proposed conservatee’s wishes,

   and if my own observations and recommendations or opinions as to what action(s) are in the proposed conservatee’s best interests are different, then I will advise the court that an expert (Evidence Code section 730) should be appointed in this matter. (Initial)

4. In my professional opinion the conservatee was unable to comprehend the disclosures set forth in

   paragraphs 5, 6 and 7 of this report.

5. I informed the proposed conservatee that I am required to make a written report to the court and that this report

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would become part of the permanent court file, which is public record. (Initial)

6. I informed the proposed conservatee of the following:

   The nature and purpose of the proceeding. (Initial)

   The identity of the petitioner. (Initial)

   The identity of the proposed conservator(s). (Initial) Name of the proposed conservator(s): Relationship(s):

   He/she may be disqualified from voting. (Initial) The request for Probate Code section 2351.5 powers and the effect of each. (Initial) Probate Code section 2351.5 powers are not requested.

7. I informed the proposed conservatee of the contents of the citation; of the nature, purpose, and effect of the
   proceeding, and his/her right to oppose the proceeding, to attend the hearing; to have the matter of the
   establishment of the conservatorship tried by a jury; and to be represented by legal counsel if the proposed
   conservatee so chooses. (Initial)

8. The following is a summary evaluation of the proposed conservatee:

   Physical abilities and limitations:
   Ambulatory Uses wheelchair Bed bound
   Verbal Language spoken (other than English)
   Sign language
   Blind
   The proposed conservatee does does not possess daily living skills (ability to
   dress, feed and toilet oneself). If the proposed conservatee does possess such skills, he/she
   performs them with without direction.

   Community Involvement and Education:
   Is Is not enrolled in Public School Special Education Program
   Is Is not a client of the Regional Center
   Is Is not employed. If employed, the employer is a Skill Center
   Private Employer

   Placement:
   Family home Group home Developmental Center/Facility
   Other, describe:

   The petitioner is is not a provider of board and care, treatment, habilitation or
   other services to persons with disabilities, or is the spouse or employee of such a provider.

   Comments:

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9. It appears that the conservatee is:

   Able and wishes to attend the hearing: Yes No

   Unable to attend: Yes No Supported by Declaration of Medical Practitioner? Yes No

   Able but unwilling to attend the hearing: Yes No N/A

   Comments:

10. Does the proposed conservatee wish to contest the establishment of the conservatorship? Yes No N/A (Does not have or cannot express an opinion) Comments:

11. Does the proposed conservatee object to the proposed conservator or does he/she prefer another person to act as conservator? Yes No N/A (Does not have or cannot express an opinion)

    If the proposed conservatee answered yes, the name(s) of person(s) he/she prefers:

    Comments: .

12. Has the proposed conservatee retained legal counsel? Yes No

    Does the proposed conservatee intend to retain legal counsel? Yes No

    If yes, the name of the attorney the proposed conservatee has or wishes to retain, if known.

13. I have interviewed the following:
    The proposed conservatee.
    The proposed conservator(s).
    The proposed conservatee’s physician. Name:
    A Regional Center Representative. Name:
    Title:
    Caregiver(s) Name(s):
    Others (describe):

    Comments:

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14. I have reviewed the following:

    The Petition for Appointment of Conservator/Limited Conservator, including:
    Request(s) for Probate Code section 2351.5 powers
    Request(s) to limit the legal and civil rights of the proposed conservatee
    The Regional Center Report The Court Investigator’s Report
    Facility Records The Confidential Supplemental Form
    The Capacity Declaration The Confidential Screening Form
    Other (describe):

15. Based on review of the documents and interview with the proposed conservatee, I have: Inquired into the nature and extent of the general intellectual functioning of the proposed conservatee. Evaluated the extent of the impairment of his or her adaptive behavior. Ascertained the proposed conservatee’s capacity to care for himself or herself and his or her property. Inquired into the qualifications, abilities, and capabilities of the person(s) seeking appointment as limited conservator(s).

16. I have determined that the proposed conservatee:
    Receives public benefits only and has no estate or his/her estate meets the requirements of Probate Code
    section 2628.

