Free GC-005 Declaration of Private Professional Conservator or Guardian--Qualifications (Probate--Guardianships and Conservatorships) - California

CONFIDENTIAL--FOR COURT USE ONLY SUPERIOR COURT OF CALIFORNIA, COUNTY OF
STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE:
FOR COURT USE ONLY

GC-005

NAME OF PROFESSIONAL GUARDIAN OR CONSERVATOR (specify):
FILE NUMBER:

CONSERVATOR DECLARATION OF PRIVATE PROFESSIONAL CONCERNING QUALIFICATIONS FOR APPOINTMENT

GUARDIAN

NOTICE TO COURT-APPOINTED PRIVATE PROFESSIONAL CONSERVATORS OR GUARDIANS: If you are a private professional conservator or guardian under Probate Code section 2341 and have been appointed by a court, you must annually file an information statement with each court that appointed you. Beginning with the first statement due after January 1, 2006, your information statement must show your qualifications to serve or continue to serve as a guardian or conservator under rules 7.1060(b) (conservators) or 7.1010(b) (guardians) of the California Rules of Court. You must make that showing by completing and signing this form and filing it as part of your information statement with each appointing court. One declaration is sufficient if you are both a private professional conservator and a private professional guardian. You may be required by the court to furnish additional information in your annual statement. If so, check item 8 of this form and provide the additional information in the manner required by the court or, if no specific manner is required, in Attachment 8 to this form. Beginning with the first annual statement due after December 31, 2007, your information statement must also show compliance with the continuing education requirements of rules 7.1060(e) or 7.1010(e) for the previous calendar year. You must complete and file a Declaration of Private Professional Conservator or Guardian--Continuing Education (form GC-006) with your information statement for that purpose. Declarant (name): 1. Contact information (complete in all cases): a. Name: Business or firm name: b. Business Address: City: c. Mailing Address: d. E-mail: e. Telephones: Day: Night: 2. Personal or professional conduct (complete in all cases): I have not (specify all that apply): a. b. c. 3. Fax: County: State: State: Zip: Zip: + + states as follows:

Cell (optional):

Been convicted of a misdemeanor involving abuse or neglect of a child or an elderly or dependent adult or of any felony. Been determined to be liable in a civil action or proceeding for conversion, embezzlement, fraud, misappropriation, misrepresentation, or theft. Been removed as a fiduciary by a court for actions involving breach of fiduciary duty, conversion, fraud, misappropriation, misrepresentation, or theft. Previous qualifications declaration filed (If you submitted this form with an annual statement previously filed with this court, you may check and complete this item and disregard all following items (except item 8) that request information unchanged from your prior declaration. In all cases, complete the signature information and sign at the bottom of page 4 of this form.) On (date): I filed with this court a completed Declaration of Private Professional Conservator or Guardian--Qualifications (form GC-005). Except as otherwise stated in this declaration, each of the statements made in that declaration are still true and correct as of the date of this declaration. All information requested of in this me declaration was provided by me in that previously filed declaration.

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Form Adopted for Mandatory Use Judicial Council of California GC-005 [Rev. July 1, 2007]

DECLARATION OF PRIVATE PROFESSIONAL CONSERVATOR OR GUARDIAN--QUALIFICATIONS (Probate--Guardianships and Conservatorships)

Probate Code, § 2344; Cal. Rules of Court, rules 7.1010, 7.1060 www.courtinfo.ca.gov

CONFIDENTIAL--FOR COURT USE ONLY
DECLARATION OF PRIVATE PROFESSIONAL (Name): 4. CONSERVATOR GUARDIAN
FILE NUMBER:

GC-005

CONCERNING QUALIFICATIONS FOR APPOINTMENT Personal information (complete unless item 3 applies):

a. Date of birth:

b. Height:

c. Eye color: e. Social security number:

d. California driver's license or DMV identification: 5.

Education and experience (Complete unless item 3 applies. You must show that you have satisfied at least one of items 5a through 5e. Check all that apply. If you do not satisfy item 5c, you must also complete item 6.) I have: (1) A four-year undergraduate degree or equivalent from the following institution, an accredited educational a. institution within the meaning of rule 7.1060 or 7.1010: (a) Institution: (b) Degree (describe): (c) Date awarded: (2) AND one or more of the following: (a) A minimum of two years' employment experience in a position and with an entity described in rule 7.1060(b)(2)(A)(i) or 7.1010(b)(2)(A)(i), as follows: Employer (name and type of entity or firm): Position and responsibilities (describe):

Inclusive dates of employment: (b) Continued on Attachment 5a(2)(a). A minimum of two years' experience as a court-appointed conservator or guardian of the person or estate of an adult or a minor, as follows: Appointing court (name of court, and state and county or other district designation):

(c)

Case number: Inclusive dates of appointment: Name of conservatee or ward: Continued on Attachment 5a(2)(b). A certificate as a paralegal from an accredited educational institution and a minimum of two years' employment as a paralegal with a primary emphasis in a probate-related area of practice, as follows: Certifying institution (specify): Employer (name): Paralegal duties (describe): Inclusive dates of employment:

b.

