MARIN COUNTY SUPERIOR COURT 3501 Civic Center Drive P.O. Box 4988 San Rafael, CA 94913-4988 FOR COURT USE ONLY CONSERVATORSHIP OF THE: Person Estate of: Conservatee CASE NUMBER CONSERVATORSHIP - GENERAL PLAN PR The conservator(s) of the person/estate of ______________________________________________________, hereby submits the conservator's General Plan. I understand this General Plan must be filed with the court within 90 days after I am appointed as conservator and that I should retain a copy for my records. Conservatee's Information: Name: Date of Birth: Address: Telephone: Conservatee's Residence: own home/apartment skilled nursing home hospital (medical/psychiatric) conservator's home/apartment board and care home other: 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? Yes No If yes, please explain: Are there any plans to return the Conservatee to his or her personal residence? Yes No Please note that the Court Investigator's Office must be notified of any change of address. Current Level of Care: requires total care requires assistance with care able to do own care has feeding tube urinary/bowel incontinence has a catheter uses wheelchair/walker ambulatory CONFIDENTIAL CONSERVATORSHIP ­ GENERAL PLAN American LegalNet, Inc. www.FormsWorkFlow.com PR017 (Rev. 1/15/14) Page 1 of 6 CASE NO: PR Other relevant information: Conservatee's Physical and Medical Condition: in good health confusion/disorientation memory loss in poor health had head injury takes regular medications (describe): has mental illness substance abuse issues (alcohol, drugs) is developmentally disabled unable to read/write deaf or communication problem Please list health problems: How often does the Conservatee see a doctor? Doctor's name: Is the Conservatee being administered psychotropic medications for the treatment of dementia? Yes No If yes, has the Court granted the Conservator "special dementia powers" as to medications? Yes No Is the Conservatee placed in a secured perimeter or locked facility with no freedom of egress? Yes No If yes, has the Court granted the Conservator "special dementia powers" as to placement? Yes No Did Conservatee express any end of life preferences in a California Advance Healthcare Directive/ Power of Attorney? Yes No If yes, what are the expressed wishes ? PR017 (Rev. 1/15/14) CONFIDENTIAL CONSERVATORSHIP ­ GENERAL PLAN Page 2 of 6 American LegalNet, Inc. www.FormsWorkFlow.com CASE NO: PR Are any other health providers involved? visiting nurse hospice care worker psychiatrist / counselor podiatrist speech therapist Personal Caregiver: If the Conservatee has a personal caregiver, please state: Is the care provider a family member(s)? Yes No If yes, is the family member(s) paid? Yes No Is the care provider employed by an agency? Yes No If yes, what agency? Is the care provider(s) a private hire? Yes No If yes, who prepares the caregivers paychecks or payroll (wages, state & federal taxes, SDI, FICA, etc.)? social worker dentist physical therapist other: Yes No Does the conservatee receive IHSS benefits? If yes, how many hours a month? Who is the IHSS social worker? Describe the normal activities of Conservatee: outings television social educational other (i.e., reading material, etc.): day program employment unwilling to participate unable to participate Yes No How often do you expect to visit the Conservatee? Will other family or friends visit the Conservatee? Are visitations from family or friends valued or upsetting? Do you plan to request conservator fees at the end of the first year? If yes, anticipated amount of request? $ Yes No PR017 (Rev. 1/15/14) CONFIDENTIAL CONSERVATORSHIP ­ GENERAL PLAN Page 3 of 6 American LegalNet, Inc. www.FormsWorkFlow.com CASE NO: PR Conservatee's Estimated Monthly Income (complete even if a conservatorship of the person only): Social Security/SSI Veteran's Benefits Dividends Rental Interest Pension (source) Other (specify) Other (specify) Total Estimated Monthly Income $ $ $ $ $ $ $ $ $ Describe any planned changes in investments to be made in the next year and the reason for any change. Identify any major asset that may be sold in the coming year and explain the reason for such sale. Identify the contents of any safety deposit box. Are there any valuable assets in the conservatee's residence that need to be protected? If so, describe them and specify what steps have been taken to protect these items from loss or theft. PR017 (Rev. 1/15/14) CONFIDENTIAL CONSERVATORSHIP ­ GENERAL PLAN Page 4 of 6 American LegalNet, Inc. www.FormsWorkFlow.com CASE NO: PR Conservatee's Estimated Monthly Expenses (complete even if a conservatorship of the person only): Living Expenses: Rent/Mortgage Food Utilities Clothing Transportation Entertainment Other (specify) Total Estimated Monthly Expenses Other Expenses: TAXES: Income Tax Property Payroll INSURANCE: Homeowner Renters Automobile Health Life Worker's Comp Long-Term Care Long-Term Care Benefits: Taxes Current? Yes Yes Yes Company $ $ $ $ $ $ No No No Coverage Amount $ $ $ $ $ $ $ $ $ $ Estimated Premium Estimated Amount $ $ $ $ $ $ $ $ Medical/Dental Medications Nursing/Care Home In-Home Care $ $ $ $ Do you expect to sell any of the Conservatee's real or personal property in the next year? Yes No If yes, please explain: Does the conservatee own a home in which he/she does not live? Yes No If yes, is it rented? Yes No Amount of rent? $ If not rented, explain why: PR017 (Rev. 1/15/14) CONFIDENTIAL CONSERVATORSHIP ­ GENERAL PLAN Page 5 of 6 American LegalNet, Inc. www.FormsWorkFlow.com CASE NO: PR If the Conservatee's monthly expenses are greater than monthly income, explain how the shortfall will be met: Does the Conservatee have a trust or is he/she entitled to receive income from a trust? Yes No If yes, please provide an attachment with the name of the trust, any court case number for the trust, the name(s) of the trustee(s) and their contact information. Does the conservatee have a Representative Payee? If yes, name of payee? Does the conservatee receive Medi-Cal benefits? What is the Medi-Cal share of cost? Yes No Yes $ No Do you anticipate any unusual activities related to the management of the Conservatee's estate during the next year? Yes No If yes, please explain: What is the surety bond amount? $ Does the bond meet the requirements for cost of recovery to collect on the bond, including attorney's f