CONFIDENTIAL ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address): TELEPHONE NO.: FAX NO. (Optional): E-MAIL ADDRESS (Optional): ATTORNEY FOR (Name): SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN BERNARDINO STREET ADDRESS: 216 Brookside AvenueMAILING ADDRESS: 216 Brookside AvenueCITY AND ZIP CODE: Redlands, CA 92373BRANCH NAME: Redlands District CONSERVATORSHIP OF THE PERSON ESTATE OF (Name): CONFIDENTIAL GENERAL CARE PLAN OF CONSERVATEE CASE NUMBER: All questions on this form must be completed and answered. If the question or blank does not apply, write 223not applicable224 or 223none224. If you need additional space to fully respond, please note on the form that a separate attachment is being provided and staple the attachment to the form. PERSONAL NEEDS Living Arrangements Current address of Conservatee: Phone: (Include name of facility if appropriate) Current living arrangement: Personal residence Home of relative Board & care home Assisted living Skilled nursing facility The Conservatee has been at the present residence since . If the Conservatee is in his/her personal residence, what is the current level of care? Household help Hours per weekNo assistance needed at this time.Personal caregivers Hours per week What will be necessary to keep the Conservatee in his/her residence? If the Conservatee is not living in his/her residence: What is the plan to return Conservatee to his/her personal residence? If there are no plans to return the Conservatee to his/her personal residence in the foreseeable future, explain the limitations or restrictions: Medical Information Confusion / DisorientationUnable to read / write Is in good healthIs developmentally disabledMemory lossDeaf or communication problemOther Name Purpose of Medication Name Purpose of Medication Pr.C.2472352.5 Local Form (Rev. 03/21/08) GENERAL CARE PLAN FOR CONSERVATEE CONFIDENTIAL 1 American LegalNet, Inc. www.FormsWorkFlow.com CONFIDENTIAL CONSERVATORSHIP OF (Name): CASE NUMBER: Pr.C.2472352.5 GENERAL CARE PLAN FOR CONSERVATEE Local Form (Rev. 4/1/08) CONFIDENTIAL2 Provider Name Phone number Last visit Physician Dentist Other (e.g. visiting nurse, case worker) Visitations How often do you visit the Conservatee? How often does the Conservatee receive visits from family and friends? Are any visitations particularly valued or upsetting to the Conservatee? Activities Describe the normal activities of Conservatee: Television / Radio Outings Social Educational Recreational Unwilling to participate Unable to participate Other (i.e. reading material) Special Problems Explain how you have addressed any special needs or problems raised by the Court Investigator, the Court, or other interested persons: FINANCIAL NEEDS Estimated Monthly Income Social Security$Income - other sources $Pension (type) $Dividends$Veterans Benefits$Rentals$Supplemental Security Income $Other$Estimated Interest from Investment $ TOTAL Estimated Monthly Income $ Estimated Monthly Expenses TAXES Currently aid? Next Due Date Estimated Monthly Payment PIncome Yes No $ Real Estate Yes No $ INSURANCE Company Premium Paid Coverage AmountEstimated Monthly Payment Homeowners Yes No $ Renters Yes No $ Automobile Yes No $ Workers Comp Yes No $ Health Yes No $ Life Yes No $ Other Yes No $ LIVING EXPENSES Rent or Mortgage $ Utilities $ Nursing Home or Telephone $ Board & Care Home $ Laundry and Cleaning $ Live-In Attendants $ Clothing $ Other Care Providers $ Entertainment / Recreation $ Medical and Transportation $ Dental Supplies $ Other $ Food $ TOTAL Estimated Monthly Expenses $ American LegalNet, Inc. www.FormsWorkFlow.com CONFIDENTIAL CONSERVATORSHIP OF (Name): CASE NUMBER: Pr.C.2472352.5 GENERAL CARE PLAN FOR CONSERVATEE Local Form (Rev. 4/1/08) CONFIDENTIAL3 If monthly expenses exceed monthly income, how do you plan to meet the shortfall a) for the present and b) for the long term? Describe any planned changes in investments to be made and/or any major assets that may be sold in the coming year and the reason for these changes and/or sales: Identify the contents of any safety deposit box. Are there any valuable assets in the conservatee222s residence that need to be protected? If so, describe them and specify what steps have been take to protect these items from loss or theft: Conservator believes it will be necessary to provide the following additional services to properly care for and maintain the personal and financial needs of the Conservatee: The undersigned conservator will: a.Carry out all mandatory duties of a conservator (refer to form GC-348);b.Maintain periodic contact with the conservatee222s family and friends, if applicable;c.Be available to the conservatee on a 24-hour basis for emergencies, or arrange forsuch coverage by a qualified agent; If appointed conservator of the estate d.Inventory all assets in which the conservatee has any interest;e.Render timely, accurate and complete accountings to the court;f.Maintain accurate records related to the estate;g.Maintain all estate assets in interest-bearing account, except as necessary foreveryday administration;h.Maintain an adequate surety bond as required by law; If appointed conservator of the person i.Maintain periodic contact with the conservatee222s physician and other health careproviders. j.Maintain conservatee in the least restrictive placement and, if moved, notice thecourt and interested parties. I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct, and that I have retained a copy of this case plan for my records. Date Attorney Date Conservator American LegalNet, Inc. www.FormsWorkFlow.com