Free SUPCV-410 - California

ATTORNEY OR PARTY WITHOUT ATTORNEY (Name and Address):

TELEPHONE NO.:

FOR COURT USE ONLY

ATTORNEY FOR (Name):

SUPERIOR COURT OF CALIFORNIA, COUNTY OF SANTA CRUZ 701 Ocean Street, Room 110 Santa Cruz, CA 95060
CONSERVATORSHIP OF (NAME ):

CONSERVATEE

PETITION FOR REAPPOINTMENT OF CONSERVATOR OF THE PERSON AND ESTATE (Welfare and Institutions Code § 5361)
PETITIONER (name):

CASE NUMBER:

ALLEGES THAT:

1. This Court appointed Petitioner the conservator of the person of the conservatee (name): on (date): 2. Letters of conservatorship were issued to Petitioner on (date):

and estate

3. Petitioner is the duly appointed, qualified, and acting conservator of the person conservatee, and has been since the date of issuance of the letters.

and estate of the

4. Petitioner has determined that the conservatorship is still required because the conservatee is still gravely disabled as a result of mental disorder or chronic alcoholism. 5.



Petitioner's determination is supported by the written opinions of the following duly licensed physician(s) and/or clinical psychologist(s). These opinions state, in effect, that the conservatee is still gravely disabled as a result of mental impairment and/or chronic alcoholism. The names and addresses of the physician(s) and/or clinical psychologist(s) are:

Physician
6.

Clinical Psychologist

Physician

Clinical Psychologist

These opinions are attached as Exhibits and made a part of this petition.



Petitioner is unable to obtain the opinion of two physicians or licensed psychologists that the conservatee is still gravely disabled as a result of mental impairment and/or chronic alcoholism. Petitioner therefore requests that this Court appoint two physicians or licensed clinical psychologists for this purpose, under the provisions of Welfare and Institutions Code Section5361.

7. Under the provisions of Welfare and Institutions Code sections 5361 and 5368, if Petitioner is not reappointed conservator, the conservatorship will automatically terminate on (date):

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SUPCV 410 (Rev. 10/05)

PETITION FOR REAPPOINTMENT OF CONSERVATOR (Welfare and Institutions Code §5361)

Page 1 of 3

CONSERVATORSHIP OF (NAME): conservatee

8. On reestablishment of the conservatorship, the following rights and privileges enumerated in Welfare and Institutions Code section 5357 should be denied to the conservatee: a. the privilege of possessing a license to operate a motor vehicle; b. the right to enter into a contract; c. the right to vote; d. the right to enter into the following types of transactions (specify): e. the right to enter into transactions that are in excess of (specify): $ f. the right to refuse treatment related specifically to the conservatee's grave disability; g. the right to refuse routine medical treatment that is unrelated to the proposed conservatee's grave disability; h. the right to possess a firearm. WHEREFORE, PETITIONER REQUESTS THAT: 1. Petitioner (name): be reappointed as conservator of the person and estate of the conservatee for a succeeding one-year period beginning (date): and ending (date): 2. 3.

This Court appoint two physicians or licensed clinical psychologists pursuant to Welfare and Institutions
Code section 5361 for the purpose of determining if the conservatee is still gravely disabled. appointment by the Court.

Conservator shall have the same powers are/were granted to the conservator on the previous

4. The conservatee shall be denied: a. the privilege of possessing a license to operate a motor vehicle; b. the right to enter into a contract; c. the right to vote; d. the right to enter into the following types of transactions (specify): e. the right to enter into transactions that are in excess of (specify): $ f. the right to refuse treatment related specifically to the conservatee's grave disability; g. the right to refuse routine medical treatment that is unrelated to the proposed conservatee's grave disability; h. the right to possess a firearm. 5. Other relief be granted that the Court considers proper.

Date:____________________________________________

(TYPE OR PRINT NAME)

(SIGNATURE OF PETITIONER)

______________________________________________________________________
SUPCV 410 (Rev. 10/05)

PETITION FOR REAPPOINTMENT OF CONSERVATOR (Welfare and Institutions Code §5361)

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CONSERVATORSHIP OF (NAME): CONSERVATEE

CASE NO.

VERIFICATION I am the petitioner in this action. I have read the foregoing Petition for Reappointment of Conservator of the Person and Estate and know the contents thereof. I certify that the same is true of my own knowledge. I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Executed on (date): __________________________, at (city): _____________________________________, California.

_________________________________________________
(TYPE OR PRINT NAME)

____________________________________________
(SIGNATURE OF PETITIONER)

______________________________________________________________________
SUPCV 410 (Rev. 10/05)

PETITION FOR REAPPOINTMENT OF CONSERVATOR (Welfare and Institutions Code §5361)

Page 3 of 3

CONSERVATORSHIP OF (NAME): CONSERVATEE

CASE NO.

ATTACH JUDICIAL COUNCIL FORM GC-020 (Rev. 7/05)

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SUPCV 410 (Rev. 10/05)

PETITION FOR REAPPOINTMENT OF CONSERVATOR (Welfare and Institutions Code §5361)

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