COURT UNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...... .. : : : Index No. Calendar No. PLEASE FILL OUT THIS QUESTIONNAIRE AND RETURN TO THE FOLLOWING ADDRESS: JUDICIAL Plaintiff(s) STANISLAUS COUNTY SUPERIOR COURT INVESTIGATOR'S OFFICE P. O. BOX 3488/800 11TH STREET RM 221 : MODESTO, -againstCA 95353 CONSERVATORSHIP QUESTIONNAIRE CONSERVATEE SUBPOENA : : CASE NUMBER ___________________ Defendant(s) : . . . .NAME:. .___________________________________________________ .... ......................................... AGE: _______ DOB: _______________ ADDRESS: ____________________________________________________________________________________ OWN OR RENT? _________________ MONTHLY MORTGAGE PAYMENT OR RENT _____________________ E PEOPLE OF THE STATE OF NEW YORK TELEPHONE # ____________ BIRTHPLACE_____________________ CARE GIVER/BOARD & CARE/FACILITY NAME:______________________________ PHYSICIAN:_______________________ SSAN#:___________________ IS THE CONSERVATEE A CLIENT OF VMRC, OTHER REGIONAL CENTER? IF YES, PLEASE GIVE THE NAME OF THE CENTER, CASE MANAGER, ADDRESS, TELEPHONE #, ATTENDANCE SCHEDULE ETC. _____________________________________________________________________________________________ _____________________________________________________________________________________________ EETINGS: _____________________________________________________________________________________________ IS THE CONSERVATEE ATTENDING ANY OTHER SCHOOL, WORK aside, you and each ofIF YES, PLEASE GIVE THE NAME OF WE COMMAND YOU, that all business and excuses being laid OR DAY PROGRAM? you attend before THE CENTER, CASE MANAGER, ADDRESS TELEPHONE #, ATTENDANCE SCHEDULE, ETC. , Honorable at the Court _____________________________________________________________________________________________ located at nty _____________________________________________________________________________________________ of _____________________________________________________________________________________________ oom , on the day of , 20 , at o'clock in the noon, and at any recessed SOURCE(S) OF the CONSERVATEE'S MONTHLY INCOME: djourned date, to testify and give evidence as a witness in this action on the part ofINCOME: ________________________ CHECKING ACCT. BAL: SAVINGS ACCT. BAL.: _________________________ OTHER ASSETS (BURIAL PLAN/TRUST, PLOT, ETC.): _______________________________________________ Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a CONSERVATOR(S): lt of your failure to comply. NAME: AGE: DOB: _____________ Witness, Honorable , one of the Justices of the rt in County, day of , 20 ADDRESS: __________________________________________________________________________________ HOME TELEPHONE: WORK TELEPHONE: EMPLOYER:___________________________________________ (Attorney must sign above and type name below) ADDRESS: ___________________________________________ HAVE YOU EVER BEEN CONVICTED OF A FELONY? _____ IF YES, PROVIDE DATE, COUNTY & DETAILS. _____________________________________________________________________________________________ Attorney(s) for _____________________________________________________________________________________________ HAVE YOU EVER FILED FOR BANKRUPTCY? _____ IF YES, PROVIDE DATE, & DETAILS. I declare under the penalty of perjury the foregoing is true and correct. Office and P.O. Address DATED:_____________________ By __________________________________________ Conservator PLEASE ADD ANY ADDITIONAL INFORMATION YOU MAY FEEL IS PERTINENT. THANK YOU FOR YOUR ASSISTANCE. (Telephone Telephone No.: calls to the Court Investigator's Office will be accepted between 10 a.m. and 3 p.m. at (209) 525-4433) Facsimile No.: E-Mail Address: Mobile Tel. No.: CON02 American LegalNet, Inc. www.USCourtForms.com Rev 06/04