Referral For Investigators Report-Conservatorship {PB-4002}

ATTACHMENT PB-4002 ATTORNEY OR PARTY WITHOUT ATTORNEY (Name and Address): TELEPHONE NUMBER: FOR COURT USE ONLY EMAIL ADDRESS (Optional): ATTORNEY FOR (Name): SUPERIOR COURT OF CALIFORNIA, COUNTY OF SANTA CLARA STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: 191 North First Street 191 North First Street San Jose, California 95113 Downtown Courthouse - Probate Division Conservatorship of (Name): Person Estate Limited Temp Hrg Date: Perm Hrg. Date: CASE NUMBER: REFERRAL FOR COURT INVESTIGATOR CONSERVATORSHIP Note: A fee may be assessed for Court Investigator Services ­ See Probate Code § 1851.5 This Referral is being sent to the Probate Investigator's Office for an investigation regarding (check all that apply): Appointment Accounting/Review Termination Medical Powers Dementia Powers Other: (specify): Sale of (former) Residence Substituted Judgment Information about the (Proposed) CONSERVATEE (Proposed) Conservatee's CURRENT address: Address: Phone number: (Proposed) Conservatee's HOME address: Address: Phone number: Birth Date: Social Security number: Marital Status: Single/Divorced Widowed Married Registered Domestic Partner Special needs (i.e. language)? Is (proposed) conservatee under an LPS Conservatorship now? If yes, LPS # Yes No (Proposed) Conservatee's Attorney (name): Address: Phone number: Fax number: PB-4002 REV 1/08 CONFIDENTIAL ­ DO NOT PUT IN COURT FILE REFERRAL FOR COURT INVESTIGATOR - CONSERVATORSHIP (PROBATE ­ SANTA CLARA COUNTY) Page 1 of 5 www.courtinfo.ca.gov American LegalNet, Inc. www.FormsWorkflow.com ATTACHMENT PB-4002 Conservatorship of (Name): Case Number: General Hearing Date: Information about the (Proposed) CONSERVATOR All proposed Conservators must complete the information on this page. If there is more than one proposed Conservator, attach a copy of this page for each person. Name: Relationship to Conservatee: Other (describe): Home Address: Home phone: Birth Date: Social Security number: Driver's License number: Work phone: (Proposed) Conservator's Attorney (name): Address: Phone number: Fax number: Cell phone: Fax number: Spouse Son/Daughter Registered Domestic Partner I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date: Signature of Proposed Conservator Information sheet(s) for (number) of (proposed) co-conservators is attached. PB-4002 REV 1/08 CONFIDENTIAL ­ DO NOT PUT IN COURT FILE REFERRAL FOR COURT INVESTIGATOR - CONSERVATORSHIP (PROBATE ­ SANTA CLARA COUNTY) Page 2 of 5 www.courtinfo.ca.gov American LegalNet, Inc. www.FormsWorkflow.com ATTACHMENT PB-4002 Conservatorship of (Name): Case Number: General Hearing Date: Information about (Proposed) Conservatee's Relatives & Friends List the spouse or registered domestic partner, 1st and 2nd degree relatives (these are parents, children, brothers/sisters, grandparents and grandchildren), neighbors and close friends of the (proposed) conservatee. Name: Relationship to (proposed) conservatee: Home Address: Home phone: Work phone: Cell phone: Name: Relationship to (proposed) conservatee: Home Address: Home phone: Work phone: Cell phone: Name: Relationship to (proposed) conservatee: Home Address: Home phone: Work phone: Cell phone: Name: Relationship to (proposed) conservatee: Home Address: Home phone: Work phone: Cell phone: Name: Relationship to (proposed) conservatee: Home Address: Home phone: Work phone: Cell phone: Name: Relationship to (proposed) conservatee: Home Address: Home phone: Work phone: Cell phone: PB-4002 REV 1/08 CONFIDENTIAL ­ DO NOT PUT IN COURT FILE REFERRAL FOR COURT INVESTIGATOR - CONSERVATORSHIP (PROBATE ­ SANTA CLARA COUNTY) Page 3 of 5 www.courtinfo.ca.gov American LegalNet, Inc. www.FormsWorkflow.com ATTACHMENT PB-4002 Conservatorship of (Name): Case Number: General Hearing Date: Information about (Proposed) Conservatee's Relatives & Friends Name: Relationship to (proposed) conservatee: Home Address: Home phone: Work phone: Cell phone: Name: Relationship to (proposed) conservatee: Home Address: Home phone: Work phone: Cell phone: Name: Relationship to (proposed) conservatee: Home Address: Home phone: Work phone: Cell phone: Name: Relationship to (proposed) conservatee: Home Address: Home phone: Work phone: Cell phone: Name: Relationship to (proposed) conservatee: Home Address: Home phone: Work phone: Cell phone: Name: Relationship to (proposed) conservatee: Home Address: Home phone: Work phone: Cell phone: PB-4002 REV 1/08 CONFIDENTIAL ­ DO NOT PUT IN COURT FILE REFERRAL FOR COURT INVESTIGATOR - CONSERVATORSHIP (PROBATE ­ SANTA CLARA COUNTY) Page 4 of 5 www.courtinfo.ca.gov American LegalNet, Inc. www.FormsWorkflow.com ATTACHMENT PB-4002 Conservatorship of (Name): Case Number: General Hearing Date: Information about OTHER ADULTS (age18 or older) who reside with the proposed Conservatee Name: Relationship to (proposed) conservatee: Home Address: Home phone: Work phone: Cell phone: Name: Relationship to (proposed) conservatee: Home Address: Home phone: Work phone: Cell phone: Name: Relationship to (proposed) conservatee: Home Address: Home phone: Work phone: Cell phone: Name: Relationship to (proposed) conservatee: Home Address: Home phone: Work phone: Cell phone: Name: Relationship to (proposed) conservatee: Home Address: Home phone: Work phone: Cell phone: Name: Relationship to (proposed) conservatee: Home Address: Home phone: Work phone: Cell phone: PB-4002 REV 1/08 CONFIDENTIAL ­ DO NOT PUT IN COURT FILE REFERRAL FOR COURT INVESTIGATOR - CONSERVATORSHIP (PROBATE ­ SANTA CLARA COUNTY) Page 5 of 5 www.courtinfo.ca.gov www.FormsWorkflow.com