Prob. Code, § 2954

A declaration issued by a peace officer under this chapter shall not be valid unless it substantially complies with the following form:

DECLARATION

PRINT OR TYPE

1. My name is: ______. My badge number is: ______. My office address and telephone number are:

______

______

______.

2. I am a duly sworn peace officer presently employed by ______ ______, in the County of ______, in the State of California.

3. On _____ (date) I personally interviewed ________ (victim) at ______ a.m./p.m. at _______ (address). The victim resides at __________ (address, telephone number, and name of facility, if applicable).

4. There is probable cause to believe that: (a) ______ (Victim) is substantially unable to manage his or her financial resources or to resist fraud or undue influence, and (b) There exists a significant danger the victim will lose all or a portion of his or her property as a result of fraud or misrepresentations or the mental incapacity of the victim, and (c) There is probable cause to believe that a crime is being committed against the victim, and (d) The crime is connected to the victim’s inability to manage his or her financial resources or to resist fraud or undue influence, and (e) The victim suffers from that inability as a result of deficits in one or more of the following mental functions:

______ INSTRUCTIONS TO PEACE OFFICER: CHECK ALL BLOCKS THAT APPLY:

______ [A] ALERTNESS AND ATTENTION

______ ◻ 1. Levels of arousal. (Lethargic, responds only to vigorous and persistent stimulation, stupor.)

______ ◻ 2. Orientation. Person ______ Time _______ (day, date, month, season, year), Place _______ (address, town, state), Situation ___________ (why am I here?).

______ ◻ 3. Ability to attend and concentrate. (Give detailed answers from memory, mental ability required to thread a needle.)

______ [B] INFORMATION PROCESSING Ability to:

______ ◻ 1. Remember, i.e., short– and long–term memory, immediate recall. (Deficits reflected by: forgets question before answering, cannot recall names, relatives, past presidents, events of past 24 hours.)

______ ◻ 2. Understand and communicate either verbally or otherwise. (Deficits reflected by: inability to comprehend questions, follow instructions, use words correctly or name objects; nonsense words.)

______ ◻ 3. Recognize familiar objects and persons. (Deficits reflected by: inability to recognize familiar faces, objects, etc.)

______ ◻ 4. Understand and appreciate quantities. (Perform simple calculations.)

______ ◻ 5. Reason using abstract concepts. (Grasp abstract aspects of his or her situation; interpret idiomatic expressions or proverbs.)

______ ◻ 6. Plan, organize, and carry out actions (assuming physical ability) in one’s own rational self–interest. (Break complex tasks down into simple steps and carry them out.)

______ ◻ 7. Reason logically.

______ [C] THOUGHT DISORDERS

____________ ◻ 1. Severely disorganized thinking. (Rambling, nonsensical, incoherent, or nonlinear thinking.)

____________ ◻ 2. Hallucinations. (Auditory, visual, olfactory.)

______ ◻ 3. Delusions. (Demonstrably false belief maintained without or against reason or evidence.)

______ ◻ 4. Uncontrollable or intrusive thoughts. (Unwanted compulsive thoughts, compulsive behavior.)

______ [D] ABILITY TO MODULATE MOOD AND AFFECT

______ ______ Pervasive and persistent or recurrent emotional state which appears severely inappropriate in degree to the patient’s circumstances. Encircle the inappropriate mood(s):

Anger______ Euphoria______Helplessness Anxiety______ Depression______Apathy Fear______ Hopelessness______Indifference Panic______ Despair____________

5. The property at risk is identified as, but not limited to, the following:

______ Bank account located at: ______

______ ______(name, telephone number, and ______ address of the bank branch)

______ Account number(s): ______

______ Securities/other funds located at: ______

______ __________________(name, telephone number,______

____________and address of ______

____________financial institution)______

______ Account number(s): ______

______ Real property located at: ______(address)______

______ Automobile described as: ______(make, model/color)______

______ ____________(license plate number and state)______

______ Other property described as:______

______ Other property located at:______

6. A criminal investigation will ◻ will not ◻ be commenced against: ______(name, address, and telephone number)______ for alleged financial abuse.

______ BLOCKS 1, 2, AND 3 MUST BE CHECKED IN ORDER FOR THIS DECLARATION TO BE VALID:

______ ◻ 1. I am a peace officer in the county identified above.

______ ◻ 2. I have consulted concerning this case with a supervisor in the county’s adult protective services agency who has signed below, indicating that he or she concurs that, based on the information I provided to him or her, or based on information he or she obtained independently, this declaration is warranted under the circumstances.

______ ◻ 3. I have consulted concerning this case with an individual qualified to perform a mental status examination.

______ ______

Signature of Declarant Peace Officer

____________ ____________ ______

Date

______ ______ ______

______ ______ Signature of Concurring Adult Protective Services Supervisor