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HomeMy WebLinkAbout96-0975ANNUAL REPORT OF GUARDIAN OF THE PERSON COURT OF COMMON PLEAS OF C U rn ~.e ~~ a~ COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION C7 ~~ ~:: ~~ ' ;~~-~ k~ . ~~ - -. ~~; J -' - _- _. s _ _ <_=~:~ -_ ~ _ r~ , - =~ - -- _,_~ ~ .; •J J C_n Estate of t- ~ y L ~. ~ a- P • S ~ ~ ~t'c~-- , an Incapacitated Person I. INTRODUCTION Je nn ~ ~.t~ Q-. ~.l~o ~ ~ac~ ~ rti~-er ~~ur ~~°~,was appointed ®Plenary ®Limited Guardian of the Person by Decree of W t S ~ 2ti ~ ~ ~~ , J., dated I~QC.trnlaer 2O. t`1~°I T ® A. This is the Annual Report for the period from a ~ 00 to 1)QCt ~ r 3~ 2~ $ (the "Report P riod"); or ® B. This is the Final Report for the period from , to (the "Report Period"), and is filed for the following reason: I . The death of the Incapacitated Person. Date of death: 2. The Guardianship was terminated by the Court by Decree of J., dated For a Final Report, omit Sections II through IY: Form G-03 rev. 10.13.06 Page I of 4 ~ ~~of ~.-D J2 ~ ~ 0.~ ~ S rn ~ `t-G~.. , an Incapacitated Person II. PERSONAL DATA Age of the Incapacitated Person: III. LIVING ARRANGEMENTS A. Current address of the Incapacitated Person: ~} g i l v; ~-~ i ~.i a. ~1 oct.~ B. The Incapacitated Person's residence is: ®own home /apartment ® nursing home ® boarding home /personal care home ® Guardian's home /apartment ® hospital or medical facility Date of Birth: ~c.~-o ~P ~ 23 ~°f .3g ® relative's home (name, relationship and address) other: ~mmVni I L~J.r~q ~'~f'~'C~hc~,2r,,,~.-~-r ~p~~'oJp hOrn~.~ STUN2Q 2~'~" ~ `K,.~. Cv,~, b,~.r~G.nU ~P2fr~.( ~SR.`CD~" ~~~fZlr4-Cd ~i~~Ze C. The Incapacitated Person has been in the present residence since ~2. ~. ~ l . ~~.OD 3* If the Incapacitated Person has moved within the past year, state prior residence and reason(s) for move: t.,~oJ 2 L 10. ~ S q rpJ p ~O+rYI Q, 1~ - ~ O C0.`!-~C1 ~ ~ i r~ i !~, l0.-~O al.~ 2~ L l ~ ZO(33 . st~.e, Carn2 ~1) ~mb.~r lamed Co,~„, tN. \`18'S"~ c~ r L ~~ ~. ~~Os~ n ~eh.YlllJ,rS'[ ~5~~~~Of~ . S~ ~ ~ ~'1 C0.re~ .~j~ (n,c~ i+ /1n' ~ V S i nCQ ~4'Z.ct-~' -h m e~ y~ i~ ~ 9 8s~ , ) ~- T Form G-03 rev. 10.13.06 Page 2 of 4 ~E a~ of l.,bVQ,~~0.. ~• Srn~-~-- , an Incapacitated Person ~J D. Name and address of the I(ncapacitatned Perso/n~'s primary caregiver: ~- I /-1-s >ti l ~ A-v~ ~. Grti~ l; S 1.~ ~A- I~-ol3 IV. MEDICAL INFORMATION A. The major medical or mental problems of the11Incapacitated Person are as follows: ' ~ro.~o J~nc~ 12ve. ~ o~ mew-~n.~ retzt.~^QcZ'hon ~=Q ~,S~S be~~oc.J aO~ ' ~IinCk~l~SS ' nn~``i ~~CAArO C,,.Qee., ~ I . (-TI"t~, r; 'F~ S I ~~ O p0(O S ~ S ~ K~~ l~!$1$, (o ~ r s ~ 't7 s t~ a5 ~ l c1 t r- u.hs dad Q0.', ~- B. Specify~h~t', if any, social, medical, psychological and support services the Incapacitated Person is receiving: ' ~to~.. - ~r i . d P ~w` S e r ~ ~ ceS~ ~-o ~~ ~ u.~;~ ~-e a ~ ~ b ra..~ ~a~ / • des. d~.~--~«~ sv~p~-~ ~{~..r~v~t~ CPA-~.e._. • /~I.,,o~. aS >~~d ~~ c~~-2c ~ also .~~. ~~~d~~ V. GUARDIAN'S OPINION A. It is the opinion of the Guardian of the Person that the guardianship should: ~{ continue ® be modified ®be terminated Form G-03 rev. 10.13.06 Page 3 of 4 IZe o~~ E e of LoJQ_~,~a-- ~• S n~~~ , an Incapacitated Person The reasons for the foregoing opinion are: 1..10_ ~erl(.