Continued on Attachment 5a(2)(c). (1) A two-year undergraduate degree or equivalent in a behavioral science, or in business, nursing, or accounting from the following institution, an accredited educational institution within the meaning of rule 7.1060 or 7.1010: (a) Institution: (b) Degree (describe): (c) Date awarded:

GC-005 [Rev. July 1, 2007]

DECLARATION OF PRIVATE PROFESSIONAL CONSERVATOR OR GUARDIAN--QUALIFICATIONS (Probate--Guardianships and Conservatorships)

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CONFIDENTIAL--FOR COURT USE ONLY
DECLARATION OF PRIVATE PROFESSIONAL (Name): 5. b. CONSERVATOR GUARDIAN
FILE NUMBER:

GC-005

CONCERNING QUALIFICATIONS FOR APPOINTMENT (2) AND one or more of the following: (a) A minimum of five years' employment experience in a position and with an entity described in rule 7.1060(b)(2)(A)(i) or 7.1010(b)(2)(A)(i), as follows: Employer (name and type of entity or firm): Position and responsibilities (describe):

Inclusive dates of employment: Continued on Attachment 5b(2)(a) . (b) A minimum of five years' experience as a court-appointed conservator or guardian of the person or estate of an adult or a minor, as follows: Appointing court (name of court, and state and county or other district designation):

Case number: Name of conservatee or ward:

Inclusive dates of appointment:

Continued on Attachment 5b(2)(b) . (c) A certificate as a paralegal from an accredited educational institution and a minimum of five years' employment as a paralegal with a primary emphasis in a probate-related area of practice, as follows: Certifying institution (specify ): Employer (name): Paralegal duties (describe): Inclusive dates of employment: Continued on Attachment 5b(2)(c) c. Been appointed, qualified, and acted as conservator of the person, the estate, or both, or guardian of the estate or the person and estate of at least 10 persons in the state of California in the five-year period immediately preceding January 1, 2006. The names of the conservatees or wards, the appointing courts and case numbers, and the dates of my appointment as conservator or guardian are stated in Attachment 5c to this declaration. A current active license in good standing, or an inactive license that was current, active, and in good standing within five years of January 1, 2006 or my appointment as a conservator or guardian by this court, whichever is later, in the California profession identified below. This license was neither revoked nor resigned or surrendered with proceedings for revocation pending (specify license and license number or other identification): Attorney at law. (1) Certified public accountant (2) Educational psychologist (3) Licensed clinical social worker (4) Marriage and family therapist (5) Physician or surgeon (6) Psychologist (7) Registered nurse (8) License number or other identification: e. Experience as a retired judge or justice of a California trial or appellate court, or a commissioner or juvenile court referee who was employed by a California court on a full-time basis at the time of retirement. Judicial officer position: Court: Retirement date:
GC-005 [Rev. July 1, 2007]

d.

DECLARATION OF PRIVATE PROFESSIONAL CONSERVATOR OR GUARDIAN--QUALIFICATIONS (Probate--Guardianships and Conservatorships)

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CONFIDENTIAL--FOR COURT USE ONLY
DECLARATION OF PRIVATE PROFESSIONAL (Name): 6. CONSERVATOR GUARDIAN
FILE NUMBER:

GC-005

CONCERNING QUALIFICATIONS FOR APPOINTMENT Certificate in professional fiduciary management (Unless item 3 applies, you must complete this item if you qualify for appointment under item 5a, 5b, 5d, or 5e of this form, but not under item 5c (prior experience as an appointed conservator or guardian in California in 10 matters within five years before January 1, 2006).) a. I have completed an educational program in professional fiduciary management for guardians or conservators approved by the California Administrative Office of the Courts and have received a certificate or its equivalent. (1) Educational institution: (2) Certificate received:

(3) Date completed:
b. (2006 and 2007 only) I will complete an educational program in professional fiduciary management for guardians or conservators approved by the California Administrative Office of the Courts during 2006 or the first six months of 2007, and will supplement this declaration with proof of completion before July 1, 2007.

7.

Pre-2006 appointments as private professional conservator or guardian (unless item 3 applies, you must complete this item if: (1) you were appointed and qualified as a conservator, or as a guardian of the estate or the person and estate, in one or more matters in this court before January 1, 2006 in your capacity as a private professional conservator or guardian; and (2) you do not qualify as a private professional conservator or guardian under any of the alternatives described in items 5a­5e of this form.) a. I was appointed and qualified before January 1, 2006 as a private professional fiduciary and am currently acting in the following matters in this court, as a conservator guardian of the estate or the person and estate. : Case Name Case Number Dates Appointed and Qualified (1) (2) (3) (4) (5) Continued on Attachment 7a. b. I would be willing to continue as conservator or guardian of the estate or the person and estate, on conditions approved by the court, in all of the matters listed in item 7a the following matters: Case Name (1) (2) (3) Continued on Attachment 7b. c. I understand that I cannot be appointed as a private professional conservator or guardian on any new matters in this court until I qualify under one of the alternatives described in items 5a­5e of this form, and that I must ask the court for permission to resign in any pending matter in which I do not desire to remain as conservator or guardian. Case Number

8.

Additional information required by court Additional information required by this court is contained in Attachment 8.

filed with this form

I declare under penalty of perjury under the laws of the State of California that the foregoing, including statements made in all attachments, is true and correct. Dated:

(TYPE OR PRINT NAME ) GC-005 [Rev. July 1, 2007]

(SIGNATURE) Page 4 of 4

DECLARATION OF PRIVATE PROFESSIONAL CONSERVATOR OR GUARDIAN--QUALIFICATIONS (Probate--Guardianships and Conservatorships)