PHYSICIAN'S LETTER REGARDING INDEPENDENT LIVING Court Administrator Probate Division Re: The Conservatorship of _______________ Court File No: ______________________ Dear Sir or Madam: I, __________________________, the undersigned physician, state that I am the attending physician of the above-named conservatee; that I have been the protected person's physician since ______________, and that I examined the above-named protected person on ________________________________________________________________. I believe that ____________________ is no longer able to live independently due to her/his diagnosis of __________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ and as evidenced by the following behavior: __________________________________________________________________________ __________________________________________________________________________ Dated:__________________________ ______________________________________ Signature of Attending Physician Address:_______________________________ ______________________________________ ______________________________________ Telephone No: __________________________ GAC 21-UL State ENG Rev 9/03-D www.mncourts.gov/forms Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com