~ ``ff~ OOs v~no~b l~ -b ~,~~ se I~f --ca.rer d.e. c i s ~ ons o-1. Iti.Q~ own . 1kt r Ntl.b't'~.Q..Y i s dece11a__ sed CslIo (S I~Lr ~~r, ~ ~ rQ,l'~a t rl l /L 1v~ Firv~ ~ ~S Q rL ~~ n ~e r~S~ Q i n S ; n~ ~~ n ~ J r~ l~-~. r S ~~ -Ev r 5 O~le~ .~e, ve +~- - v2-1C. wati~l- w~a..-~ ~ s ~ s{ ~~ h~ '_~y~,~,,~ ~v~,~~e.~` S ~ nom- Lai- 1 ~.~ 3 ~ B. During the past year-; the Guardian of the~ers~ on has v~ isited t`~e Incapa~t't~t~~er~on ~_ times with the average visit lasting ~ hours, 36 minutes. The report of a social service organization employed by the Guardian to oversee and coordinate the care of the Incapacitated Person for the period covered by this Report may be attached to supplement this Report. fT~~ Ot' La~e.~~.a.~S -~por~ a~~ 0~-~~2 a-~'~ CUrv~.b,Qr~0.n~~Pe,~~l I verify that the foregoing information is correct to the best of my knowledge, information and belief; and that this Verification is subject to the penalties of 18 Pa. C.S.A. § 4904 relative to unsworn falsification to authorities. Date a Sigma re of Guar n of the Perso Name of Guardian ojthe Person (type or print) Address ls.,~ City, State, Zip (71`7) x-95- 8~ 90 Telephone Form G-03 rev. 10.!3.06 Page 4 of 4 / ~ . ANNUAL REPORT OF GUARDIAN OF THE PERSON COURT OF COMMON PLEAS OF c'u..m b~ (" I Cln LCOUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION (-.., ~~o , ::':'] 1-.:> = c.:::> --.I ;:::1'" -I:] :::'0 f'-) ..-J " , " Estate of Lou. e.. \ lo- p, Sm'lR ',',! - . an IncapaCitated Wrson . Ul ..-J No. 21- 9(, - oCf7S- I. INTRODUCTION Jtn n ',.{: r \ ,I' (' l;Jo\ bD.-cL~) L '{\01.i) ...} U- V\. I tt (+, W 0 I back . was appointed lJPlenaryClLimited Guardian of the Person by Decree of lJQ.S \~e..r . J., dated ~D.te.... '"Z..lJ I3qg- . cr have... ~~eora("'II't fo(\;splo.ced ""'f artif., J:- be.li~Je... '-tt-.:s dctk IS corrie+-) , urA. This is the Annual Report for the period from J ct t'\ LJ a ~~ . 2.00(, to 'hi (' P rY\ kI r 3 J . 7-00(., (the "Report eriod"); or D B. This is the Final Report for the period from to (the "Report Period")~ and is filed for the following reason: 1. The death of the Incapacitated Person. Date of death: 2, The Guardianship was terminated by the Court by Decree of J., dated For a Final Report, omit Sections II through IV. Form G-03 rev. /0.13.06 Page 1 of 4 \.>.. r / Estate of Lo u-e.. II CL- P. S t"rl " +t, , an Incapacitated Person II. PERSONAL DATA Age of the Incapacitated Person: 6.'6 Date of Birth: l 0 /2-3 / I q 3 ~ III. LIVING ARRANGEMENTS A. Current address of the Incapacitated Person: Lf55 I \ Vi r3 i V\. i 0- Road MtcJ,unic5 bu~1 PA 1705"0 B. The Incapacitated Person's residence is: [J own home / apartment . [J nursing home [J boarding home / personal care home [J Guardian's home / apartment [J hospital or medical facility [J relative's home (name, relationship and address) !:iiother: c..,mmLln-.+'f L;vinj ArranJement) tund,,j ~ tu""k,.,lc",d I Perr, f'v{,,,ht.O ({einrda:l;on SenJiCeSj s-hitCecl ~ ~ C.umbu la.nd / Purl 4. iii. . C-. CC.PMe-) c. The Incapacitated Person has been in the present residence since Fe.1.o. Ll, 2003* . If the Incapacitated Person has moved within the past year, state prior residence and reason(s) for move: t- S hlL hct5 res i ded ~+ V; orji ^ i Q. tZd So j IlCQ. 2.