ATTORNEY OR PARTY WITHOUT ATTORNEY (NAME, STATE BAR NUMBER AND ADDRESS) FOR COURT USE ONLY TELEPHONE NUMBER: FAX NO. (Optional): EMAIL ADDRESS (Optional): ATTORNEY FOR (Name): SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN LUIS OBISPO STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: 1035 Palm Street, Room 385 Same as above San Luis Obispo, CA 93408 San Luis Obispo Division LPS CONSERVATORSHIP OF: CASE NUMBER: LPS CONSERVATORSHIP LETTERS STATE OF CALIFORNIA, COUNTY OF SAN LUIS OBISPO Petitioner ______________________________(name), is hereby reappointed LPS conservator of the person of the above named LPS conservatee, with the rights and powers attendant to such office and all of the powers enumerated in section 5358 of the Welfare and Institutions Code. This appointment shall remain effective for 1 year, until ____________________(date), or unless otherwise ordered by the Court. The LPS conservator shall have the power to (mark all that are ordered): 1. The power to place, for the purpose of involuntary care and treatment, the conservatee in a medical, psychiatric, nursing or other state-licensed facility, or a state hospital, county hospital, hospital operated by the Regents of the University of California, United States Government Hospital, or other non-medical facility approved by the State Department of Mental Health or an agency accredited by the State Department of Mental Health; or, in cases of chronic alcoholism, in a county alcoholic treatment center, as provided in Welfare and Institutions Code §5358. The power to require the LPS conservatee to receive treatment related specifically to remedying or preventing the recurrence of the LPS conservatee's being gravely disabled. 2. Form Adopted for Optional Use San Luis Obispo Superior Court Local Form PR015 Rev. 1/1/15 LPS CONSERVATORSHIP LETTERS Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com LPS CONSERVATORSHIP OF: CASE NUMBER 3. The power to require the LPS conservatee to receive other medical treatment unrelated to remedying or preventing the recurrence of the LPS conservatee's being gravely disabled. Further, the LPS conservatee____________________________________(name) shall be prohibited from the following: 1. 2. 3. 4. Possess a license to operate a motor vehicle; To possess or carry firearms; To enter into contracts; To vote. I solemnly affirm that I will perform according to the laws and duties of LPS conservator of the person of the above named LPS conservatee. Executed on ________________________, San Luis Obispo, CA. ________________________ (LPS Conservator print name) _______________________ (LPS Conservator signature) *********************** WITNESS, SUSAN MATHERLY, Court Executive Officer of the above Court, with the seal of the Court affixed. Dated: _____________________________ FOR COURT USE By Order of the Court Susan Matherly Court Executive Officer By: ____________________ Deputy Clerk Form Adopted for Optional Use San Luis Obispo Superior Court Local Form PR015 Rev. 1/1/15 LPS CONSERVATORSHIP LETTERS Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com