STATE OF CALIFORNIA
SANTA CLARA COUNTY
LPS CONSERVATOR APPOINTMENT FORM
I, [INSERT NAME] (may hereinafter be referred to as “Petitioner”), of [INSERT FULL
ADDRESS AND ZIP CODE], [INSERT TELEPHONE NUMBER], [INSERT EMAIL],
request that [INSERT CONSERVATOR’S NAME], of [INSERT FULL ADDRESS AND
ZIP CODE], [INSERT TELEPHONE NUMBER], [INSERT EMAIL], be appointed
Conservator and Letters issue upon qualification.
I hereby request:
(a) orders authorizing independent exercise of powers under California Welfare and
Institutions Code § 5350. Granting the proposed conservator powers to be
exercised independently under California Welfare and Institutions Code § 5350
would be to the advantage and benefit and in the best interest of the
conservatorship estate; and
(b) the (proposed) conservatee be adjudged to lack the capacity to give informed
consent for medical treatment or healing by prayer and that the proposed
conservator be granted the powers specified in California Welfare and
Institutions Code § 5350.
The (proposed) conservatee’s name is [INSERT NAME], of [INSERT FULL ADDRESS
AND ZIP CODE], [INSERT TELEPHONE NUMBER], [INSERT EMAIL].
The proposed conservatee has no conservator in California and is a (circle the one that
applies):
a. Resident of California and:
i. Is a resident of this county.
ii. Is not a resident of this county.
b. Nonresident of California but:
i. Is temporarily living in this county.
ii. Has property in this county.
Petitioner (circle all that apply):
a. Is a creditor or an agent of a creditor of the (proposed) conservatee.
b. Is not a creditor or an agent of a creditor of the (proposed) conservatee.
c. Is a debtor or an agent of a debtor of the (proposed) conservatee.
d. Is not a debtor or an agent of a debtor of the (proposed) conservatee.
e. Is the (proposed) conservator.
f. Is the (proposed) conservatee.
g. Is the domestic partner or former domestic partner of the (proposed)
conservatee.
h. Is a relative of the (proposed) conservatee as:
i. Is an interested person or friend of the (proposed) conservatee.
j. Is the guardian of the (proposed) conservatee.
k. Is a professional fiduciary within the meaning of Business and Professions Code
section 6501(f) who is licensed by the Professional Fiduciaries Bureau of the
Department of Consumer Affairs.
Proposed conservator (circle all that apply):
a. Is a creditor or an agent of a creditor of the (proposed) conservatee.
b. Is not a creditor or an agent of a creditor of the (proposed) conservatee.
c. Is a debtor or an agent of a debtor of the (proposed) conservatee.
d. Is not a debtor or an agent of a debtor of the (proposed) conservatee.
e. Is the (proposed) conservator.
f. Is the (proposed) conservatee.
g. Is the domestic partner or former domestic partner of the (proposed)
conservatee.
h. Is a relative of the (proposed) conservatee as:
i. Is an interested person or friend of the (proposed) conservatee.
j. Is the guardian of the (proposed) conservatee.
k. Is a professional fiduciary within the meaning of Business and Professions Code
section 6501(f) who is licensed by the Professional Fiduciaries Bureau of the
Department of Consumer Affairs.
The (proposed) conservatee owns real property as follows:
The estimated value of the (proposed) conservatee’s personal property is
$__________.
Proposed conservatee (circle all that apply):
a. Is a patient in or on leave of absence from a state institution under the
jurisdiction of the California Department of State Hospitals or the California
Department of Developmental Services at:
b. Is not a patient in or on leave of absence from a state institution under the
jurisdiction of the California Department of State Hospitals or the California
Department of Developmental Services.
c. Is receiving or entitled to receive benefits from the U.S. Department of Veterans
Affairs.
d. Is neither receiving nor entitled to receive benefits from the U.S. Department of
Veterans Affairs.
e. Is a member of a federally recognized Indian tribe.
f. Is not a member of a federally recognized Indian tribe.
g. Is an adult.
h. Will be an adult on the effective date of the order.
i. Is a married minor.
j. Is a minor whose marriage has been dissolved.
(Proposed) conservatee requires a conservator and is (circle the one that applies):
a. Unable to provide for his or her personal needs for physical health, food,
clothing, or shelter.
b. Substantially unable to manage his or her financial resources or to resist fraud or
undue influence.
(Proposed) conservatee is a gravely disabled person due to (circle the one that applies):
a. A condition in which he/she, as a result of a mental disorder, is unable to provide
for his or her basic personal needs for food, clothing, or shelter.
b. A condition in which a person, has been found mentally incompetent under
Section 1370 of the Penal Code and all of the following facts exist:
i. The indictment or information pending against the defendant at the time
of commitment charges a felony involving death, great bodily harm, or a
serious threat to the physical well-being of another person.
ii. The indictment or information has not been dismissed.
iii. As a result of a mental disorder, the person is unable to understand the
nature and purpose of the proceedings taken against him or her and to
assist counsel in the conduct of his or her defense in a rational manner.
c. For purposes of Article 3 (commencing with Section 5225) and Article 4 (commencing
with Section 5250), of Chapter 2, and for the purposes of Chapter 3 (commencing with
Section 5350), gravely disabled means a condition in which a person, as a result of
impairment by chronic alcoholism, is unable to provide for his or her basic personal
needs for food, clothing, or shelter.
The names, residence addresses, and relationships of the spouse or registered domestic
partner and the second-degree relatives of the (proposed) conservatee (his or her
parents, grandparents, children, grandchildren, and brothers and sisters), so far as
known to Petitioner, are:
Name and relationship to conservatee Residence address
1).
2).
3).
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I declare under penalty of perjury under the laws of the State of California that the
foregoing is true and correct.
Dated this ___ day of [INSERT MONTH], [INSERT YEAR].
Respectfully Submitted,
______________________________
[INSERT NAME]
Petitioner
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