Form Gc 335A PDF Details

Form GC 335A is an application to the IRS for exemption from automatic revocation of exempt status. The form is used by organizations that have lost their tax-exempt status and are seeking to have it reinstated. There are a number of reasons why an organization might lose its tax-exempt status, including failure to file required returns or notices, engaging in prohibited political activities, or not meeting the requirements for continued exemption. An organization must file Form GC 335A within 90 days of losing its tax-exempt status in order to regain eligibility for exemption. If your organization has lost its tax-exempt status, don't panic! There are a number of steps you can take to get it reinstated. The first step is to fill out Form GC 335A and submit it to the IRS. This form is used by organizations that have lost their tax-exempt status and are seeking reinstatement. You must submit Form GC 335A within 90 days of losing your tax-exempt status in order to be eligible for re

QuestionAnswer
Form NameForm Gc 335A
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesgc335a, gc 335a, dementia capacity form, gc335a capacity declaration form

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GC-335A

CONSERVATORSHIP OF THE

PERSON

CONSERVATEE

ESTATE OF (Name):

PROPOSED CONSERVATEE

CASE NUMBER:

ATTACHMENT TO FORM GC-335, CAPACITY DECLARATION—CONSERVATORSHIP, ONLY FOR (PROPOSED) CONSERVATEE WITH A MAJOR NEUROCOGNITIVE DISORDER

9. It is my opinion that the (proposed) conservatee

 

HAS

 

does NOT have

a major neurocognitive disorder (such

as dementia) as defined in the current edition of Diagnostic and Statistical Manual of Mental Disorders.

a.

(1)

(2)

(3)

(4)

Placement of (proposed) conservatee. (If the (proposed) conservatee requires placement in a secured-perimeter residential care facility for the elderly, please complete items 9a(1)–9a(5).)

The (proposed) conservatee needs or would benefit from placement in a restricted and secure facility because (state reasons; continue on Attachment 9a(1) if necessary):

The (proposed) conservatee's mental function deficits, based on my assessment in item 6 of form GC-335, include (describe; continue on Attachment 9b(2) if necessary):

The (proposed) conservatee HAS the capacity to give informed consent to this placement.

The (proposed) conservatee does NOT have the capacity to give informed consent to this placement. The deficits in mental function assessed in item 6 of form GC-335 and described in item 9a(2) above significantly impair the (proposed) conservatee's ability to understand and appreciate the consequences of giving consent to placement in a restricted and secure environment.

(5)A locked or secured-perimeter facility needs of the (proposed) conservatee.

is

is NOT

the least restrictive environment appropriate to the

b.

Administration of medications. (If the (proposed) conservatee requires administration of medications appropriate to the care and treatment of major neurocognitive disorders (including dementia), please complete items 9b(1)–9b(5).)

(1)For the reasons stated in item 9b(5), the (proposed) conservatee needs or would benefit from the following medications appropriate to the care and treatment of major neurocognitive disorders (including dementia) (list medications; continue on Attachment 9b(1) if necessary):

(2)The (proposed) conservatee's mental function deficits, based on my assessment in item 6 of from GC-335, include (describe; continue on Attachment 9b(2) if necessary):

(3) The (proposed) conservatee HAS the capacity to give informed consent to the administration of medications appropriate to the care and treatment of major neurocognitive disorders (including dementia).

(4) The (proposed) conservatee does NOT have the capacity to give informed consent to the administration of medications appropriate to the care and treatment of major neurocognitive disorders (including dementia). The deficits in mental function assessed in item 6 of form GC-335 and described in item 9b(2) above significantly impair the (proposed) conservatee's ability to understand and appreciate the consequences of giving consent to the administration of medications for the care and treatment of major neurocognitive disorders (including dementia).

(5)The (proposed) conservatee needs or would benefit from the administration of the medications listed in item 9b(1) because (discuss reasons; continue on Attachment 9b(5) if necessary):

10. Number of pages attached:

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date:

(TYPE OR PRINT NAME)

(SIGNATURE OF DECLARANT)

Page 1 of 1

 

 

Form Adopted for Mandatory Use

MAJOR NEUROCOGNITIVE DISORDER ATTACHMENT

Judicial Council of California

GC-335A [Rev. January 1, 2019]

TO CAPACITY DECLARATION—CONSERVATORSHIP

 

For your protection and privacy, please press the Clear

 

 

 

 

This Form button after you have printed the form.

Print this form

 

Save this form

 

 

 

 

 

 

 

Probate Code, §§ 811, 2356.5 www.courts.ca.gov

Clear this form

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