ATTORNEY OF RECORD: TO BE COMPLETED BY THE CONSERVATOR AND FILED THIRTY DAYS PRIOR TO THE GENERAL PLAN HEARING DATE. THE CONSERVATOR SHOULD RETAIN A COPY. A COPY OF THE PLAN AND INVENTORY AND APPRAISMENT MUST BE SENT TO THE COURT INVESTIGATORS OFFICE. SUPERIOR COURT OF CALIFORNIA COUNTY OF ALAMEDA Conservatorship of the [person/and/estate] of ) ) ) ) ) conservatee) Probate No. CONSERVATORSHIP GENERAL PLAN Date: Time: Department: _______________________________, the conservator(s) of the person/estate of _______________________________ hereby submits the conservator's General Plan in compliance with Local Court Rules. 1. Conservatee Information: Name: _____________________________________________________ Date of Birth: _______________________________________________ Social Security Number: ______________________________________ 2. Address: ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ Telephone: ____________________________________________________________ 3. Conservatee's residence: _____conservator's home/apartment _____board and care home ____own home/apartment ____skilled nursing home ____hospital (medical/psychiatric)_____other (specify)______________ 1 American LegalNet, Inc. www.FormsWorkflow.com 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? _____No _____Yes (explain)________________________________ Please note that the Court Investigator's Office must be notified of any change of address. 4. Current level of care: _____requires total care _____requires assistance with care _____able to do own care _____has feeding tube _____ambulatory _____uses wheelchair/walker _____urinary/bowel incontinence _____has a catheter Other relevant information____________________________________________ 5. Conservatee's physical and medical condition: _____in good health _____is developmentally disabled _____confusion/disorientation _____unable to read/write _____memory loss _____deaf or communication problem _____takes regular medications (describe)______________________________ Please list health problems____________________________________________ _________________________________________________________________ How often does the Conservatee see a doctor?____________________________ Doctor's name_____________________________________________________ Are any other health providers involved? ____No ____Yes _____visiting nurse ______social worker _____podiatrist ______dentist _____counselor ______physical therapist _____speech therapist ______other (specify)____________ 6. 7. How often do you expect to visit the Conservatee? _____________ Will other family or friends visit the Conservatee? ____ 8. Do you plan to request conservator fees at the end of the first year? ______No ______Yes (anticipated amount of request) $________________ Conservatee's Estimated Monthly Income (complete even if a conservatorship of the person only) Social Security/SSI $_______ Dividends $_________ Pension (source)________ $_______ Veteran's benefits $_______ Rental Interest $_________ $_________ $_________ $_________ American LegalNet, Inc. www.FormsWorkflow.com 9. Other (specify)__________________________ Total Estimated Monthly Income 2 10. Conservatee's Estimated Monthly Expenses (complete even if a conservatorship of the person only) LIVING EXPENSES Rent/Mortgage Nursing/Care Home Food Medical/Dental Transportation $_______ $_______ $_______ $_______ $_______ Utilities In-home care Clothing Medications Entertainment $________ $________ $________ $________ $________ $________ $________ Other (specify)_____________________________ Total Estimated Monthly Expenses 11. Other Expenses Current ___Yes ___Yes ___Yes Estimated Amount ___No $______________ ___No $______________ ___No $______________ TAXES Income Tax Property Payroll INSURANCE Homeowner Renters Automobile Worker's Comp Health Life Company Coverage Amount Estimated premium _________ $_________ $______________ _________ $_________ $______________ _________ $_________ $______________ _________ $_________ $______________ _________ $_________ $______________ _________ $_________ $______________ Does the Conservatee receive Medi-Cal benefits? _____No _____Yes $_________ share of cost 12. Do you expect to sell any of the Conservatee's real or personal property in the next year? _____No ______Yes If yes, explain why:___________________________________________ 13. Does the conservatee own a home in which he/she does not live? ____No ______Yes If Yes, is it rented? ____ Amount of rent: $____ If not rented explain why: _________________________ _______ 14. If the conservatee's monthly expenses are greater than monthly income, explain how the shortfall will be met: _________________________________________________________________ 15. Does the conservatee have a trust or is he/she entitled to receive income from a trust? _____If so, please provide an attachment with the name of the trust, any court case number for the trust, the name(s)of the trustee(s) 3 American LegalNet, Inc. www.FormsWorkflow.com and their contact information. 16. Do you anticipate any unusual activities related to the management of the conservatee's estate during the next year? _____No _____Yes (explain)_________________________________ ____________________________________________________________ The undersigned conservator will: a. b. c. d. Inventory all assets in which the conservatee has any interest; Render timely, accurate and complete accountings to the court; Carry out all mandatory usual and general duties of a conservator; Maintain periodic contract with the conservatee's physician and other health care providers, if appointed conservator of the person; e. Maintain periodic contract with the conservatee's family and friends, if applicable; f. Be available to the conservatee on a 24-hour basis for emergencies, or arrange for such coverage by a qualified agent; g. h. i. Maintain accurate records related to the estate; Maintain all estate assets in a separate identifiable manner; Maintain estate cash assets in interest-bearing accounts, except as necessary for everyday administration; j. k. l. Maintain an adequate surety bond as required by law. Update case plan as needed. Refer to the "Conservator's Handbook". I declare under penalty of p