Conservatorship Information Form Page 2
ADVERTISEMENT
1
2
3FOR NOTICE PURPOSES YOU MUST LIST THE DISABLED INDIVIDUAL’S CLOSEST LIVING
RELATIVES. See the requirements from Tenn. Code Ann. § 34-3-104 (5):
The name, mailing address and relationship of the closest relative or relatives of the respondent and the
name and mailing address of the person or institution, if any, having care and custody of the respondent or with
whom the respondent is living. If the respondent has no then living spouse, child, parent or sibling, the petition
shall so state and more remote relatives are not to be listed;
(Aunts, uncles, and cousins do not need to be listed, unless they are the closest living relative.)
Name & Address:
Phone: (
)
Name & Address:
Phone: (
)
Name & Address:
Phone: (
)
(If you have names and addresses of additional family members, please attach a sheet with this form.)
*** You must include dates of efforts to contact family members regarding their willingness and ability to
serve as conservator if you are asking that a corporate conservator be appointed. This is not option! By
submitting this form you are affirming that the information contained herein is true and correct to the best of
your knowledge and belief. ***
================================================================================
PROPOSED CONSERVATOR(S)
Have you ever been convicted of a felony and sentenced to a penitentiary?
Yes
No
Please note that the State (Office of General Counsel) will not request that a conservator also be
allowed to be a paid caregiver (or vice versa) due to the conflict of interest this situation presents.
Name:
SSN:
(Full Name)
DOB:
Mailing Address:
Relationship:
Phone: (
)
Work: (
)
If the proposed conservator is not the closest relative, explain why the closest relative is not
recommended:
PROPOSED STANDBY CONSERVATOR(S):
Have you ever been convicted of a felony and sentenced to a penitentiary?
Yes
No
Name of :
(Full Name)
SSN:
DOB:
Mailing Address:
Relationship:
Phone: (
)
Work: (
)
2
Revised 1/04, 6/06, 12208sc, 81308sc,81309SC, 7212010, 382011sc
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal