Santa Clara — PB-4015

Source: https://santaclara.courts.ca.gov/system/files/forms/pb-4015_rem.pdf

ATTACHMENT PB-4015 Conservatorship of the Person Estate of (Name) Case Number

Conservatee Proposed Conservatee

PROFESSIONAL DECLARANT'S ATTACHMENT TO FORM GC-335

ABILITY TO ENTER INTO FINANCIAL TRANSACTIONS

1. Based on the information on pages 1-3 of this declaration, it is my opinion that the (proposed) conservatee a. has the capacity to enter into financial transactions and should not have his or her right to enter into contracts terminated by the Court. b. lacks the capacity to enter into financial transactions because the mental deficits indicated above significantly impair the (proposed) conservatee’s ability to understand and appreciate the consequences of his or her actions such that the (proposed) conservatee lacks the capacity to understand and/or enter into any contracts or agreements regarding property. (If this paragraph applies, declarant shall initial here : .)

2. Additional Comments:

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

Date:

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 (TYPE OR PRINT NAME) (SIGNATURE OF DECLARANT)

————————————————————————————————————————————— CAPACITY DECLARATION—CONSERVATORSHIP OF THE ESTATE ATTACHMENT

PB-4015 REV. 7/04

Superior Court of California County of Santa Clara

Instructions to Counsel and Declarants for Completing GC-335,

GC-335A, and Conservatorship of Estate for Attachments PB-4015 and PB-4016

Attachments PB-4015 or PB-4016 shall be used where the petitioner is seeking conservator of the estate powers. Petitioners shall use Attachment PB-4015 when they request a medical or psychological professional to complete Judicial Council Form GC-335. Petitioners shall use Attachment PB-4016 for conservatorships of the estate when no orders regarding inability to attend the hearing, medical consent powers, or dementia powers are being sought and where petitioners wish to have a lay person complete a capacity declaration.

(1) For non-attendance of proposed conservatee at appointment hearing: Use page one
only of Form GC-335. Complete items 1-5. A lay person cannot complete form GC-335.

(2) To support a petition for appointment of conservator of estate:

When a medical or psychological professional is used as a declarant, the declarant must
complete pages one to three of GC-335 and attach the Conservatorship of the Estate
Attachment (Attachment PB-4015). The declarant should sign the declaration on page
three and should sign the Conservatorship of the Estate Attachment. Declarant must
initial on the line in item 1 of the Conservatorship of the Estate Attachment. Complete
items 1-4 and item 6 of form GC-335. If proposed conservatee is not to be excused from
attendance, leave item 5 blank.

When a lay person is used as a declarant, the declarant must complete pages one to
three of Attachment PB-4016. A lay person cannot complete form GC-335.

(3) To support a petition for appointment of conservator of person with medical powers; or
for a subsequent grant of medical powers to a conservator of the person: Use pages
one to three of Form GC-335. Declarant should sign the declaration on page three only.
Complete items 1-4 and 6 and 7. Declarant must initial on the line in item 7b. If
proposed conservatee is not to be excused from attendance, leave item 5 blank. A lay
person cannot complete form GC-335.

(4) To support a petition for grant of dementia powers pursuant to Probate Code Section
2356.5, either at time of initial appointment or for a subsequent grant of dementia
powers: Complete pages 1 through 3 of declaration GC-335 and complete GC335A.
Declarant should sign the declaration Form GC 335A only. Use items 1-4, 6, 7, and 9. If
the proposed conservatee is not to be excused from attendance, leave item 5 blank. A
lay person cannot complete form GC-335.

Please note the following restrictions in the law governing who is authorized to prepare the different portions of this declaration:

Instructions to Counsel and Declarants for Completing GC-335,

GC-335A, and Conservatorship of Estate for Attachments PB-4015 and PB-4016

PB-4015A REV 01/01/07 Page 1 of 2 PB-4016A

(1) Non-attendance at Hearing: May be executed only by a licensed medical practitioner, including a psychologist acting in the scope of his/her licensure, and including an accredited religious healing practitioner. (2) Establishment of Conservatorship of Estate: May be executed by anyone with knowledge of the circumstances of the proposed conservatee. A layperson cannot complete form GC-335 but can complete Local Form "Lay person's Declaration Re Legal Capacity," Attachment PB-4016.

(3) For grant of medical powers: May be executed by a licensed physician or a licensed
psychologist acting within the scope or his/her licensure.

(4) For grant of dementia powers under Probate Code Section 2356.5: May be executed by
a licensed physician or a licensed psychologist acting within the scope of his/her
licensure and who has at least two years experience in diagnosing dementia.

To the person preparing the Capacity Declaration form prior to sending it to declarant:

(1) Complete the box on page one that indicates for what purpose(s) you are having this
form completed and indicate in the space provided on page one, which pages of this
multipurpose declaration you are filing. If you are completing page one only, you should
not file pages two and three. If you are completing pages one to three only, you should
not file Form GC-335A.

(2) Judicial Council form GC-335 contains two declaration clauses, and GC-335A contains a
declaration clause. The Conservatorship of the Estate Attachment and the Lay Person's
Declaration re Legal Capacity also contain declaration clauses. Prior to sending it to
declarant, strike out the declaration clauses to be left blank. For example, if you are
seeking medical powers as well as a finding that the conservatee should be excused
because of medical inability from attending the hearing, strike out the declaration clause
on page one. If you are seeking dementia powers, strike out the declaration clauses on
pages one and three.

(3) Special instructions for Item 9, Form GC-335A: Declarant should refer to special mental
function deficits as noted in item 6, relevant to the need for secure placement or need for
administration of dementia medications, when completing item 9a1 and 9b1. Declarant
should describe specific medical or behavior problems in items 9a and 9b that secure
placement or administration of dementia medications will address.

Instructions to Counsel and Declarants for Completing GC-335,
GC-335A, and Conservatorship of Estate for Attachments PB-4015 and PB-4016

PB-4015A REV 01/01/07 Page 2 of 2 PB-4016A