San Joaquin — Confidential Conservatorship Questionnaire

Source: https://www.sjcourts.org/sites/default/files/forms/2026-02/SJPR300-Confidential-Conservatorship-Questionnaire.pdf

FOR COURT USE ONLY In the Superior Court of the State of California In and for the County of San Joaquin

CONFIDENTIAL CONSERVATORSHIP QUESTIONNAIRE (DECLARATION BY PROPOSED CONSERVATOR(S))

SAN JOAQUIN COUNTY SUPERIOR COURT 315 W. ELM STREET LODI, CA 95240

CASE NAME: CASE NUMBER: Is an interpreter needed? ☐ Yes ☐ No If yes, for whom and in what language: Instructions to Petitioner(s) / Proposed Conservator(s): This questionnaire MUST be completed and failure to turn it in may result in delays. DO NOT leave any questions blank. State N/A if the question does not apply or “unknown” if you do not know the answer to a question. (If there is not enough room to complete your answer, attach a separate sheet of paper clearly identifying the question.) PETITION IS FOR: Person Only Limited Person Only Estate Only Person and Estate PETITIONER / PROPOSED CONSERVATOR Full Legal Name: Pronoun of Preference: he/him/his she/her/hers they/them/theirs Home Address: Home Phone: Cell Phone: E-mail Address: Relationship to Proposed Conservatee: ADDITIONAL PETITIONER / PROPOSED CONSERVATOR (If more than 2 Petitioners or Proposed Conservators add an attachment with information) Full Legal Name:

Pronoun of Preference: he/him/his she/her/hers they/them/theirs

Home Address: Home Phone: Cell Phone: E-mail Address: Relationship to Proposed Conservatee:

CONFIDENTIAL CONSERVATORSHIP QUESTIONNAIRE

Mandatory Page 1 of 4 SJPR-300 (Rev 07/2023) Local Rule 4-502

PROPOSED CONSERVATEE Full Legal Name: Date of Birth: Age: Pronoun of Preference: he/him/his she/her/hers they/them/theirs Does the Proposed Conservatee receive regional center services: Yes No If yes, what regional center: Case Manager: Telephone: Does the Proposed Conservatee attend school and/or a day program: Yes No If yes, name of school and/or day program: Address of school and/or day program: Teacher/Administrator: Telephone: PROPOSED CONSERVATEE’S ATTORNEY, if applicable: Name: Telephone: Address: (Street) (City, State, Zip Code) ADDITIONAL INFORMATION REGARDING PROPOSED CONSERVATEE Proposed conservatee currently resides at: Personal Residence Residential Care Facility Other: ________________________

Anyone living in the Conservatee's personal residence on probation, parole, or have a history of mental illness? Yes No

If yes, provide name of person and information:

Any firearms in the home? Yes No Any pets in the home? Yes No PROPOSED CONSERVATEE’S MEDICAL INFORMATION DOCTOR(S) (List Proposed Conservatee's primary care physician, treating physicians and specialists)

1. Name: Telephone: Address: (Street) (City, State, Zip Code)

Specialty, what the proposed conservatee is seen for:

2. Name: Telephone: Address: (Street) (City, State, Zip Code)

Specialty, what the proposed conservatee is seen for:

3. Name: Telephone: Address: (Street) (City, State, Zip Code)

Specialty, what the proposed conservatee is seen for:

MEDICATIONS PRESCRIBED Medication: Prescribed for what condition: Medication: Prescribed for what condition: Medication: Prescribed for what condition: Medication: Prescribed for what condition: Medication: Prescribed for what condition: Continued on attachment

CONFIDENTIAL CONSERVATORSHIP QUESTIONNAIRE

Mandatory Page 2 of 4 SJPR-300 (Rev 07/2023) Local Rule 4-502

RELATIVES OF THE PROPOSED CONSERVATEE Name: Deceased DOD: Father Telephone: Email:

Name: Deceased DOD:

Mother Telephone: Email: Sibling Name: Deceased DOD: brother sister Telephone: Email:

Name: Deceased DOD:

Sibling brother sister Telephone: Email:

Name: Deceased DOD:

Sibling brother sister Telephone: Email:

Name: Deceased DOD:Sibling

brother sister Telephone: Email:

Name: Deceased DOD:

Paternal Grandfather Telephone: Email:

Name: Deceased DOD:

Paternal Grandmother Telephone: Email:

Name: Deceased DOD:

Maternal Grandfather Telephone: Email:

Name: Deceased DOD:Maternal

Grandmother Telephone: Email:

Name: Deceased DOD: Spouse Domestic Partner Telephone: Email: Deceased Name: DOB: Child DOD: son daughter Telephone: Email: Deceased Name: DOB: Child DOD: son daughter Telephone: Email: Deceased Name: DOB: Child DOD: son daughter Telephone: Email: Deceased Name: DOB: Child DOD: son daughter Telephone: Email: Continued on attachment

CONFIDENTIAL CONSERVATORSHIP QUESTIONNAIRE

Mandatory Page 3 of 4 SJPR-300 (Rev 07/2023) Local Rule 4-502

OTHER RELATVES, NEIGHBORS, OR FRIENDS OF THE PROPOSED CONSERVATEE Relationship: Name: Telephone: Address (Street, City, State and Zip Code):

---

Relationship: Name: Telephone: _________________ Address (Street, City, State and Zip Code):

Relationship: Name: Telephone: _________________ Address (Street, City, State and Zip Code):

Relationship: Name: Telephone: _________________ Address (Street, City, State and Zip Code):

Relationship: Name: Telephone: _________________ Address (Street, City, State and Zip Code):

Relationship: Name: Telephone: _________________ Address (Street, City, State and Zip Code):

Relationship: Name: Telephone: _________________ Address (Street, City, State and Zip Code):

Relationship: Name: Telephone: _________________ Address (Street, City, State and Zip Code):

Continued on attachment

SIGNATURES

(Each Proposed Conservator must sign the acknowledgement under penalty of perjury.)

I declare under penalty of perjury under the laws of the State of California that all of the information I have submitted in this Conservatorship Questionnaire is true and correct. Date:

Type or print name Signature of Proposed Conservator

Date:

Type or print name Signature of Proposed Conservator

Note: If another person filled out this document for you, that person must also sign the acknowledgement under penalty of perjury.

Date:

Type or print name Signature

CONFIDENTIAL CONSERVATORSHIP QUESTIONNAIRE

Mandatory Page 4 of 4 SJPR-300 (Rev 07/2023) Local Rule 4-502