    Is a beneficiary of a trust as follows:
    Special Needs Trust, Trust Funded by Court Order [as defined in CRC Title 7 Rule 7.903(a)(1)]
    or otherwise subject to the Court’s continuing jurisdiction
    A proceeding relating to the Trust has been filed in County under case
    number
    No trust proceeding has been commenced
    A trust that is not subject to court jurisdiction
    A trust established by a third party for the benefit of the proposed conservatee.
    Comments:

17. The proposed conservatee is is not a party to another court action as follows: Dissolution. The proposed conservatee is the Petitioner Respondent. Criminal. Nature of the proceeding: Civil. Nature of the proceeding: The proposed conservatee is a Plaintiff Defendant. Bankruptcy. Estate Beneficiary. The above referenced proceeding was filed in County under case number . Comments:

Case Name: Case Number:

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RECOMMENDATIONS

Based upon my interview with the persons noted above and my review of the documents described above,

1.I will will not waive service of the citation and the appearance of the proposed conservatee at the hearing.

2. An Evidence Code section 730 expert should be appointed to advise the Court on the best interests of
   the proposed conservatee.
   unable to properly provide for his or her personal needs.3.The proposed conservatee is able
   unable to manage his or her own financial resources.4.The proposed conservatee is able

5.The proposed conservatee is able unable to communicate, with or without reasonable accommodations, a desire to participate in the voting process.

6.The proposed conservatee:

Consents or does not oppose the establishment of the conservatorship and the appointment of the proposed conservator(s).

The proposed conservatee is opposed to the establishment of a conservatorship and/or the appointment of the proposed conservator. Comments:

The proposed conservatee cannot express an opinion regarding the appointment of a conservators because he/she is non-communicative or is not capable of engaging in meaningful communications.

7. The proposed conservatee is in need of a conservator and the proposed conservator(s) should be appointed. the proposed conservator(s) should not be appointed and the following person/entity should be appointed: Should be referred to the Public Guardian for appointment pursuant to Probate Code section 2920(b). Should be referrred to the Regional Center for alternatives to the conservatorship. The proposed conservatee is not in need of a conservatorship.

   Comment:

8.The proposed conservator should be appointed as: Limited Conservator of the Person Estate Person and Estate OR General Conservator of the Person Estate Person and Estate

9.The proposed conservatee has lacks capacity to give informed medical consent. Medical authority is not requested or there is prior court adjudication regarding lack of medical capacity.

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10.Probate Code section 2351.5 powers should be acted upon by the court as follows:

A.Fix the residence or specific dwelling of the proposed conservatee.
Grant Deny Modify:

B.Access to the confidential records and papers of the proposed conservatee.
Grant Deny Modify:

C.To consent or withhold consent to the marriage of, or the entrance into a registered domestic partnership
by, the limited conservatee.
Grant Deny Modify:

D.The right of the conservatee to contract.
Grant Deny Modify:

E.The right of the conservatee to give or withhold medical consent.
Grant Deny Modify:

F.The conservatee’s right to control his or her own social and sexual contacts and relationships.
Grant Deny Modify:
G.Decisions concerning the education of the proposed conservatee.
Grant Deny Modify:

Are not requested.

Comments:

11.Orders limiting the legal and civil rights of the conservatee should be: Granted as prayed. Modified as follows:

Denied without prejudice. Are not requested.

Comments:

12. Other Orders:

    Bond should be ordered in the amount of:

    Bond, accounts and payment of Court Investigator’s Assessments should be waived as long as the requirements of Probate Code sections 2323 and 2628 are satisfied.

    Specify other orders:

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ATTORNEY FEE REQUEST

I request the sum of as reasonable compensation for legal services rendered to the
conservatee (proposed) and the sum of for expenses incurred in representing the conservatee
(proposed) in this proceeding.

I have expended a total of hours which were billed at the rate of per hour. A detailed description
of the services rendered are set forth in Exhibit A, attached hereto. No detail is needed if compensation is for
less than 5 hours and payment will be made from the estate.

I waive compensation for legal services rendered to the conservatee (proposed) herein. (Initial)

The conservatee (proposed) has the ability to pay none a portion all of the fees and
expenses requested.

The fees should be ordered paid as follows:
from the estate of the conservatee
by Los Angeles County.

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

Dated: Signature: SIGN Print Name:

Updated 7/20/06

Case Name: Case Number: SCLAC PRO 076 Rev. 04/26 -7- For Mandatory Use Print This Form Clear This Form