Fillable Confidential Conservator Screening Form (Page 2 of 2) in pdf

CONFIDENTIAL

GC-314

CONSERVATORSHIP OF (Name):

CASE NUMBER:

PROPOSED CONSERVATEE

I have

I have not

filed for bankruptcy protection within the last 10 years. (If you checked "I have," explain in

Attachment 7.)

I have

I have not

been convicted of a felony or had a felony expunged from my record. (If you checked "I have,"

explain in Attachment 8.)

I have

I have not

been charged with, arrested for, or convicted of embezzlement, theft, or any other crime

involving the taking of property. (If you checked "I have," explain in Attachment 9.)

10.

I have

I have not

been charged with, arrested for, or convicted of a crime involving fraud, conspiracy, or

misrepresentation of information. (If you checked "I have," explain in Attachment 10.)

11.

I have

I have not

been charged with, arrested for, or convicted of any form of elder abuse or neglect.

(If you checked "I have," explain in Attachment 11.)

12.

I have

I have not

had a restraining order or protective order filed against me in the last 10 years.

(If you checked "I have," explain in Attachment 12.)

13.

I am

I am not

required to register as a sex offender under California Penal Code section 290.

(If you checked "I am," explain in Attachment 13.)

14.

I have

I have not

previously been appointed conservator, executor, or fiduciary in another proceeding.

(If you checked "I have," explain in Attachment 14.)

15.

I have

I have not

been removed or resigned as a conservator, guardian, executor, or fiduciary in any other case.

(If you checked "I have," explain in Attachment 15.)

I do not have

an adverse interest that the court may consider to be a risk to, or to have an

16.

I have or may have

effect on, my ability to faithfully perform the duties of conservator. (If you checked "I have or

may have," explain in Attachment 16.)

17.

I am

I am not

a private professional fiduciary, as defined in Business and Professions Code section 6501(f).

(If you checked "I am," respond to item 18. If you checked "I am not," go to item 19.)

18.

I am

I am not

currently licensed by the Professional Fiduciaries Bureau of the Department of Consumer

Affairs. My license status and information is stated in item 1 on page 1 of the Professional

Fiduciary Attachment signed by me and attached to the petition that proposes my appointment

as conservator in this matter. (Complete and sign the Professional Fiduciary Attachment and

attach it to the petition, or deliver it to the petitioner for attachment, before the petition is filed.

See item 3c(7) of the petition. Use form GC-210(A-PF)/GC-310(A-PF) for this attachment.)

19.

I am

I am not

a responsible corporate officer authorized to act for (name of corporation):

a California nonprofit charitable corporation that meets the requirements for appointment as

conservator of the proposed conservatee under Probate Code section 2104. I certify that the

corporation's articles of incorporation specifically authorize it to accept appointments as

conservator. (If you checked "I am," explain the circumstances of the corporation's care of,

counseling of, or financial assistance to the proposed conservatee in Attachment 19.)

20.

Do you, or does any other person living in your home, have a social worker or parole or probation officer assigned to him or her?

Yes

(If you checked "Yes," explain in Attachment 20 and provide the name, address, and telephone

number of each social worker, parole officer, or probation officer.)

DECLARATION

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

Date:

(TYPE OR PRINT NAME OF PROPOSED CONSERVATOR)

(SIGNATURE OF PROPOSED CONSERVATOR)*

*Each proposed conservator must fill out and file a separate screening form.

GC-314 [Rev. July 1, 2009]

Page 2 of 2

CONFIDENTIAL CONSERVATOR SCREENING FORM

(Probate—Guardianships and Conservatorships)

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Confidential Conservator Screening Form Page 2

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