1 FCS-402-2016-M Mandatory Form July 2016 Attorney for/Acting In Pro Per SUPERIOR COURT OF THE STATE OF CALIFORNIA IN AND FOR THE COUNTY OF TULARE ) Conservatorship of: ) ) ) (Conservatee) ) CONSERVATORSHIP QUESTIONNAIRE ) ) (Case number) ) ) Because you may be making medical, financial, and life decisions for the proposed Conservatee, the Court, prior to granting Conservatorship powers, would like to determine the stability, experience, and decision-making ability of the proposed Conservator(s). For each person petitioning the Court for conservatorship, please complete the following questionnaire. If you at (559) 733-6052. Residence: Do you RentLeaseOwnyour residence? Years lived at this address Do you plan to remain in the residence? YesNo List residences for the three previous years Is your residence provided by your employer? Value of donated housing per month Is your residence a Mobile Home? Apartment? House? Other? If other, please explain Is your residence in a rural setting? Residential neighborhood? Mobile home park? Apartment complex? Other? If other, please explain How much is your rent/mortgage payment per month? To whom are payments made?(Name) (Address) If you are buying your home, provide the following information: American LegalNet, Inc. www.FormsWorkFlow.com 2 FCS-402-2016-M Mandatory Form July 2016 Purchase price Current estimated market value Balance owed Lending Institution(Name) (Address) What are your monthly utility bills? Gas Propane Electricity Telephone(home) Sewer/Water (cell/pager) Garbage (other) Have you ever been served with a Three Day Notice to Pay Rent or Quit Possession of Real Property pursuant to an oral or written agreement for the rental of residential real property? If so, provide the date and the name and address of the lessor or landlord. Income: Monthly income from employment Monthly income from commissions Do you have checking accounts? Yes No Please list the balance of each account separately. Do you have savings accounts? Yes No Please list the balance of each account separately. Monthly income from investments Name and address of investment broker Monthly income from other sources: Sources of income Amount Monthly income from public assistanceSocial Security Disability payments Monthly/annual income from insurance settlement(s) Debts: Describe all long term debt other than mortgage listed above (include second, third, and fourth mortgages, vehicles, business property, rental property, etc.) List all short term debt including each credit card debt, debt to private parties or family members, etc. (do not include bankruptcy debt) American LegalNet, Inc. www.FormsWorkFlow.com 3 FCS-402-2016-M Mandatory Form July 2016 Have you have ever filed for bankruptcy? Yes No Please provide the following information for each time Type of petition Date filed Court in which filed Outcome Date debts discharged Have you ever been sued? Yes No Please explain Have you ever sued another person or entity, individually or on behalf of an entity? YesNo Please explain Employment: Length of employment (List your previous employers for the last 5 years) 1. NameTelephone Address Job description Date began Date left Reason for leaving 2. NameTelephone Address Job description Date began Date left Reason for leaving American LegalNet, Inc. www.FormsWorkFlow.com 4 FCS-402-2016-M Mandatory Form July 2016 3. NameTelephone Address Job description Date began Date left Reason for leaving Education: Highest level completed Age left school Reason for leaving Last school attended Last year attended Degree(s) achieved Health: Do you have health insurance? Yes No Name of company and type of coverage Dental Vision Health Status: Good Fair Poor Fair or poor, please explain Are you taking any medication, prescription or over-the-counter? Yes No If yes, list types and for what reasons List any special health problems Have you ever had a problem with any of the following: Drugs: Prescription or Illegal Alcohol Mental/Emotional problems Please explain Vehicles: For each vehicle you own provide the make, model, year, and license number, as well as the name(s) on the registration. MakeModelYearLicense Number 1. 2. 3. 4. For each vehicle you own, list the whether or not insured and the amount of public liability coverage. Make/YearInsured or notType/Amount of coverage 1. 2. 3. 4. American LegalNet, Inc. www.FormsWorkFlow.com 5 FCS-402-2016-M Mandatory Form July 2016 Expiration Date Criminal History: Have you ever been arrested or had charges filed against you for any crime other than a traffic infraction? (This question must be answered even if you were only arrested and not convicted, or if convicted, the charges were thereafter dismissed and the record ordered sealed.) YesNo Please indicate the reason for arrests, charges, years, county, and state. Have you ever been arrested for driving under the influence of alcohol or a controlled substance? Yes No If so, please indicate date(s), year, county, and state Have you ever been tried for any crime in any court? Please indicate the crime, year, county, and state.If so, please explain Have you ever been convicted, pled guilty or pled no contest to a crime other than a traffic infraction? Indicate the type of conviction, year, county, and state. If so, please explain What was the sentence? Was the sentence completed? Yes No Release date Are you currently or have you ever been on probation or parole? Yes No If so, please explain Name of Probation or Parole Officer Telephone No. Are you the plaintiff or defendant in any current or pending criminal or civil matter? YesNo If so please Have you ever applied for a domestic violence restraining order or had one issued against you? Yes No If so, please explain Have you ever been the victim or perpetrator of physical, verbal, emotional, psychological, or sexual abuse? Yes No If so, Please explain American LegalNet, Inc. www.FormsWorkFlow.com 6 FCS-402-2016-M Mandatory Form July 2016 Household Composition: Please list the names and telephone numbers and relationship of all persons who reside with you on a daily or part-time basis. 1. 2. 3. Please list all persons who may have access to the personal mail, bank statements, or other financial records or information about the Conservatee. 1. 2. 3. Proposed Conservatee: Length at the present address. List all residences/placements of the proposed Conservatee for the last 5 years. 1. 2. 3. Will it be necessary to change of residence of the proposed Conservatee now? If yes, please explain Does the proposed Conservator work for the proposed Conservatee in any capacity (health care, housekeeping, etc.)? If yes, please explain Will the proposed Conservator be available to transport the proposed Conservatee to medical, dental, optical, audiological, psychiatric, or other appointments? Yes No If no, please explain how these needs will be met Who will actually m Does the proposed Conservatee have a Will? American LegalNet, Inc. www.FormsWorkFlow.com 7 FCS-402-2016-M Mandatory Form July 2016 If so, where is it located? When was it signed? Who are the beneficiariesRelationship Does a Durable Power of Attorney or a Durable Power of Attorney for Health Care exist? If so, where is it located? When was it signed? Who is named with powers? Does the proposed Conservatee have a Trust(s)? RevocableIrrevocable If so, please list (a) Preparer of the Trust (b) Date of Trust (c) Assets and value of assets in Trust (d) Named Trustee(s) Is the proposed Conservatee the beneficiary of a Trust? Revocable Irrevocable If so, please list (a) Preparer of the Trust (b) Date of Trust (c) Named Trustee (d) Nature of beneficial interest for the Conservatee Current marital status of the proposed Conservatee is: MarriedDivorcedRemarriedWidowedDomestic partners SeparatedCurrently living apart from spouse (please explain) Is the proposed Conser Was there community property? Was there a Will? Has a probate petition of the Will been filed? If so, where? Will a probate petition of the Will be filed? If so, where? FOR RELATIVES SEEKING CONSERVATORSHIP: How are you related to the proposed Conservatee? Please state the exact nature of the relationship. Am