THIS INFORMATION IS CONFIDENTIAL AND IS AVAILABLE ONLY TO THE Court CERTIFICATE OF REGISTRATION OF PRIVATE PROFESSIONAL CONSERVATOR (Section 2342 Probate Code) Name of Conservator: Date: Home Address: Home Phone Number: Business Address: Business Phone Number: Annual Statement: (Required to be filed for each year that you hold your designated Conservatorship.) Initial Statement 1. List educational background and professional experience. A. Educational Background: Name and Location of College or University Attended B. 2. Name Annual Statement Major Subject Dates Attended From - To Units Completed Semester Quarter List Degree Earned & Date of Graduation Professional Experience: List at least three professional references: Address Relationship PR-E-LP-017 (formerly Local Probate Form #44) Rev: 02/17/98 American LegalNet, Inc. www.FormsWorkflow.com 3. List the name of your current Conservatees: 4. List the aggregate dollar value of assets of conservatees currently under your supervision: 5. Have you as a Conservator ever been removed for cause as a Conservator, or have you resigned as a NO (Check appropriate box.) Conservator in a specific case? YES If yes to above, list the circumstances causing that removal or resignation, and the case names, Court locations and case numbers: 6. List case names, Court locations and case numbers of three closed Conservatorship cases in which you served as the Conservator. CASE NAME 7. COURT LOCATIONS CASE NUMBERS When I am no longer serving as a Private Professional Conservator, I will submit a “No Longer Interested Notification” form to the probate support clerk. I certify under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Executed on: ________________________, 19 _____, at _____________________________________________ (Date) (City and State) Signature: ___________________________________________________________________________________ FOR COUNTY CLERK USE 1. A Petition for Appointment of Private Professional Conservator was filed on _________________________, as Sacramento Superior Court case number _______________________________________. 2. A fingerprint card was made by the Department of Motor Vehicles and forwarded to the Department of Justice on _____________________________. 3. A background check has been requested to include a record of all arrests resulting in conviction and all arrests for which final deposition is pending. Date Requested: ____________________________ Date Received: _________________________ -2- American LegalNet, Inc. www.FormsWorkflow.com