Confidential Status Report {PR-19}

SUPERIOR COURT OF THE STATE OF CALIFORNIA COUNTY OF SAN MATEO PROBATE COURT INVESTIGATIONS 400 County Center, 2nd Floor, SMC-127 PI Redwood City, CA 94063 CONFIDENTIAL STATUS REPORT Status Report of Conservatee Pursuant to Local Court Rule 4.81.18 NOTE: If there is more than one conservator, only one Status Report must be completed. Each co-conservator must sign the Status Report or attach a separate signature page that, when signed indicates agreement to the contents of the Confidential Status Report. The Confidential Status Report is also available online at www.sanmateocourt.org. www.sanmateocourt.org Please type or print legibly when completing this document. 1. 2. 3. 4. Conservatee's Name: Case Number: Name of Facility (if applicable): Facility or Home Address: Street City Zip Date of Birth: Age: 5. 6. 7. Phone: Type of Residence/Facility: Facility Contact: (Nursing Home, Residential Care, Assisted Living, Private Home) What is date of placement? Describe facility services and medical monitoring of conservatee? Do you plan to continue placement or change placement? Page 1 of 5 Form adopted for Mandatory Use Local Court Form PR-19 [New February 2009] www.sanmateocourt.org CONFIDENTIAL STATUS REPORT Local Court Rule 4.81.18 American LegalNet, Inc. www.FormsWorkflow.com 8. Current health status/functional level: Primary Diagnosis: Comments: stable declined improved 9. Hospitalizations during the review period? hospitalizations: Yes No If yes, list dates and reasons for 10. DAY PROGRAM - If the conservatee attends a day program such as a vocational program, sheltered work program, adult day health program or any other day program, please complete the following information: Program Name: Address: Phone: Days attended: Program services and activities: Contact person: Hours: American LegalNet, Inc. www.FormsWorkflow.com 11. VISITATION - Dates of visits to the conservatee (not living with conservator): Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: Date: 12. FINANCIAL INFORMATION: A. Complete for ALL Conservatorships: Yes Does the conservatee have a trust? If yes, Trustee: Does the conservatee have a Special Needs Trust? If yes, Trustee: No Current Market Value: Yes No Current Market Value: B. Conservator of the Person ONLY (conservatees who receive public benefits), complete the following section: Does the conservatee have monthly income? Yes No If yes, what is the source? Social Security/Supplemental Security Income (SSI)/Trust/Other Total average monthly income: Average monthly expenses Does the conservatee have a Representative Payee? Name of Representative Payee: C. Conservator of Estate, complete the following section: Yes No American LegalNet, Inc. www.FormsWorkflow.com For a Conservatorship of the Estate, an accounting is required unless waived by the Court pursuant to Section 2628 of the Probate Code. If waived, a Declaration in Support of Waiver of Accounting (Local Form Number PR-24) must be filed each review period. If an accounting is being filed, complete the following information: (Use additional sheets of paper if necessary.) Total current fair market value (FMV) of estate: Total average monthly income: Total average monthly expenses: 1) Explain any "internal accounting adjustments" not otherwise delineated in the accounting: 2) Describe any unusual receipts or disbursements, sales, purchases or changes in the form of assets not otherwise delineated in the accounting. Address any unusual compensation paid to third parties, especially if they are relatives of the conservatee or the conservator. (For example, if the monthly phone bill averages $50.00, explain a phone bill of $250.00; or, if a rental property earns gross monthly rent of $2,500.00, explain why the listed net rent is $2,275.00.) Use additional sheets, if necessary. 13. Current Issues: Conservator's personal observations and compliance with Court orders and recommendations; also include information regarding any criminal matters or civil litigation involving the conservatee or conservator. 14. Name of person completing this document: American LegalNet, Inc. www.FormsWorkflow.com 15. I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Executed on Place at Location Conservator Signature: Print Name: I am a co-conservator in this matter and I have read the Confidential Status Report of Conservatee and know the contents thereof. The report is true of my own knowledge and understanding. I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Executed on Place at Location Co-Conservator Signature: Print Name: Please mail completed form and one additional copy, at least thirty (30) days prior to the review hearing date, to: Superior Court, County of San Mateo Probate Clerk's Office 400 County Center, 1st Floor Redwood City, CA 94063-1655 American LegalNet, Inc. www.FormsWorkflow.com