(2-1 /2-003. Lou"llo.- ,^as nSi&fd '/I'+"" C-OmrnU/1i+tI wN-t--'Ke t..../p O~ c.PA-~~1 S'j nC-<2- 4/' Il~ 8'5"". Form G-03 rev. 10.13.06 Page 2 of 4 ....:1". / / , ., Estate of Lo~ ~ II 0-- P. s rY\ j~ . an Incapacitated Person D, Name and address of the Incapacitated Person's primary caregiver: N (Pr ~P~R.c.- r rovides 2.Y hour- QuJQ.1ce s-hU,-j IV. MEDICAL INFORMATION A. The major medical or mental problems of the Incapacitated Person are as follows: ProtoClhd Ie.ue..( O~ me.nkl n-/-arclQ-h'on em -kst--s Io.e.low ~o) ljl'AdVltSS I TY-aJAfI/lQ~'C CQ-krac.i:s Cb~ ty~s) fvt. i crO c~p hctl'f ~~,,; -k 5 I Oskoporos; S I 1<-, f hOS;S I 8vrs ;11-s in V!)S houlJ.er G-E rz 1> I I-h- ctM h u Y"\ ; a.... U.1'15-\:ea&~ ~ r 1-1 ed' a1 hi' I d . . th B. SpecIfY what, Irany, SOCIa, m IC , psyc 0 ogtca an support servIces e Incapacitated Person is receiving: (ZtSid.en:hcJ ~rOj("a.m .sufport ~Om CjJf+{<.C-, (j(\clu&.eS 8ot\.Ls ~ Lout 110-- -to W0r Ie On) D~ proW,:-m _sen) ius ~"d-iJ ~ C.umlo/ Pury H((S +- M~J\' CQ,d Stn) I tR-S pY'"Ovl'd-tJ @ Uc:p 4/~rno...i,'ves p rC> d retrn) Li "dlA... lctne., ~ '* II) fvl Of) - Fr; , v. GUARDIAN'S OPINION A. It is the opinion of the Guardian of the Person that the guardianship should: ~ontinue [] be modified [] be terminated Form G-03 rev. 10.13.06 Page 3 of 4 Estate of Lou.tllo.- P. Sm~~ . an Incapacitated Person f The reasons for the foregoing opinion are: Ot.h u.. ~a n 'tL... f:)( tI c uAi v L ); rR ctv d~ tPAA(j whO sevJes as ~. loc<cK-ufJ J Loue.UO- hast r -\-0 lu d ., f' h .,- I. _ 11/ . no On~ t s~ (Y'Q ~ CI S ~oC'\.s -rtY\ er. oJ-. roll<.. f--,.hOw(\ loue..lla.. s; nee- I ~g3 - ~Y'k( of)~ ot. her c.-Urr~i')+ skt{ hQ-S ICnO/.J.X) h~r"'f.ha.f IOnC1 l...U 1 S VV\ uC ~ -fv I nQvtr. lha.+ \ S uJ h. \f :r: was M h rl -k IaL CJ- lltlrd. icm'-1- ~ 'h e.~ B. During the past year, the Guardian offhe Person has vlsliedThe blcapacittted Person 0 pe~. '5 times with the average visit lasting ~ hours, 30 minutes. A\so +eJe.phonL ~cdls uj'(~ her skPf2, Pt<~. The report of a social service organization employed by the Guardian to oversee and coordinate the care of the Incapacitated Person for the period covered by this Report may be attached to supplement this Report. A l \ ex. v-L 01\ .(J, I €.... (A+- c.. U m ~ r tar<:!! P-e If' ~tnw. Kej'ZLrda..J.ion &vvic:es' Of-h'ce l Sa.u) no nQ..12d +n d up 1 ; ca..{e , I verify that the foregoing information is correct to the best of my knowledge, information and belief; and that this Verification is subject to the penalties of 18 Pa. C.S.A. 9 4904 relative to unsworn falsification to authorities. ZS-+Ji 'f d-OO-:f-. Date '-. J~, 41'" () 1/ halL ~/T(JJl..S Name ofGua", ian of the Person (type or print) 10-::;-2--/1 14 nth.. ~.J-,r. -:B lvi, Address :!:!2~ ( hA/t ,ice; '}11~ fJ If- 171J,~ City, tate, Zip U / (7 II) 1-1 s-:-- 8& Cj() Telephone Form G-03 rev. 10.13.06 Page 4 of 4 ANNUAL REPORT OF GUARDIAN OF THE PERSON C) So ,e: -;g IC") -, J:> L_"" .'-:;:::-i j I r ,. --"~: ""IJ (J)/:..: (")0 QT' ':0 .