Fillable ATTACHMENT PB-4016 SUPERIOR COURT OF CALIFORNIA, COUNTY OF (The Superior Court of California, County of Santa Clara)

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ATTACHMENT PB-4016 SUPERIOR COURT OF CALIFORNIA, COUNTY OF (The Superior Court of California, County of Santa Clara)

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ATTACHMENT PB-4016
PB-4016 REV. 7/01/12 LAYPERSON’S DECLARATION RE: LEGAL CAPACITY Page 1 of 3
Prob C. §811, 812, 1872
ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar Number and Address):
TELEPHONE NUMBER: FAX NUMBER:
ATTORNEY FOR: (name):
SUPERIOR COURT OF CALIFORNIA, COUNTY OF SANTA CLARA
FOR COURT USE ONLY
STREET ADDRESS: 191 North First Street
MAILING ADDRESS: 191 North First Street
CITY AND ZIP CODE: San José, CA 95113
BRANCH NAME:
PROBATE DIVISION
Conservatorship of the Person Estate of
Conservatee Proposed Conservatee
CASE NUMBER:
LAYPERSON’S DECLARATION RE: LEGAL CAPACITY
TO LAYPERSON DECLARANT
The purpose of this form is to enable the court to determine whether the (proposed) conservatee
has the capacity to enter into financial transactions
GENERAL INFORMATION
1. (Name):
2. (Address and Telephone Number):
3. I am a layperson. I know the (proposed) conservatee in the following capacity (describe):
4.
(Proposed) Conservatee:
I last saw the proposed conservatee on (date):
(Continued on next page)
To keep other people from
seeing what you have
entered, please press the
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of this form when finished.
ATTACHMENT PB-4016
PB-4016 REV. 7/01/12 LAYPERSON’S DECLARATION RE: LEGAL CAPACITY Page 2 of 3
Prob C. §811, 812, 1872
Conservatorship of the Person Estate of (Name):
Conservatee Proposed Conservatee
Case Number:
EVALUATION OF (PROPOSED) CONSERVATEE’S MENTAL FUNCTION.
5. Note to the Declarant: This form is not a rating scale. It is intended to assist you in recording your impressions of
the (proposed) conservatee’s mental abilities. Where appropriate, please feel free to refer to scores on
standardized rating instruments.
Instructions (Items A-C): Check the appropriate designation below: a = no apparent impairment; b = moderate
impairment; c = major impairment; d = so impaired as to be incapable of being assessed; e = I have no opinion.
A. Alertness and Attention
(1) Levels of arousal. (Lethargic, responds only to vigorous and persistent stimulation, stupor.)
a
b c d e
(2) Orientation. Encircle each type of orientation which is impaired:
a
b c d e Person
a
b c d e Time [date, month, season, year]
a
b c d e Place [address, town, state]
a b c d e Situation [why am I here?]
(3) Ability to attend and concentrate. (Give detailed answers from memory, mental ability required to thread a
needle.)
a
b c d e
B. Information Processing. Ability to:
(1) Remember. (Ability to remember question before answering, to recall names, relatives, past presidents,
events of past 24 hours.)
i. Short-term memory:
a
b c d e
ii. Long-term memory:
a b c d e
iii. Immediate recall:
a b c d e
(2) Understand and communicate either verbally or otherwise. (Deficits reflected by: inability to
comprehend questions follow instructions, use words correctly or name objects; nonsense words.)
a
b c d e
(3) Recognize familiar objects and persons. (Deficits reflected by: inability to recognize familiar faces,
objects, etc.)
a
b c d e
(4) Understand and appreciate quantities. (Perform simple calculations.)
a
b c d e
(5) Reason using abstract concepts. (Grasp abstract aspects of his/her situation; interpret idiomatic
expressions or proverbs.
a
b c d e
(6) Plan, organize and carry out actions (assuming physical ability) in one’s own rational self interest.
(Break complex tasks down into simple steps and carry them out.)
a
b c d e
(7) Reason logically.
a
b c d e
C. Thought disorders.
(1) Severely disorganized thinking. (Rambling thoughts, nonsensical, incoherent or non-linear thinking.)
a
b c d e
(2) Hallucinations. (Auditory, visual, olfactory)
a
b c d e
(3) Delusions. (Demonstrably false belief maintained without or against reason or evidence.)
a
b c d e
(4) Uncontrollable or intrusive thoughts. (Unwanted compulsive thoughts, compulsive behavior.)
a
b c d e
ATTACHMENT PB-4016
PB-4016 REV. 7/01/12 LAYPERSON’S DECLARATION RE: LEGAL CAPACITY Page 3 of 3
Prob C. §811, 812, 1872
Conservatorship of the Person
Case Number:
Estate of (Name):
Conservatee Proposed Conservatee
D. Ability to modulate mood and affect. The (proposed) conservatee has does NOT have a pervasive and
persistent or recurrent emotional state that appears inappropriate in degree to his or her circumstances.
(If so, complete remainder of 5D.)
I have no opinion.
Instructions: Rate the degree of impairment of each inappropriate mood state (if any) as follows:
a = mildly inappropriate; b = moderately inappropriate; c = severely inappropriate
Anger a
b c Euphoria a b c Helplessness a b c
Anxiety a b c Depression a b c Apathy a b c
Fear a b c Hopelessness a b c Indifference a b c
Panic a
b c Despair a b c
E. The (proposed) conservatee’s periods of impairment from the deficits indicated in Items 5A – 5D
(1)
do NOT vary substantially in frequency, severity, or duration.
(2)
do vary substantially in frequency, severity, or duration (explain):
(Optional) Other information regarding my evaluation of the (proposed) conservatee’s mental function (e.g.,
particular observation, problems noticed):
F.
Stated in Attachment 5F.
ABILITY TO ENTER INTO FINANCIAL TRANSACTIONS.
6. Based on the information above, it is my opinion that the (proposed) conservatee
a.
has the capacity to enter into financial transactions and should not have his or her rights to enter into contracts
terminated by the Court.
b.
lacks the capacity to enter into financial transactions because the mental deficits indicated above significantly
impair the (proposed) conservatee’s ability to understand and appreciate the consequences of his or her actions such
that the (proposed) conservatee lacks the capacity to understand and/or enter into any contracts or agreements
regarding property. (If this paragraph applies, declarant shall initial here:
.)
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) (SIGNATURE OF DECLARANT)
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ATTACHMENT PB-4016 SUPERIOR COURT OF CALIFORNIA, COUNTY OF (The Superior Court of California, County of Santa Clara)

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Completed 29 June 2021

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