THIS FORM MUST BE KEPT CONFIDENTIAL ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, state bar number, and address): TELEPHONE AND FAX NOS: FOR COURT USE ONLY ATTORNEY FOR (Name): SUPERIOR COURT OF CALIFORNIA, COUNTY OF CONTRA COSTA STREET ADDRESS: 725 COURT STREET MAILING ADDRESS: P.O. BOX 911 CITY AND ZIP: MARTINEZ, CA 94553 Guardianship Conservatorship of (Name): Proposed Minor Conservatee CASE NUMBER: APPLICATION AND ORDER FOR DEFERRAL OF COURT INVESTIGATION ASSESSMENT 1. PETITIONER (Name): ____________________________________________________________________________________ requests a court order deferring payment of assessment required by Probate Code 1513.1 or 1851.5. My address and date of birth are (specify): Address: ____________________________________________________________ Birthdate: ______________________ _____________________________________________________________ 2. Check applicable box: The Ward The Proposed Ward The Conservatee is receiving financial assistance under one or more of the following programs: The Proposed Conservatee a. AFDC: The Aid to Families with Dependant Children Program c. 3. SSI/SSP: The Supplemental Security Income and State Supplemental Payments Programs b. Food Stamps: The Food Stamps Program d. County Relief, General Relief (G.R.) or General Assistance (G.A.) (If you completed Item 2, sign your name at Item 7 and DO NOT fill out the rest of this form.) Payment of the assessment would create a personal hardship for petitioner. If you checked this box you must complete Item 5 and DO NOT complete Item 4. 4. For Conservatorship cases only. Payment of the assessment would create a hardship for the estate. If you checked this box you must complete Item 6. 5. My pay changes considerably from month to month. (If you check this box, each of the amounts reported in Item 5 should be your average for the past 12 months.) a. Gross monthly pay $ b. Total payroll deduction amount $ c. Monthly take-home pay (a. minus b.) $_________________ d. Other income I get each month (Specify source and amount) 1. __________________________ $ _________________ 2. __________________________ $ _________________ Total other income (d1. plus d2.) $_________________ $ _________________ e. Total monthly income (c. plus d.) f. The number of people in my family, including me, supported by this money is: _____________________________________ $ _________________ g. Total monthly expenses h. I own the following: Cash $ __________ Checking, savings and credit union accounts (list banks) 1. __________________________ $ _________________ 2. __________________________ $ _________________ 3. __________________________ $ _________________ Cars, other vehicles, boats (list make, model and value) 1. __________________________ $ _________________ 2. __________________________ $ _________________ Real estate equity $ _________________ Other personal property—jewelry, furniture, furs, stocks, bonds, etc. (list separately) $ _________________ $ _________________ Total assets (total of all items listed under h.) GC-06/10-25-00 CONFIDENTIAL Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com i. Other facts which support this application are (describe unusual medical needs, expenses for recent family emergencies, or other unusual expenses to help the judge understand your budget). If more space is needed, attach page labeled “Attachment 5.” ___________________________________________________________________________________________________ 6. Estimated value of the property of the estate: a. Personal Property b. Annual gross income from 1. Real property 2. Personal property $ _________________ $ _________________ $ _________________ 7. I understand that this fee is subject to reconsideration after the investigation and I may be required to pay all or a portion of the investigation fee. 8. I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Dated: ________________________________ _________________________________________________________ (Signature) _________________________________________________________ (Type or print name) ORDER It is ordered that the above Application for Deferral of Court Investigation Assessment is: Granted subject to reconsideration after the investigation Dated: _____________________________ GC-06/10-25-00 Denied _______________________________________________________ Judge of the Superior Court CONFIDENTIAL Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com