-, --, ~. '..J .J.'.'" COURT OF COMMON PLEAS OF tVMh( r \~ ",d_ COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION Estate of lcve.-ll~ 7. SM..~'+L , an Incapacitated Person No. Z, 1- "I Ct - 0 q 7S- I. INTRODUCTION J.e.~VLi.c.r A. CUo l kcl (Je,.."..,\C,.. Wolb..cL'60~~~s appointed o Plenar:J:.DLimited Guardian of the Person by Decree of Wl51~ 0 l~r , J., dated O<t c. 2..0 I l4 q 9 . EI A. This is the Annual Report for the period from jo..t\vo.,~ \ , "l.OOi to D(.c-{,...M..'a.Lr 3:. \ , 2-ocJi (the "Report Period"); or o B. This is the Final Report for the period from to (the "Report Period"), and is filed for the following reason: 1. The death of the Incapacitated Person. Date of death: 2. The Guardianship was terminated by the Court by Decree of J., dated For a Final Report, omit Sections II through IV. Form G-03 rev. 10.13.06 Page I of 4 t'..) = c."::j co :3t :0- -< \..0 II -0 :x N c..n N Estate of LoULUlL- r. Si\M'-tL , an Incapacitated Person II. PERSONAL DATA Age of the Incapacitated Person: ~ '\ Date ofBirth:~ III. LIVING ARRANGEMENTS A. Current address of the Incapacitated Person: Lf~ /! V\tjiilia.- ~d fvte-CJ~LtMGSk~ Pit I ~O B. The Incapacitated Person's residence is: o own home / apartment o nursing home o boarding home / personal care home o Guardian's home / apartment o hospital or medical facility o relative's home (name, relationship and address) 181 other: c..orr.lV\\.II'\-J-~ Li-J; ~ A-rra..t'\8'--vn-tJ 5 ktkd ~ ~ tIJMb,\q,rJ f P{rr'-{ A-ssoc"o-.-kO("l f;,.. Ke.~,..-d~d c..it-:"Un.5 C. The Incapacitated Person has been in the present residence since fth. 2.l,2m~ '* . If the Incapacitated Person has moved within the past year, state prior residence and reason(s) for move: 4>- Lo.;d l", 's j ,.-0'; f hOynL l C Ul-M -tr, V; >' f!J ' ~ "- K.cJ 0 oLfZ.-t{-U'::;3, Sk hGt-S livt-d it1.-~ ~MU(\-;~ Ct.0N-L'tL..z..<-t~r QSs ~ 5+-tt nC'l- o-P ~PA-R-c-) &iAU- Y {I lit q g~ Form G-03 rev. 10.13.06 ' Page 2 of 4 Estate of l.ou~llo..- 7. S ~'i-L , an Incapacitated Person D. Name and address of the Incapacitated Person's primary caregiver: ~Mbu t~ f Pt-r-r'l A .f<. ~. 7f Ask.(~d kvt-IU-UL- ~ ( IS l-t..- r A-- I :r-o \ 3 IV. MEDICAL INFORMATION A. The major medical or mental problems of the Incapacitated Person are as follows: -p r-ofov(\d. {e-ve.-l o~ MU\ II r-e..1arda.:h' 01^-- (:r:C1 4eS+-S 6~lOLJ ;)D) \S\~"dV\essl \Ya.M.~~C-- c_O,J~.fClC-h Ch~ ~es) Mic-ro~f~ . A-~"'-i ~ S I OS4-eoforo.si~ I K.,~has IS )6vr5i -h"S ()i,-... ~S h01A.J~ tY e fZ- ':D I tk o...-hQ... hi. rr\...(' ex- Cl(\.s+et-l~ Q-~+ B. Specify what, if any, s'rlcial, medical, psychological and support services the Incapacitated Person is receiving: MOn- Fri d'4 proB r<lm'- s~. 'i1MO~lll"'i.w ~re.b rall p~) ~ ~H l~CCL'~ 'R~side.J;a..O Supfort SUlile-e.5 ~ ~Jl ~ ~f:s ~ \; ~ ; "Cj> "" + ..J. t .\; rne.S C~€ft w4.- oJ- ~ f"'<8 rM>'--- ') A-dvo~~V;Ges as w-dut.. ~\'"00()l,... e..1.~. Q..c... [~ v. GUARDIAN'~PINIO~va..rd;ll+-- a...s w&JL) A. It is the opinion of the Guardian of the Person that the guardianship should: 1&1 continue o be modified o be terminated Form G-03 rev. 10.13.06 Page 3 of 4 Estate of LOcJ~llo....... P. S~'+L , an Incapacitated Person The reasons for the foregoing opinion are: Q-t{..L (' ~ 'tl.L ~'X.e...c-ui1 vL- lJ j r-ec1r of- L~Pr (Lc..