Probate Code § 2954

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):

AngerEuphoriaHelplessness

AnxietyDepressionApathy

Fear HopelessnessIndifference

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