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: |
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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: |
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_____
| 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
_____
_____
|
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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,
_____
|
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_____
_____
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 |
| | |
_____
_____
|
_____
_____
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| | Date |
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_____
|
_____
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_____
|
_____
| Signature of Concurring Adult Protective Services
Supervisor |