Free DECLARATION OF SERVICE - California

INSTRUCTIONS 4 OF 4 DOCUMENTS NEEDED WHEN REQUESTING REAPPOINTMENT Numbers on the left hand side of these instructions match numbers on the form REMEMBER USE BLACK INK PEN ONLY

DECLARATION OF SERVICE Once you have completed and filed the "Petition for Re-Appointment" and you are given a hearing date, you will need to complete the "Notice of Hearing " form. You will than need to make six (6) copies of these two documents "Petition for Re-Appointment" and "Notice of Hearings" and then mail or give copies to certain parties and\or agencies connected with the case. You will need to document whether you mailed or gave and to whom you notified of the hearing on the following "Declaration of Service" 1. Fill in the Court Case# 2. Fill in the Conservatee's (patient's) name Fifteen days (15) days prior to the hearing, you are required by law to give or mail copies of the "Petition for Re-appointment as Conservator" and "Notice of Hearing" to the parties/agencies/attorneys on this form. 3. For each party/agency/attorney you will check the box if you mailed or gave a copy of the "Petition for Re-Appointment as Conservator" and "Notice of Hearing" and the date you mailed or gave them the copies. 4. Fill in the Conservatee's (patient's) name 5. Fill in the facility name and address where the Conservatee is currently living. (You need only send copies to the Veteran's Administration if the Conservatee is a Veteran). 6. Fill in the name and address of any other parties/ agencies/attorneys to whom you are required to give Notice to. 7. If you have questions, please call the Mental Health Clerk's Office at (323) 226-2917 or 2918.

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DECLARATION OF SERVICE STATE OF CALIFORNIA COUNTY OF LOS ANGELES 1. |COURT CASE #_____________________ 2. |CONSERVATEE_____________________________ (Name) I the undersigned hereby declare under penalty of perjury that the following is true and correct; That I gave or mailed a copy of the Petition for Re-appointment and Notice of Hearing to the following agencies on the date indicated: 3. Mailed Date: _______ Gave 3. Mailed Date: _______ Gave 3. Mailed Date: _______ Gave Mailed Date: _______ Gave Mailed Date: _______ Gave Mailed Date: _______ Gave Mailed Date: _______ Gave Director of Health, State of California Bureau of Patients' Accounts 1600 Ninth Street, 2nd Floor South Sacramento, CA. 95814 Director Los Angeles County Mental Health/Public Guardian 320 West Temple Street, 9th Floor Los Angeles, CA. 90012 Los Angeles County Public Defender 1150 North San Fernando Road Los Angeles, CA. 90065 4. Conservatee_________________________ C/O (Facility Name)____________________ Address______________________________ _____________________________________ 5. Facility_____________________________ Address_______________________________ ________________________________ Veteran's Administration Regional Office 11000 Wilshire Blvd. Los Angeles, CA. 90024 6. Any Other________________________ ___________________________________ ___________________________________

Executed on _______________________,20___ at___________________________,California (City) _____________________________________ Signature of Conservator Once you have completed this Declaration of Service please file it with the Court.

declaration of service.doc

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