Conservatorship Questionnaire

1. What is your name, address, and telephone number?

2. What is the name, address, and telephone number of your proposed co-conservator, if any?

3. What is the name, address, and telephone number of the proposed conservatee?

4. What is the name and address of the proposed conservatee’s relatives within the first degree
(brothers, sisters, parents, grandparents, children, grandchildren)?

5. What is your relation to the proposed conservatee?

6. What is the relation to the proposed conservatee of the proposed co-conservator, if any?

7. Are you seeking powers to sell or operate the proposed conservatee’s business, manage
stock/hedge funds or other investment accounts, or sell/lease/manage/encumber his/her real
property?

8. Please provide a list and value (best estimation if exact value unknown) of all of proposed
conservatee’s property (includes financial accounts, personal property, and real property).
9. Does the proposed conservatee owe you or the proposed co-conservator money? If so, explain
how much and the nature of the debt.

10. Do you or the proposed co-conservator owe the conservatee money? If so, please explain.

11. Is the proposed conservatee entitled to receive veterans benefits or is he/she part of a federally
recognized Native American tribe? If yes, please explain.

12. Please list where the proposed conservatee has lived in the last 6 months.

13. Please describe all of the daily assistance you or others provide to the conservatee in managing
his/her finances, providing food, clothing, shelter, medication, transporting him/her, and all
other assistance provided to him/her.

14. Please provide your date of birth, social security number, and driver’s license number.

15. Please provide the proposed co-conservator’s (if any) date of birth, social security number, and
driver’s license number.

16. Please provide the proposed conservatee’s date of birth, social security number, and driver’s
license number.
17. Does the proposed conservatee have a health care power of attorney, advanced health care
directive, general durable power of attorney, trust, will, or any other estate planning documents
in place?

18. Have you ever been convicted of a crime? If so, please explain.

19. Has the proposed co-conservator, if any, ever been convicted of a crime? If so, please explain.

20. Have you ever declared bankruptcy? If so, please explain.

21. Has the proposed co-conservator ever declared bankruptcy? If so, please explain.

22. How long have you known the proposed conservatee?

23. How long has the proposed co-conservator known the proposed co-conservatee?

24. Have you ever been removed from a fiduciary position?

25. Has the proposed co-conservator ever been removed from a fiduciary position?

26. Has a restraining order ever been filed against you or the proposed co-conservator? If so, please
explain.