-I vJ~ s'e.rve5 ctS 0... bCLC-k.LJr? J LouL-llo-... ~ V\o OtUL -\0 a.g s 15+ ~ r 11\ du i S I Bn - Mc{J(.i 'j (.fo r m~ Or f't\ed; eaJ t'rI.aAltrs) ::r:: ho..uQ...- t-hDl-O f\ Lo,v.e..U lL SA I\. c-e..- 1 q q-.S it- l,..ct~ bU..." ~nu'l1\eJ\..{ ~ ci ~ Gi AC(l.- ovr vne.-t.-'h "j' e..lv~C- "-sk:e& ~ +0 ~~ ~ II I . B. During the past year, the Guardian of the Person has visited the Incapacitated Person (M~ co..Q ~ Ua..-t(J.i i~. II S times with the average visit lasting \ hours, -35"" minutes. AlSo kltfhOv'\t- ~s w~ ~ s.fa*, eLffV-O'l. ~~ ~,- WL(;~ The report of a social service organization employed by the Guardian to oversee and f R.. rJ ) coordinate the care of the Incapacitated Person for the period covered by this Report may be ' attached to supplement this Report. A-\l a,u. 0/\ .AlL tt+ CVMbu--{4.nd/ PeIrj ~tfL,~ Q~~rda.-+;on &u-vic.e.s- 5a..u) no ~d ~ 6vf>licec-k. lou'!.-lLo... i S d~j 1\8 ~ tts.~ ~ y~ Svppor1-\vt- s~f-f worb~ w(~. { I verify that the foregoing information is correct to the best of my knowledge, information and belief; and that this Verification is subject to the penalties of 18 Pa. C.S.A. S 4904 relative to unsworn falsification to authorities. Da!e S-7rl~ &DO? ~u J./f',L -:;Jm<1f_ Signa re of Guard of the Perso JelLlIl'kr Wo/bar,^- 750cdS Name of Guardian of the Person (type or print) /072-/1 Wtl1ctl~/e( IS/lid, Address ?!2U htVIU"r: r; 1,<''(1' (J,If- (~ City. tate, Zip I (7ft) 1-GJS-- g-c, 90 Telephone Form G-03 rev. 10.13.06 Page 4 of 4 LOUELLA P. SMITH Guardian of Person Review 2007 Louella turned 69 years old this year and remains in good health and good spirits, as usual. She continues to be appropriate for CPARC's small group home setting. As guardian of person I attend her residential reviews as I'm able, visit with her during the year, attend parties for her & her housemates, speak with her staff via telephone, and accompany her on medical appointments as needed. I also review her quarterly reports from UCP (day pgm) and CPARC. Louella enjoys numerous outings, such as shopping trips, hair appointments, movies, the ballet, and eating out. She attends the Alternatives day program Monday - Friday. Staff at home and at the day program continue to assist her with eating and drinking, with taking a sip following each bite. Her liquids are thickened with Thick It. Louella continues to thrive in her home environment; she is always clean, well-fed and well cared for. Her staff know her preferences and her likes and dislikes, such as funny movies, country music, having her back lightly rubbed or her hands lightly rubbed, and having a great sense of humor. They accompany her in shopping and social events, such as the dances at Silver Springs Presbyterian Church, the CPARC Thanksgiving dinner, and visiting a friend in Carlisle. Louella is still an active member of the community. Her current goal in the home setting is to make a seasonal craft project monthly. She is making good progress on this goal. I have been the recipient of many of the items she creates. It is delightful to see the