VN182 ATTORNEY OR PARTY WITHOUT ATTORNEY (Name and Address) Telephone Number FOR COURT USE ONLY ATTORNEY FOR (Name): SUPERIOR COURT OF CALIFORNIA, COUNTY OF VENTURA 4353 E. VINEYARD AVE., OXNARD, CA 93036 CONSERVATORSHIP OF (NAME): CONFIRMATION OF VIEWING CONSERVATORSHIP VIDEO (Ventura County Local Rule 10.02A(3) CASE NUMBER: This shall confirm that (name of conservator(s)) _______________________________________________, viewed the video "With Heart: Understanding Conservatorship", pursuant to Rule 10.02A(3) of the Ventura County Rules of Court. The video was viewed on (date) _________________________________________ at the following location: Ventura Self-Help Legal Access Center JC Family Resource Center Law Firm of (name): ___________________________________________________________ Address of firm: ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ Other: ______________________________________________________________________ I am the [proposed] conservator and I certify that I have viewed this video: Date: _____________________ Print Name: ________________________________ Confirmed by: ______________________________ Signature of SHLA Staff or Law Firm Representative Signature: ____________________________ Date: ________________________ Optional Form VN182 (Rev. 07/09) CONFIRMATION OF VIEWING CONSERVATORSHIP VIDEO American LegalNet, Inc. www.FormsWorkFlow.com