ANNUAL COMPLIANCE CERTIFICATION FOR APPOINTED COUNSEL PANEL LASC PRO 058 REV 1/19 Page 1 of 3 For Mandatory Use 1. Personal Information Name Last First Middle Address Firm Name Street/P.O. Box City State Zip Telephone: Office Cell Fax 2. State Bar Membership A. I am an active member of the California State Bar. My Bar number is . (Initials) B. As of the date of this Certification, I have no disciplinary proceedings pending with the California State Bar, and I have had no discipline imposed on me within the 12-month period immediately preceding that date. (Initials) C. If, at any time that I am a member of this panel and my status as a member of the State Bar changes, I agree to notify the Court, in writing, within 10 days of that change. (Initials) 3. Professional Liability Insurance A. I carry professional liability insurance with policy limits consistent with the values of the matters to be handled, at a minimum amount of $100,000 per claim and $300,000 per year. (Initials) B. As of the date of this Certification, I have no disciplinary proceedings pending with the California State Bar, and I have had no discipline imposed on me within the 12-month period immediately preceding that date. (Initials) C. Proof of policy attached. (Initials) NAME, ADDRESS, AND TELEPHONE NUMBER OF ATTORNEY OR PARTY WITHOUT ATTORNEY E-MAIL ADDRESS: FOR COURT USE ONLY SUPERIOR COURT OF CALIFORNIA, COUNTY OF LOS ANGELES BRANCH NAME: Stanley Mosk Courthouse STREET ADDRESS: 111 N. Hill Street CITY AND ZIP CODE: Los Angeles, CA 90012-3014 PROBATE ANNUAL COMPLIANCE CERTIFICATION FOR APPOINTED COUNSEL PANEL CONFIDENTIAL 226 FOR COURT USE ONLY American LegalNet, Inc. www.FormsWorkFlow.com ANNUAL COMPLIANCE CERTIFICATION FOR APPOINTED COUNSEL PANEL LASC PRO 058 REV 1/19 Page 2 of 3 For Mandatory Use 4. California Rules of Court The California Rules of Court establish qualifications for attorneys accepting appointments in conservatorship and guardianship cases A. I am qualified to accept appointments by the Court to represent conservatees or proposed conservatees under Probate Code 247247 1470 and 1471. Pursuant to Rule 7.1101(b)(2) of the California Rules of Court, I have filed or am filing herewith mandatory Judicial Council form GC-010, Certification of Attorney Concerning Qualifications for Court Appointment in Conservatorships and Guardianships. (Initials) B. I am qualified to accept appointments by the Court to represent wards or proposed wards under Probate Code 247 1470. Pursuant to Rule 7.1101(b)(1) of the California Rules of Court, I have filed or am filing herewith mandatory Judicial Council form GC-010, Certification of Attorney Concerning Qualifications for Court Appointment in Conservatorships and Guardianships. (Initials) C. Proof of compliance with educational requirements is attached. (Initials) 5. Los Angeles Superior Court A. Check one: I have completed the mandatory appointed counsel training program. I have NOT completed the mandatory appointed counsel training program. (Initials) B. I have completed at least 12 hours of MCLE during my State Bar reporting period in the areas of decedents222 estates, conservatorships, guardianships, or trust administration (Initials) C. My specific areas of interest during this compliance period are (check all that apply): Decedents222 estates and trust administration Conservatorships and guardianships of the estate * Guardianships of the person (minor222s counsel 226 custody only) * Conservatorships of the person * Limited conservatorship for developmentally disabled adults * Completion date of last Limited Conservatorship Program: Capacity determinations and health care decisions for adult without Conservators (Probate Code 247 3200) Estate planning and taxation Medi-Cal planning (Probate Code 2473100 and 2473600) Compromises / Judgments, special needs trusts, minors222 trusts (probate) Compromises / Judgments, special needs trusts, minors222 trusts (civil) Tuberculosis detention proceedings Fiduciary appointments Guardian ad litem Completion of last Guardian ad litem Program: 10 years of practice? Yes or No If so, give specific court information, type of case served as GAL; fiduciary case name; case number; and date: LASC Probate cases LASC Civil Cases Evidence Code 247 730 experts / referees / special masters Other (specify): *Attorneys accepting appointments as counsel in conservatorships and guardianship proceedings must meet the qualifications and continuing education requirements set forth in California Rules of Court Rule 7.1101. D. I certify that I meet the requirements specified in Los Angeles Superior Court Rules, Rule 4.124, for each area of interest marked above. (Initials) American LegalNet, Inc. www.FormsWorkFlow.com ANNUAL COMPLIANCE CERTIFICATION FOR APPOINTED COUNSEL PANEL LASC PRO 058 REV 1/19 Page 3 of 3 For Mandatory Use E. I speak the following language(s) (other than English) and may accept appointments requiring the translation/communication skills of language(s): 6. District Appointments I am willing to accept appointments in the following Los Angeles Superior Court districts: Central (Los Angeles) North (Antelope Valley) 7. Private Professional Fiduciary Representation I am or have been the attorney of record for the following private professional fiduciaries: Firm Name Estimated Number of Cases Firm Name Estimated Number of Cases Firm Name Estimated Number of Cases 8. Compensation Attorney Compensation in Los Angeles Superior Court Proceedings I have reviewed and agreed to be bound by the terms of Los Angeles Superior Court General Order Re: Probate Appointed Counsel Panel Appointments dated January 11, 2019, concerning the court222s policies of accepting (or continuing) any appointed counsel appointments to represent proposed conservatees, conservatees, proposed wards or wards or any other individual in Los Angeles Superior Court Proceedings. (Initials) Compensation for services as fiduciaries, guardians ad litem (including appointments in Central District U.S. Federal District Court cases), and Evidence Code 730 experts will be determined on a case-by-case basis. By accepting such appointments, I agree that, except in cases involving unusual problems requiring extraordinary expertise, the hourly rates shall not exceed $250.00. (Initials) 9. Conflicts I understand that I may not represent any other party in cases in which I have been appointed as counsel, or in cases that are related to cases in which I was appointed as counsel (for example, representation of an executor after the death of a conservatee whom I was appointed to represent). (Initials) 10. Appointments within the Court222s Discretion I understand that submission of an Attorney Application for Appointment to Probate Appointed Counsel Panel and/or Annual Compliance Certification for Probate Appointed Counsel Panel Attorneys does not guarantee entitlement to appointments as counsel and acknowledge that all appointments of court appointed counsel are entirely within the discretion of the Los Angeles Superior Court. (Initials) I declare under penalty of perjury under the laws of California that the foregoing is true and correct. Date Signature American LegalNet, Inc. www.FormsWorkFlow.com