creativity and thoughtfulness that staff use with Lou for the projects. Staff continue to assist her with ambulation inside the home, she really doesn't use a wheelchair once she's in her home. In my opinion, Louella could not get better care anywhere, and I hope she stays in her home as long as possible. Louella is now part of a smaller, quieter group at her day program. This new room has provided a calmer environment for Louella. Alternatives provides a wide range of activities for Louella to experience, and this setting also continues to remain appropriate for meeting her needs. As guardian I continue to oppose any change to an unstructured "one-on-one" program at home. I fully support continued placement where she is - both at home and at her day program. Respectfully submitted, n ~ ~tU. f/,~bwl&-- J~~;er'~~I~ Boweg' 1072-11 Lancaster Blvd. Mechanicsburg, PA 17055 o :n -TJ :TO :~~ "-' .~ ,....,-, ) ~~~~ ~~~ :) ::0 ~;J -i ~L-.-- I''':> = C-? co :::~ :;.;..... ',- --' i -< ---.. -j !-. ~-' I. '\ \D ~ v -"'- -', N .. ;:r:l en N ~ ANNUAL REPORT OF o ~ ra _~ ~ , - '' GUARDIAN OF THE PERSON ~ ~ -~ ~~ ~~ ~ GJ - .r>~ ' O - ~ ^ - c_ ~~;~ ^p r. ,, -;-~ COURT OF COMMON PLEAS OF '~ ~ rv ~ = ;=r ~- U lti ~ ~= f2 ~-~ ~ D COUNTY, PENNSYLVANIA -~ w , , ORPHANS' COURT DIVISION Estate of ~ O ~ 2-~ I ~t, ~ ~ .S Yr ;~}-~(,~ an Incapacitated Person No. Z I - `=14 ~ C c1-~~ I. INTRODUCTION appointed Plenary Limited Guardian of the Person by Decree of _ U`U k ~ (1 ~ ~ ,.~ J., dated ~ ~ c . ZO ~ l ~ ~ c`) A. This is the Annual Report for the period from J ci h V 0.r. 7 Q~1 to I Z-OD (the "Report Pei od"); or ~ B. This is the Final Report for the period from to (the "Report Period"), and is filed for the following reason: I . The death of the Incapacitated Person. Date of death: 2. The Guardianship was terminated by the Court by Decree of J., dated For a Final Report, omit Sections II through IV. Form G-03 rev. 10.13.06 Page 1 of 4 Estate of ~-- v `I e ((cam, (~ , ~ ,-~-~ ~, ~'-~'~. an Incapacitated Person II. PERSONAL DATA Age of the Incapacitated Person: ~' ~ Date of Birth:_ ~ic ~ . ?,3 , (~'1 ~ ~' III. LIVING ARRANGEMENTS A. Current address of the Incapacitated Person: ?~a Z v (cl S-E-v,,e~ I~,~vSe. I~c~acl (~~; I; .~J 5~,~; ~~~, P~~ 1 ~GO~- B. The Incapacitated Person's residence is: ® own home /apartment ® nursing home boarding home /personal care home ~ Guardian's home /apartment hospital or medical facility ® relative's home (name, relationship and address) ,other: ~.•v rYl M v /1 i ~ ~. ~ Vy ~ ,'1 c~ 1TY ~CZ /1 C ~ s T~~ t ~ -P C( J ~ Iti~ e ~"1 C. The Incapacitated Person has been in the present residence since /-1 y q ~ S ~' I • f ?,(~") `~ ~ _ If the Incapacitated Person has moved within the past year, state prior residence and reason(s) for move: ~" L.v~~l~ c~, I~ct S I~.S ~ ~ ~c~ i n C~:~ IZC ~~Oi'P dame s S•~nC~ y (, (l~~S, ~r C ~J T re. ~~ ~O<JS~ W Q,.S ~o c,~ i ~ ~~'~ ~ Sv t ~ lie ~ p~s ~ ~a..l 'v~.QC~ ~ (~~}-e,c~se c~~ he Form G-03 rev. 1 .13.06 ~--I ~ I I U ~ ~~ ; ,~ ~ ~ ~~c~c~ (~~ P_ C I/1C~ u~ ~ (_ S ~~ r C~ (~¢~ (~~ `~ Z. ~o~S e v~ Ct~'--~=~ , age 2 of 4 Estate of ~--C7 yC~~ '~ , S ,~ `~~~-- , an Incapacitated Person D. Name and address of the Incapacitated Person's primary caregiver: C~~CZL ~- l ash ~~r~ cl l~ ~e n ~L IV. MEDICAL INFORMATION A. The major medical or mentalffproblelms off the Incapacitated Person are as follows: ~~+"G ~ J ~~ fMe n~-ctiI 1~" t~ ~" C: t GL ~ U ;'1 ~ ~ ~ S ~5 ~Q ~ Q-w ~~~ ~ ~ ; nc~ n e s s, ~ ;rte ~,,, a ~' c e_ c~-~-~,- a c-{`~ C b ~ ~..