Conservatorship_Guardianship Questionnaire

Current address of PC/W:

Proposed new address for PC/W:

Were health services provided to PC/W during the past year?

Yes No
If yes, please explain:
Was estate management assistance provided to the PC within the past year?

Yes No
If no, please explain:
Do you want to request a Conservatorship over the person?

Yes No
Do you want to request a Conservatorship over the estate?

Yes No

C. CONSERVATOR/GUARDIAN INFORMATION:
Conservator/Guardian's Name, address and telephone #:
Conservator/Guardian's Date of Birth:
Conservator/Guardian's Social Security Number:
Conservator/Guardian's Driver License #:
D. FACTS SUPPORTING CONSERVATORSHIP/GUARDIANSHIP:
Reasons Conservatorship/Guardianship is required: (Explain why you believe a Conservatorship is necessary and appropriate).
Is a temporary Conservatorship/Guardianship required immediately?

Yes No
Why is a Temporary Conservatorship/Guardianship required immediately? What is the imminent harm that would result if the conservatorship is not established immediately?

A. PROPOSED CONSERVATEE/WARD INFORMATION: