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 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 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