Attorney or Party without attorney (Name and Address) Telephone No.: Attorney for: SUPERIOR COURT OF CALIFORNIA, COUNTY OF SHASTA MAILING ADDRESS: 1500 Court Street, Room 319 1500 Court Street, Room 319 STREET ADDRESS: CITY AND ZIP CODE: Redding, CA 96001 BRANCH NAME: IN THE MATTER OF Case Number: CONSERVATORSHIP CARE PLAN _________________, the Conservator of the person/estate of ____________________________ hereby submits the Conservator's General Plan in compliance with local court rules. 1. Conservatee's current residence address: a. Type of facility (i.e. home, skilled nursing, hospital, etc.) ___________________________ b. How long has the conservatee been in the present residence? ________________________ c. Do you anticipate making any changes in the Conservatee's residence in the next year? _____ No ____Yes (explain): ________________________________________________ _________________________________________________________________________ d. What is the plan to return the Conservatee to his/her personal residence if not now living at home? ___________________________________________________________________ _________________________________________________________________________ e. If there are no plans to return the Conservatee to his/her personal residence in the foreseeable future, explain the limitations or restrictions for not doing so: ______________ _________________________________________________________________________ _________________________________________________________________________ 2. Current level of care (mark all that apply): ___ requires total care ___ requires assistance with care ___ able to do own care ___ ambulatory ___ has feeding tube ___ has a catheter ___ uses wheelchair/walker ___ urinary/bowel incontinence Other relevant information: ___________________________________________________________ If residing in a facility or group home, attach a copy of the facility's care plan: __________________________________________________________________________________ If client of a regional center, identify regional center and social worker and telephone number: __________________________________________________________________________________ __________________________________________________________________________________ Form Approved for Mandatory Use Shasta County Superior Court LF-PRB-100 [rev July 1, 2012] CONSERVATORSHIP CARE PLAN Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com CONSERVATORSHIP OF (Name): CONSERVATEE CASE NUMBER: 3. Conservatee's physical and medical condition: _______________________________________ a. Please list health problems: __________________________________________________ _________________________________________________________________________ b. Are any other health providers involved? ___ No ___ Yes ___ visiting nurse ___ social worker ___ podiatrist ___ dentist ___ counselor ___ physical therapist ___ speech therapist ___ other (specify): _________________________________ c. Medications: ______________________________________________________________ d. Activities Conservatee is involved in? __________________________________________ 4. How often do you expect to visit the Conservatee? ________ Does the family visit? _________ 5. Are there plans to give the Conservator a rest? ___ respite care ___ adult day care ___other care takers ___ In Home Supportive Services (IHSS) Names & relationships of relief caregivers: ____________________________________________ 6. Conservatee's Estimated Monthly Income (complete even if a conservatorship of the person only): __________________________________________________________________________ 7. Conservatee's Estimated Monthly Expenses (complete even if a conservatorship of the person only): __________________________________________________________________________ a. LIVING EXPENSES Rent/Mortgage Nursing/Care Home Food Medical/Dental Transportation $ _________ $ _________ $ _________ $ _________ $ _________ Utilities In-Home Care Clothing Medications Entertainment $ _________ $ _________ $ _________ $ _________ $ _________ $ _________ Total Estimated Monthly Expenses: Form Approved for Mandatory Use Shasta County Superior Court LF-PRB-100 [rev July 1, 2012] CONSERVATORSHIP CARE PLAN Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com CONSERVATORSHIP OF (Name): CONSERVATEE CASE NUMBER: b. OTHER EXPENSES TAXES Current Income Tax $ ___________ Property $ ___________ Payroll $ ___________ c. INSURANCE Homeowner Renters Automobile Worker's Comp Health Life Coverage Amount $ ___________ $ ___________ $ ___________ $ ___________ $ ___________ $ ___________ Estimated Amount $ ______________ $ ______________ $ ______________ Estimated Premiums $ ______________ $ ______________ $ ______________ $ ______________ $ ______________ $ ______________ 8. What are the contents of any safety deposit boxes? ____________________________________ 9. Does the Conservatee receive Medi-Cal benefits? ___ No ___ Yes $_____ share of cost 10. Do you expect to sell any of the Conservatee's real or personal property in the next year? ___ No ___ Yes If yes, what will be sold and explain the reasons: _______________________________________ _______________________________________________________________________________ 11. Does the Conservatee own a home in which s/he does not live? __________________________ If so, is it rented? ______ Amount of rent: $ ______ If not rented, explain why: _________________________________________________________ _______________________________________________________________________________ 12. If the Conservatee's monthly expenses are greater than his/her income, explain how the shortfall will be met: ____________________________________________________________ _______________________________________________________________________________ 13. Does the Conservatee have a trust or is s/he a beneficiary of a trust and entitled to receive income from the trust? If so, please provide an attachment with the name of the trust, the name(s) of the trustee(s) and their contact information, and if applicable court case number for the trust: ___________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ Form Approved for Mandatory Use Shasta County Superior Court LF-PRB-100 [rev July 1, 2012] CONSERVATO