San Francisco — General Plan for Personal and Financial Needs of Conservatee

Source: https://sf.courts.ca.gov/system/files/prb-pcn-002-general-plan_0.pdf

CONFIDENTIAL ATTORNEY OR PARTY WITHOUT ATTORNEY STATE BAR: FOR COURT USE ONLY NAME: FIRM NAME: STREET ADDRESS: CITY AND ZIP CODE: E-MAIL ADDRESS: ATTORNEY FOR (NAME):

SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN FRANCISCO STREET ADDRESS MAILING ADDRESS: 400 MCALLISTER STREET, ROOM 103 CITY AND ZIP CODE: SAN FRANCISCO, 94102 BRANCH NAME:

CONSERVATOR(S):

CONSERVATORSHIP OF:

☐ PERSON ☐ ESTATE ☐ LIMITED CONSERVATORSHIP
GENERAL PLAN FOR PERSONAL AND CASE NUMBER:
FINANCIAL NEEDS OF CONSERVATEE

All questions on the form must be completed and answered. If the question or blank does not apply, write “not applicable” or “none”. If you need additional space to fully respond, please note on the form that a separate attachment is being provided and staple the attachment to the form.

PERSONAL NEEDS

Living Arrangement

Current address of Conservatee Phone:

(include name of facility, if appropriate)

Current living arrangement ☐ Personal residence ☐ Home of relative ☐ Board and care home ☐ Assisted living ☐ Skilled nursing facility

The Conservatee has been at the present residence since

If the Conservatee is in his or her personal residence, what is the current level of care? ☐ No assistance needed at this time ☐ Household help Hours per week ☐ Personal caregivers Hours per week

What will be necessary to keep the Conservatee in his/her residence?

If the Conservatee is not living in his/her personal residence: What is the plan to return the Conservatee to his/her personal residence?

CONFIDENTIAL

GENERAL PLAN FOR PERSONAL AND FINANCIAL NEEDS OF CONSERVATEE

PRB-PCN-002 Rev. Jul-01-2020

CASE NAME: CASE NUMBER:

If there are no plans to return the Conservatee to his/her personal residence in the foreseeable future, explain the limitation or restrictions for not doing it.

Medications

Name Purpose of Medication Name Purpose of Medication

Visitations

How often do you visit the Conservatee?

How often does the Conservatee receive visits from family and friends?

Are any visitations particularly valued or upsetting to the Conservatee?

Activities

Describe the normal activities of Conservatee: ☐ Outings ☐ Television/Radio ☐ Social (i.e. Face Time/Skype/Zoom) ☐ Educational ☐ Recreational ☐ Unwilling to participate ☐ Unable to participate ☐ Other (i.e. reading material) Describe

Special Problems

Explain how you have addressed any special needs or problems raised by the Court Investigator, the Court, or other interested persons.

FINANCIAL NEEDS

Estimated Monthly Income

Social Security $ Estimated Income from Other Sources $ Pension (Type ) $ Dividends $ Veterans Benefits $ Rentals $ Supplemental Security Income $ Other $ Estimated Interest from Investment $ TOTAL Estimated Monthly Income $

CONFIDENTIAL

GENERAL PLAN FOR PERSONAL AND FINANCIAL NEEDS OF CONSERVATEE

PRB-PCN-002 Rev. Jul-01-2020

CASE NAME: CASE NUMBER:

Estimated Monthly Expenses

TAXES

Currently Paid? Next Due Dates Estimated Monthly
Amount

Income ☐ Yes ☐ No $ Real Estate ☐ Yes ☐ No $

INSURANCE

Company Premium Paid? Coverage Estimated Monthly
Amount Amount

Homeowners ☐ Yes ☐ No $ $ Renters ☐ Yes ☐ No $ $ Automobile ☐ Yes ☐ No $ $ Workers Comp ☐ Yes ☐ No $ $ Health ☐ Yes ☐ No $ $ Life ☐ Yes ☐ No $ $ Other ☐ Yes ☐ No $ $

LIVING EXPENSES

Rent or Mortgage $ Telephone $ Nursing Home or Board and Care Home $ Laundry and Cleaning $ Live-in Attendants $ Clothing $ Other Care Providers $ Entertainment and Recreation $ Medical and Dental Supplies $ Transportation $ Food $ Other $ Utilities $ TOTAL Estimated Monthly Expenses $

Describe any planned changes in investments to be made in the next year and the reason for any changes.

Identify any major asset that may be sold in the coming year and explain the reason for such sale.

Identify the contents of any safe deposit box.

Are there any valuable assets in the Conservatee’s residence that need to be protected? If so, describe them and specify what steps have been taken to protect these items from loss or theft.

Date: Date:

Attorney Conservator(s)

CONFIDENTIAL

GENERAL PLAN FOR PERSONAL AND FINANCIAL NEEDS OF CONSERVATEE

PRB-PCN-002 Rev. Jul-01-2020