EXHIBIT C CONFIDENTIAL: REFERRAL FOR INVESTIGATOR’S REPORT (Santa Clara County) A fee may be assessed for court investigator services: Prob. Code §1851.5 ATTORNEY OF RECORD: (Include ZIP and TEL.#) PROBATE #: HEARING: TEMP.: REGULAR: CONSERVATORSHIP OF _____ PERSON _____ ESTATE _____ LIMITED This referral is made pursuant to the following proceeding (check all that apply): _____ Appointment _____ Request for Medical Powers _____ Account Review _____ Request for Dementia Powers _____ Sale of residence or former residence _____ Other (Specify): RE: THE (PROPOSED) CONSERVATEE NAME: Date of Birth: Social Security #: Marital Status: Is the person under an LPS conservatorship? _____ If “yes”: LPS # __________ CURRENT ADDRESS & TEL. #: NOTE: You must inform the court in writing of any changes in the address of the conservatee (Prob. C §2352). HOME ADDRESS & TEL. #: RE: THE (PROPOSED) CONSERVATOR (Complete the information for each person) NAME: Relationship to conservatee: Date of Birth: Social Security #: Driver’s License #: HOME ADDRESS & TEL. #: WORK ADDRESS & TEL. #: ON THE BACK OF THIS PATE, EACH CONSERVATOR SHALL COMPLETE ALL OF THE FOLLOWING CONFIDENTIAL INFORMATION : (PROBATE CODE 2650). REFERRAL FOR INVESTIGATOR’S REPORT – Conservatorship 2001 © American LegalNet, Inc. EXHIBIT C 1. Have you ever been convicted of a misdemeanor or felony offense? _____ If yes: what offense(s) and what were the dates and in what county? 2. Is there a social worker, probation or parole officer supervising you or ANY member of the household shared by the conservatee? _____ If yes: explain the circumstances: I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Dated: Signed: Dated: Signed: NOTE: A fee may be assessed for court investigator services: see Probate Code §1851.5 2001 © American LegalNet, Inc.