Marin — PR017

Source: https://www.marin.courts.ca.gov/system/files/pr017-conservatorshipgeneralplan1-14.pdf

MARIN COUNTY SUPERIOR COURT FOR COURT USE ONLY 3501 Civic Center Drive P.O. Box 4988 San Rafael, CA 94913-4988

CONSERVATORSHIP OF THE:

Person Estate of:

Conservatee
CASE NUMBER
CONSERVATORSHIP - GENERAL PLAN PR

The conservator(s) of the person/estate of ______________________________________________________, hereby submits the conservator's General Plan. I understand this General Plan must be filed with the court within 90 days after I am appointed as conservator and that I should retain a copy for my records.

Conservatee's Information:

Name: Date of Birth: Address:

Telephone:

Conservatee's Residence:

own home/apartment conservator's home/apartment
skilled nursing home board and care home
hospital (medical/psychiatric) other:

How long has the Conservatee been in the present residence?

Do you anticipate making any changes in the Conservatee's residence in the next year? Yes No If yes, please explain:

Are there any plans to return the Conservatee to his or her personal residence?
Yes No

Please note that the Court Investigator's Office must be notified of any change of address.

Current Level of Care:

requires total care urinary/bowel incontinence
requires assistance with care has a catheter
able to do own care uses wheelchair/walker
has feeding tube ambulatory

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CASE NO: PR

Other relevant information:

Conservatee's Physical and Medical Condition:

in good health has mental illness
confusion/disorientation substance abuse issues (alcohol, drugs)
memory loss is developmentally disabled
in poor health unable to read/write
had head injury deaf or communication problem
takes regular medications (describe):

Please list health problems:

How often does the Conservatee see a doctor? Doctor's name:

Is the Conservatee being administered psychotropic medications for the treatment of dementia?
Yes No
If yes, has the Court granted the Conservator “special dementia powers” as to medications?
Yes No

Is the Conservatee placed in a secured perimeter or locked facility with no freedom of egress?
Yes No
If yes, has the Court granted the Conservator “special dementia powers” as to placement?
Yes No

Did Conservatee express any end of life preferences in a California Advance Healthcare Directive/ Power of Attorney? Yes No If yes, what are the expressed wishes ?

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Are any other health providers involved? Yes No visiting nurse social worker hospice care worker dentist psychiatrist / counselor physical therapist podiatrist other: speech therapist

Personal Caregiver:

If the Conservatee has a personal caregiver, please state:

Is the care provider a family member(s)? Yes No
If yes, is the family member(s) paid? Yes No
Is the care provider employed by an agency? Yes No
If yes, what agency?
Is the care provider(s) a private hire? Yes No
If yes, who prepares the caregivers paychecks or payroll (wages, state & federal taxes, SDI, FICA, etc.)?

Does the conservatee receive IHSS benefits? Yes No If yes, how many hours a month? Who is the IHSS social worker?

Describe the normal activities of Conservatee:

outings day program
television employment
social unwilling to participate
educational unable to participate
other (i.e., reading material, etc.):

How often do you expect to visit the Conservatee?

Will other family or friends visit the Conservatee?

Are visitations from family or friends valued or upsetting?

Do you plan to request conservator fees at the end of the first year? Yes No If yes, anticipated amount of request? $

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Conservatee's Estimated Monthly Income (complete even if a conservatorship of the person only):

Social Security/SSI $

Veteran's Benefits $

Dividends $

Rental $

Interest $

Pension (source) $

Other (specify) $

Other (specify) $

Total Estimated Monthly Income $

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

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

Identify the contents of any safety 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.

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Conservatee's Estimated Monthly Expenses (complete even if a conservatorship of the person only):

Living Expenses:

Rent/Mortgage $ Medical/Dental $

Food $ Medications $

Utilities $ Nursing/Care Home $

Clothing $ In-Home Care $

Transportation $

Entertainment $

Other (specify) $

Total Estimated Monthly Expenses $

Other Expenses:

TAXES: Taxes Current? Estimated Amount

Income Tax Yes No $ Property Yes No $ Payroll Yes No $

INSURANCE: Company Coverage Amount Estimated Premium

Homeowner $ $ Renters $ $ Automobile $ $ Health $ $ Life $ $ Worker's Comp $ $ Long-Term Care $

Long-Term Care Benefits:

Do you expect to sell any of the Conservatee's real or personal property in the next year? Yes No If yes, please explain:

Does the conservatee own a home in which he/she does not live? Yes No If yes, is it rented? Yes No Amount of rent? $ If not rented, explain why:

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If the Conservatee's monthly expenses are greater than monthly income, explain how the shortfall will be met:

Does the Conservatee have a trust or is he/she entitled to receive income from a trust? Yes No If yes, please provide an attachment with the name of the trust, any court case number for the trust, the name(s) of the trustee(s) and their contact information.

Does the conservatee have a Representative Payee? Yes No If yes, name of payee?

Does the conservatee receive Medi-Cal benefits? Yes No What is the Medi-Cal share of cost? $

Do you anticipate any unusual activities related to the management of the Conservatee's estate during the next year? Yes No If yes, please explain:

What is the surety bond amount? $ Does the bond meet the requirements for cost of recovery to collect on the bond, including attorney’s fees and costs? Yes No

The undersigned Conservator will periodically review the Duties of Conservator Form GC-348 or consult with an attorney if needed.

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct, and that I have retained a copy of this case plan for my records.

DATE

PRINT NAME CONSERVATOR'S SIGNATURE

DATE

PRINT NAME CONSERVATOR'S SIGNATURE

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