PROB §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.

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