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Form Dhcs 1009 - California Quarterly Report Of Conservatorships Established By The Superior Court Of The County - Health And Human Services Agency

State of California - Health and Human Services Agency

Department of Health Care Services

QUARTERLY REPORT OF CONSERVATORSHIPS ESTABLISHED BY

THE SUPERIOR COURT OF THE COUNTY

Year

County Name:

Quarter 1

July 1 to Sept. 30

County Code:

Quarter 2

Oct. 1 to Dec. 31

Quarter 3

Jan. 1 to March 31

Quarter 4

April 1 to June 30

1. Number of persons placed under temporary conservatorships during this quarter:

2. Number of newly established & re-established permanent conservatorships during

this quarter:

The above information is required by the California Welfare and Institutions Code (WIC) Section

5402(a).

The information provided in this quarterly report will be incorporated into an annual report as required by

WIC Section 5402(d).

Please see next page or reverse side for Reporting Instructions.

This quarterly report should be submitted by the 30

of the month following the end of each

quarter via fax, email, or U.S. Mail.

If you need assistance preparing this report, please send an email to one of the persons below.

Fax Number:

(916) 552-8555

Email Address:

kenneth.lee@dhcs.ca.gov

bryan.fisher@dhcs.ca.gov

Mailing Address: DEPARTMENT OF HEALTH CARE SERVICES

Research and Analytic Studies Branch, MS1200

P.O BOX 997413

SACRAMENTO, CA 95899-7413

Date

Contact Person

Phone Number

DHCS 1009 (8/12)

Form Dhcs 1009 - California Quarterly Report Of Conservatorships Established By The Superior Court Of The County - Health And Human Services Agency