Name, address and telephone number(s): FOR COURT USE ONLY MARIN COUNTY SUPERIOR COURT 3501 Civic Center Drive P.O. Box 4988 San Rafael, CA 94913-4988 GUARDIANSHIP FOR: CONSERVATORSHIP TRUST CASE NUMBER: FIDUCIARY FEE DECLARATION I, _______________________________________________, declare as follows: 1. I am the ______________________________________________ (identifying information). I have personal knowledge of the facts set forth in this declaration, and offer it in support of my request for payment of $_____________ to me as fees for services that I have provided (including time spent by declarant's assistants). This request is for the period beginning ________________ and ending ________________. I am also requesting approval of reimbursement for out-of-pocket expenses in the amount of $______________, of which $______________ has already been reimbursed. Rates for Services Charged. Declarant's normal billing rate is $__________ /hour. Declarant has staff that assists with services related to the conservator of the person and estate. Staff time is billed at $__________ /hour. Services provided by staff included: . 3. Summary of Time Categories / Fees. This declaration describes services provided by declarant (and any assistants). A total of _________ hours of services were provided, broken down as follows: Total Hours a. Conservator / guardian of the person by declarant: b. Conservator / guardian / trustee of the estate by declarant: c. Conservator / guardian of the person by assistant: d. Conservator / guardian / trustee of the estate by assistant: e. Travel time by declarant: f. Travel time by assistant: Hrs Hrs Hrs Hrs Hrs Hrs $ $ $ $ $ $ Hourly Rate $ $ $ $ $ $ Total Fees 2. TOTAL FEES: $ PR036 (Rev. 1/1/14) ATTORNEY FEE DECLARATION Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com GUARDIANSHIP FOR: CONSERVATORSHIP TRUST CASE NUMBER: 4. Summary of Services Provided. The services for which I am now seeking compensation are summarized as follows (provide attachment, if needed): a. Services prior to appointment: b. Initial petition: c. Temporary petition and powers: d. General administration (e.g., marshaling assets, preparation of the I&A, bill-paying, account reconciliation, investment decisions, accounting, fee declaration): e. Conservatee's personal care. Who is providing the care? Who is supervising the care? f. Change in residence: g. Conservatee's healthcare: h. Conservatee's family and friends: i. j. Contested or complex issues: Management of real property or business: k. Sale of residence: l. Substituted judgment / petition for instructions: m. Agents hired / disclosure of relationships (if the conservator provided a service directly rather than hiring an agent, discuss the basis for this decision): 5. Declarant's Travel Policy: PR036 (Rev. 1/1/14) ATTORNEY FEE DECLARATION Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com 6. Reimbursement of Out-of-Pocket Expenses: 7. Conclusion (include a discussion of the factors in California Rule of Court 7.756): I declare under penalty of perjury that the foregoing is true and correct and that this declaration was executed on _____________________ in _______________________________, California. DATE SIGNATURE PR036 (Rev. 1/1/14) ATTORNEY FEE DECLARATION Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com