In the State of California, there are specific forms that must be filed in order to initiate or terminate a guardianship. Guardianship is a legal process through which a person is appointed by the court to care for and make decisions on behalf of another person who is unable to do so themselves. One such form, Form Doa 6496, specifically deals with the termination of a guardianship. In this post, we will take a closer look at what this form entails and how it can be used.
| Question | Answer |
|---|---|
| Form Name | Form Doa 6496 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | dotted, Seatbelt, citations, doa form |
Wisconsin Department of Administration |
Vehicle Accident/Incident Report |
Bureau of State Risk Management
Instructions: |
In case of an accident involving a |
1.Report the accident promptly to a local law enforcement agency and obtain a copy of the officer’s report.
2.Contact your supervisor and fleet manager as soon as practical to report the accident.
3.Within 24 hours of the accident, submit this completed & signed form to your supervisor.
4.Submit this completed form, signed by your supervisor, to the appropriate Fleet Office within 48 hours.
5.If the police do not respond or complete the accident report and the accident has caused bodily injury, vehicle property damage is $1,000 or more and/or
Agency/Dept.
Location
Location of the
Accident
State
Vehicle
Information
Assigned
Pool/
Functional
Information
on
Driver
of
State
Vehicle
Other
Party(s)
Involved
(add additional sheets if more than one other party involved)
Agency/Department Name |
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Division/Institution/Campus |
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Supervisor’s Name |
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Phone Number ( |
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Street Address |
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City |
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ZIP + 4 |
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Street/Highway |
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Accident Date (mm/dd/ccyy) |
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City |
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County |
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State |
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Accident Time |
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AM |
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State Vehicle Owner Agency/Dept. Name |
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Reason for Vehicle Use |
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Year |
Make/Model |
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Body Type |
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Mileage |
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Color |
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Fleet Number |
Vehicle Identification Number |
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License Plate Number |
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Describe Parts Damaged |
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Circle numbered areas of vehicle damage. |
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6 |
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Front |
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5 |
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Rear |
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Driver Name |
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Driver Injured |
Home Phone ( |
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Work Phone ( |
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Wearing Seat Belt |
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Email Address |
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Date of Birth |
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Driver’s License Number |
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Work Address |
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City |
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ZIP + 4 |
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Home Address |
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City |
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ZIP + 4 |
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Were There Passengers in This Vehicle? |
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No |
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Injuries |
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Wearing Seat Belt |
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If Yes, List Names: ______________________________________________ |
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______________________________________________ |
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No |
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(Please indicate what type of |
Describe Parts Damaged |
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If automobile, circle numbered areas of |
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property was damaged.) |
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vehicle damage. |
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automobile |
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Front |
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fence |
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5 |
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Rear |
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building |
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guard rail |
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other |
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Property Owner (if different from driver) |
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Home Phone |
( |
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Work Phone ( |
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Home Address |
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City |
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State |
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ZIP + 4 |
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Year |
Make/Model |
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Body Type |
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License Plate Number |
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Vehicle Identification Number |
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Insurance Company |
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Phone ( |
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Agent Name |
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Address |
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Driver Name |
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Driver Injured |
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Home Phone ( |
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Work Phone ( |
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Wearing Seatbelt |
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Home Address |
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City |
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State |
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ZIP + 4 |
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Driver’s License Number |
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Were there passengers in this vehicle? |
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Yes |
No |
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Injuries |
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Wearing Seat Belt |
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If Yes, List Names: ______________________________________________ |
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Yes |
No |
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No |
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______________________________________________ |
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No |
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No |
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Pg. 2 of 2
Was the accident investigated by a law |
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Were photographs taken at the scene? |
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By whom? |
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enforcement agency? |
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Yes |
No |
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No |
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Name of the Investigating Officer |
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Law Enforcement Agency Name |
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Case Number |
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Were citations issued? |
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To whom? |
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No |
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Road Conditions |
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Did the state vehicle have lights on? |
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Did the other vehicle have lights on? |
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Wet |
Dry |
Icy |
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Yes |
No |
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No |
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Bright |
Dim |
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Other |
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At what speed were you (state vehicle) traveling?
At what speed was the other vehicle traveling?
Posted Speed Limit
What traffic controls were in effect?
For whom?
Who had the right of way?
What signals were given by you?
What signals were given by the other driver?
What did you do to avoid the accident?
What did the other driver do to avoid the accident?
Witness
Information
Name of Witness
Home Address
City
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Phone Number ( |
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State |
ZIP + 4 |
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Driver Description of the Accident/Incident
Attached sheets include additional description, witness and passenger information.
Please complete this diagram. Indicate names of streets, direction, position of vehicles and point of contact. Use a solid line to show path before the accident and a dotted line to show path after the accident.
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1 |
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State Vehicle |
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Other Vehicle |
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3 |
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Third Vehicle |
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Pedestrian |
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Indicate North |
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Stop Sign |
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Yield Sign |
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Stop Light |
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Scope of Employment Statement |
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As the driver of the state owned vehicle described in this report, I |
As supervisor of this position, I affirm that the individual named |
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acknowledge that all information provided is true and accurate to |
driver was operating the vehicle within his or her authorized scope |
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the best of my knowledge. |
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of employment at the time of the accident. |
Yes |
No |
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Signature of Driver (Required) |
Date (mm/dd/ccyy) |
Signature of Supervisor (Required) |
Date (mm/dd/ccyy) |
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