The Honorable , Judge presiding this in Department 95A. The Court finds as follows: The petition for (re)appointment of a conservator for the above-named conservatee came on regularly for hearing on this day. All notices required by law have been given. Evidence in support of the petition has been produced and presented. The Court finds that the conservatee is gravely disabled due to a mental health disorderThe Court grants only those powers and imposes those disabilities that it has checked below. As to each checked power or disability, the Court finds that the evidence presented establishes that the power or disability is necessary to the care, custody, maintenance and protection of the conservatee. No additional power shall be granted nor disability imposed except upon a duly-noticed hearing in which the necessity and propriety of the power or disability is established. The conservatee will reside/be placed at: NOW, THEREFORE, IT IS ORDERED: Page 1 of 3 LASC MH 036 Rev 1/1 For Optional Use STATE BAR NO: STATE: ZIP CODE: FAX NO: ATTORNEY OR PARTY WITHOUT ATTORNEY: NAME: FIRM NAME: STREET ADDRESS: CITY: TELEPHON NO: EMAIL ADDRESS: ATTORNEY FOR (name): Reserved for Clerk222s File Stamp SUPERIOR COURT OF CALIFORNIA, COUNTY OF LOS ANGELES STREET ADDRESS: CITY AND ZIP CODE: BRANCH NAME: CONSERVATORSHIP OF (name): CONSERVATEE ORDER RE APPOINTING CONSERVATOR AMENDED Pursuant to Lanterman-Petris-Short Act (W.I.C. 5350 et seq.) CASE NUMBER: WARNING: THIS APPOINTMENT IS NOT EFFECTIVE UNTIL LETTERS HAVE ISSUED. 1.A. That is appointed re-appointed successor conservatorco-conservator of the PERSON. B.That is appointed re-appointed successor conservatorco-conservator of the ESTATE. The acts of the conservator since the termination are ratified and the appointment is retroactive to the date oftermination. 2.Letters of Conservatorship to issue upon posting of a BOND in the amount of $ . BOND Increased/ Decreased by $. 3.This Order shall terminate on . American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 3 LASC MH 036 Rev 1/1 For Optional Use CONSERVATORSHIP OF (name): CONSERVATEE CASE NUMBER: CONSERVATOR SHALL BE GIVEN THE FOLLOWING POWERS IN RESPECT TO THE CONSERVATEE 4. To place the conservatee in a private residence, psychiatric or non - psychiatric residential care facility, board and care, nursing or other State licensed facility whereat the conservatee has free access into or out of the premises. 5. To place the conservatee in a portion of a private acute care psychiatric hospital, State or County hospital operated by the Regents of the University of California or by the United States Government, where the conservatee has free access into or out o f the hospital. 6. To place the conservatee in a medical or psychiatric nursing facility or other State or County licensed facility, where the conservatee does not have free access into or out of the premises. Pending further order of the Court, this power shall terminate . 7. To place the conservatee in that portion of a State or County hospital facility or a hospital operated by the Regents of the University of California or by the United States Government or of a private acute care psychiatric hospital, where the conservatee does not have free access into or out of such hospital. Pending further order of the Court, this power shall terminate . 7a. The conservator is authorized to place the conservatee in any facility for the developmentally disable d. Power 7a imposed Yes No 8. To require the conservatee to have treatment related specifically to remedying or preventing the recurrence of his/her being gravely disabled. 8a. To require the conservatee to accept psychotropic medications. THE FOLLOWING DISABILITIES AND NO OTHERS ARE TO BE IMPOSED ON THE CONSERVATEE 9. The privilege of possessing a license to operate a motor vehicle. Disability 9 imposed Yes No 9a. The privilege of possessing, controlling or maintaining custody of a firearm or any other deadly weapon. Disability 9a imposed Yes No 10. The right to refuse or consent to treatment related specifically to the conservatee222s being gravely disabled. Disability 10 imposed Yes No 11. The right to enter into any contract in which the consideration for performance is money or property. Disability 11 imposed Yes No 11a. The right to vote. Disability 11a imposed Yes No 12. The right to refuse or consent to medical treatment necessary for that existing or continuing medical condition(s) unrelated to the conservatee222s being gravely disabled, set forth in the minute order of this date. The Court finds thatspecific evidence of such condition(s) has/have been presented which justify(ies) the impositions of this/thesedisability(ies) in respect to this/those condition(s). No treatment(s) or course(s) of treatment for such condition(s)shall be given unless the Court has authorized the treatment(s) pursuant to Welfare and Institutional Code, Section5358.2. Disability 12 imposed Yes No ANEMIA ASTHMA C.O.P.D DIABETES DISLIPIDEMIA GLAUCOMA G.E.R.D G - TUBE HEART DISEASE HEPATITIS HYPERTENSION HYPONATREMIA HYPERLIPIDEMIA HYPOTHYROIDISM HYPERCHOLESTEMIA KIDNEY DISEASE OSETO SEIZURE DISORDER OTHER American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 3 LASC MH 036 Rev 1/1 Fr Optional Use CONSERVATORSHIP OF (name): CONSERVATEE CASE NUMBER: 13a. WITHOUT PRIOR COURT APPROVAL: Payment with the conservatee222s estate income for support and maintenance but not to exceed $2000.00 per month; payment of debts incurred prior to and during conservatorship for necessities of life; to maintain the residence of the Conservatee including payment of mortgage, taxes and insurance; to dispose or abandon valueless personal property; to collect debts and other benefits owing to the Conservatee and to endorse and deposit checks and drafts; to establish checking and savings accounts in the name of the conservatorship; to hire an accountant to prepare and pay all taxes of the conservatee and an attorney for assisting in general legal matters. 13b. WITH PRIOR COURT APPROVAL: Conservator shall notice a hearing for confirmation and/or approval of the Court to institute and maintain all actions and other proceedings for the benefit of and to defend all actions and other proceedings against the conservatee; to contract in excess of $2000.00 of the conservatorship; to alter, improve and repair or rebuild conservatorship property; to sell, pledge mortgage, or transfer real or personal property of the conservatee; and to pay attorney, accountant and others employed by the conservator as well as conservator222s fees. THE CONSERVATOR OF THE ESTATE SHALL, within ninety (90) days of appointment, file with the Court an Inventory and Appraisal and mail a copy to the conservatee222s attorney. Next ACCOUNTING is DUE: . DATE JUDICIAL OFFICER American LegalNet, Inc. www.FormsWorkFlow.com