ATTACHMENT PB-4016 ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar Number and Address): FOR COURT USE ONLY TELEPHONE NUMBER: ATTORNEY FOR: (name): FAX NUMBER: SUPERIOR COURT OF CALIFORNIA, COUNTY OF SANTA CLARA STREET ADDRESS: 191 North First Street 191 North First Street San José, CA 95113 PROBATE DIVISION MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: Conservatorship of the Person Estate of Conservatee Proposed Conservatee CASE NUMBER: LAYPERSON'S DECLARATION RE: LEGAL CAPACITY TO LAYPERSON DECLARANT The purpose of this form is to enable the court to determine whether the (proposed) conservatee has the capacity to enter into financial transactions GENERAL INFORMATION 1. 2. (Name): (Address and Telephone Number): 3. I am a layperson. I know the (proposed) conservatee in the following capacity (describe): 4. (Proposed) Conservatee: I last saw the proposed conservatee on (date): (Continued on next page) PB-4016 REV. 7/01/12 Prob C. §811, 812, 1872 LAYPERSON'S DECLARATION RE: LEGAL CAPACITY American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 3 ATTACHMENT PB-4016 Conservatorship of the Person Estate of (Name): Conservatee Proposed Conservatee Case Number: EVALUATION OF (PROPOSED) CONSERVATEE'S MENTAL FUNCTION. 5. Note to the Declarant: This form is not a rating scale. It is intended to assist you in recording your impressions of the (proposed) conservatee's mental abilities. Where appropriate, please feel free to refer to scores on standardized rating instruments. Instructions (Items A-C): Check the appropriate designation below: a = no apparent impairment; b = moderate impairment; c = major impairment; d = so impaired as to be incapable of being assessed; e = I have no opinion. A. Alertness and Attention (1) Levels of arousal. (Lethargic, responds only to vigorous and persistent stimulation, stupor.) a b c d e (2) Orientation. Encircle each type of orientation which is impaired: a b c d e Person b c d e Time [date, month, season, year] a a b c d e Place [address, town, state] b c d e Situation [why am I here?] a (3) Ability to attend and concentrate. (Give detailed answers from memory, mental ability required to thread a needle.) a b c d e B. Information Processing. Ability to: (1) Remember. (Ability to remember question before answering, to recall names, relatives, past presidents, events of past 24 hours.) i. Short-term memory: a b c d e ii. Long-term memory: a b c d e iii. Immediate recall: a b c d e (2) Understand and communicate either verbally or otherwise. (Deficits reflected by: inability to comprehend questions follow instructions, use words correctly or name objects; nonsense words.) a b c d e (3) Recognize familiar objects and persons. (Deficits reflected by: inability to recognize familiar faces, objects, etc.) a b c d e (4) Understand and appreciate quantities. (Perform simple calculations.) a b c d e (5) Reason using abstract concepts. (Grasp abstract aspects of his/her situation; interpret idiomatic expressions or proverbs. a b c d e (6) Plan, organize and carry out actions (assuming physical ability) in one's own rational self interest. (Break complex tasks down into simple steps and carry them out.) a b c d e (7) Reason logically. b c d e a C. Thought disorders. (1) Severely disorganized thinking. (Rambling thoughts, nonsensical, incoherent or non-linear thinking.) b c d e a (2) Hallucinations. (Auditory, visual, olfactory) b c d e a (3) Delusions. (Demonstrably false belief maintained without or against reason or evidence.) b c d e a (4) Uncontrollable or intrusive thoughts. (Unwanted compulsive thoughts, compulsive behavior.) b c d e a PB-4016 REV. 7/01/12 Prob C. §811, 812, 1872 LAYPERSON'S DECLARATION RE: LEGAL CAPACITY American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 3 ATTACHMENT PB-4016 Conservatorship of the Person Estate of (Name): Conservatee Proposed Conservatee Case Number: D. Ability to modulate mood and affect. The (proposed) conservatee has does NOT have a pervasive and persistent or recurrent emotional state that appears inappropriate in degree to his or her circumstances. (If so, complete remainder of 5D.) I have no opinion. Instructions: Rate the degree of impairment of each inappropriate mood state (if any) as follows: a = mildly inappropriate; Anger Anxiety Fear Panic a a a a b b b b c c c c b = moderately inappropriate; Euphoria Depression Hopelessness Despair a a a a b b b b c c c c c = severely inappropriate Helplessness Apathy Indifference a a a b b b c c c E. The (proposed) conservatee's periods of impairment from the deficits indicated in Items 5A ­ 5D do NOT vary substantially in frequency, severity, or duration. (1) do vary substantially in frequency, severity, or duration (explain): (2) F. (Optional) Other information regarding my evaluation of the (proposed) conservatee's mental function (e.g., particular observation, problems noticed): Stated in Attachment 5F. ABILITY TO ENTER INTO FINANCIAL TRANSACTIONS. Based on the information above, it is my opinion that the (proposed) conservatee a. has the capacity to enter into financial transactions and should not have his or her rights to enter into contracts terminated by the Court. b. lacks the capacity to enter into financial transactions because the mental deficits indicated above significantly impair the (proposed) conservatee's ability to understand and appreciate the consequences of his or her actions such that the (proposed) conservatee lacks the capacity to understand and/or enter into any contracts or agreements regarding property. (If this paragraph applies, declarant shall initial here: .) 6. I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date: ............................................................... (TYPE OR PRINT NAME) (SIGNATURE OF DECLARANT) PB-4016 REV. 7/01/12 Prob C. §811, 812, 1872 LAYPERSON'S DECLARATION RE: LEGAL CAPACITY American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 3