NAME, ADDRESS, AND TELEPHONE NUMBER OF ATTORNEY OR PARTY WITHOUTATTORNEY:STATE BAR NUMBERReserved for Clerk222s File StampSUPERIOR COURT OF CALIFORNIA, COUNTY OF LOS ANGELESCOURTHOUSE ADDRESS:IN THE CONSERVATORSHIP OF: CASE NUMBER: 1.Has the proposed conservatee been diagnosed with ? Yes NoDiagnosis confirmed by: Capacity Declaration on file in this proceeding Review of medical records Discussions with medical staff at facility where proposed conservatee resides Discussions with proposed conservatee222s physician Other: 2.I have considered, to the extent practicable, whether I believe that the proposed conservatee suffers fromany of the mental deficits listed in subdivision(a) of Probate Code Section 811 that significantly impair theproposed conservatee222s ability to understand and appreciate the consequences of his/her action(s) inconnection with the proposed conservatee222s ability to: Provide properly for his or her personal needs for physical health, food, clothing or shelter. Able Unable Manage his or her own financial resources or resist fraud or undue influence. Able Unable3.Does the proposed conservatee currently reside in a locked skilled nursing facility which specializes in thecare and treatment of people with dementia pursuant to subdivision (c) of Section 1569.691 of the Healthand Safety Code and which has a care plan that meets the requirements of Section 87724 of Title 22 of theCalifornia Regulations? Yes NoIf yes, is this the least restrictive placement? Yes NoComments: 4.Is the proposed conservatee administered medications appropriate to the care of dementia? Yes No N/A (Cannot determine)Comments: I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.Dated: Signature: Print Name: American LegalNet, Inc. www.FormsWorkFlow.com