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