~e s ) L ir0 Cam. ~ ~c~ ~ ~- ~ ~2 ./-~,~-~~ ,- ~ ~; S , vS~O . rp S ~ S , K "~~ ~C> S ~ S r {J J ~S i ~ S c~-c ~~.~, F-h she ,- ~, ; ~7 ~~,s~a~~I. ~a~~ B. Specify what, if any, social, medical, psychological and support services the Incapacitated Person is receiving: ~ i I~es,cle~.-l,~~. s~~~o~f Se~v,ces ~~ ~1~ ~~~; ~~s(cs o~ ~~~~,~,~ ~ ~ ~o ~.c~ct-~ se ~~ ~ ce S c~S ~~~c~ ~~. ro ~~' ~~ c} ('(~-(Z.C~ t- ~~a ~c~. ~ c~ V. GUARDIAN'S OPINION A. It is the opinion of the Guardian of the Person that the guardianship should: continue ®be modified 0 be terminated Form G-03 rev. 10.13.06 Page 3 of 4 Estate of ~ v UC', l ~ CL- ~, Sm ~~~. , an Incapacitated Person The reasons for the foregoing opinion are: ~`~~`,~`-~~ CX` C ~U~, `~ ; ~~~ c~F~PA-~L., w~,v serves cis ~. ~a~(L~~ ~ C...eL~etlc~... his -~o ~~~~ ~ CiS5~~5`f" her i n C~eci S~o~-v~c~~n ~ ~o mct~ o~ vrtee< i c~~ 1rnc~~.S, Z have,- ILv~c~wn 1.~,~e llo,., S ~ nce l~3 ~ ~~., der ~~ .~ S i S~ >'- Z--a~~re ~ 10. v~ rv ~ ~~eQ C.0. r~ c~ ~r- {fir C~.v.e r S ~ nce , CP~~ c~.S k'~c1 h~~ a n ~.yy ',~~I-c re s (- ~-z, l9-e c c~ ~_ he ~ P ~{ ~ c ~ q v a t- ~ , ~Oa~c~ B. Ddring the past year, the Guardian of the Perrson fias visited`EIIe Incapaci a~te`~13erson ~_ times with the average visit lasting ~_ hours, ~_ minutes. /~risc a~ i~c,s~- `~ i Cs ~;; -4-~. ~e ~ 5~z,~-(- (.~ cL~e c(~ v.L. ~~,- l,..pc '~- ~ The report of a social service organization employed by the Guardian to oversee and coordinate the care of the Incapacitated Person for the period covered by this Report may be attached to supplement this Report. /.~ (~ 0.~ ~ n ~ ~~ ~ ~~~ ~ ~ (any{ ~ (j~ r ~ ~~ ~~~~~ ho ~~z c~ -~ d ~ I ~ cz~-l~ ~ c__-~, ve ~ l ct.. s s I o ~:.~ S c~o~~.~ ~ ~ doti~n ~ lo; ~ b,.tf-ov~~t ~x~lY-e n~e~ we.l C w ~ti-~-~-2,~ pe rson0. ~ ~ ~ cl cU re s!~ r~ c~ ~veS, I verify that the foregoing information is correct to the best of my knowledge, information and belief; and that this Verification is subject to the penalties of 18 Pa. C.S.A. § 4904 relative to unsworn falsification to authorities. Z ~ ~~~ ~ 2~(j l Q Date ~_ Signatur of Guardian he Person - ,~~ e h n ~ ~e ~- l'.-C.~o ~ b a c l~ ~ o u.~5 Name of Guardian of the Person (type or print) i ~ ~~ - ~ f LQ nc~cs~ r ~ 1 ~c~ , Address lyl e ~ pct n ~ c s~ ~, r~,~- ~ BOSS. City, State, Zip Telephone Form G-03 rev. 10.13.06 Page 4 of 4 A CPARC Newsletter Winter 2010 It's Official...CPARC is now The Arc of Cumberland and Perry Counties At the November meeting of the General Membership, CPARC's legal name changed from The Cumberland Perry Association For Retarded Citizens to The Arc of Cumberland and Perm Countzes. The organization's desire to become The Arc of Cumberland and Perry Counties reflects the National and State movement of the Arc to be unified in its message and brand. a Beautiful Addition to Residential Services ."',hurchtown, Residential Services first ever new construction, had its groundbreaking on February Lath, 2009. It took over six months for the beautiful iew home to be built on the 2-acre lot. Today, the f-bedroom 2,500+ square-foot home is complete, Nith three individuals living there, six staff and a room tvailable for respite visits. :ndividuals began moving into Churchtown on August l7th. associate Director, Laurie Foose, said that the residents ire very happy in the new Churchtown home. They especially enjoy the large living spaces and occasionally ;ee deer in the backyard. ~ccessibiliry was a focal point when the plans were irawn. The two full baths feature awalk-in shower and a bathtub that is designed to make transfers from a wheelchair into a bathtub easier. geeing the individuals experience such happiness with their new home makes all the hard work ~vorthwhile -Director Carol Ferenz To this end, our name utilizes `The Arc of as an identifier. The Arc has essentially used an acronym (Arc) to replace what was the wording `retarded citizens.' This people first language is consistent with today's cultural movement of eliminating labels. Our programs and services, as well as the CPARC logo and brand, remain the same. Consumer ,.S~potl ig~ht '~ S~and~T~lcCauslin, aresident.at Carlisle Group Home, received ber 1 st Level Black Belt in Sho '~ Dui K,rrate on December 5th. .'_Sand~ has been taking karate ~~iessons for the past seven years =''-'from Bill Shank's Isshinryu ~trate Club. Sandy became .,:.:. _, ~~~'iiiteitsted in karate to "learn sdiiiething new" and also enjoys arts and crafts, music iLrid u~vrlin~. '~~ Sandy McCauslin with instructor Brll Shank .. , ~, r ~ .r' .,,r ~ -- -- --- -- ~. , .. , .'.r The Arc of Cumberland & Perry Counties 'residential Service's Newest Addition, Churchtown Lovell rs hew l,oT,-,~ First Ever~New Construction . + ANNUAL REPORT OF GUARDIAN OF THE PERSON �,.: � � � � � `_' m � p '� � � C5 r� � � � c�� :�+ COURT OF COMMON PLEAS OF �, ,y ,.._ � _.� c� �Jm I�.r LGt�_COUNTY,PENNSYLVAN�A`;= �.; rv �;;` `�� ca ORPHANS' COURT DIVISION F�� <, "; ---, `;; `' , . :, -� _ . , . . t `'� � ; ,-� ., ti, �� �t P. s�.��. �� �r� � :�� E of �-�V� �- ,an Incapacitated Person No. ��- ��r ' �q�}� I. INTRODUCTION ��-�1n`�i-�r /'�'. w°I�-�c G, �Jenn��-Z� lN���C� �5�,was appointed �Plenary�Limited Guardian of the Person by Decree of �1v2S I�a � r' , J., dated P c d-0 I �--- � A. This is the Annual Report for the period from��n �i 0.r�_� , �(D to P C o�,.,,���r 3 j �0 I D (the "Report Period");or [� B. This is the Final Report for the period from , to , (the "Report Period"), and is filed for the following reason: 1. The death of the Incapacitated Person. Date of death: 2. The Guardianship was terminated by the Court by Decree of J., dated For a Final Report, omit Sections II through Ii! Form G-03 rev. 10.13.06 Page 1 of 4 'l..�G.l E�3�c�S� �.Q UQ, � ' S ' , an Incapacitated Person II. PERSONAL DATA Age of the Incapacitated Person: �a Date of Birth:�C�', �3 � �'13� III. LIVING ARRANGEMENTS A. Current address of the Incapacitated Person: 30 a. O I c� S-�n�. �o vs�. �vac� �', l�� n ��n S p.�}- I�-C�o�-- � � � B. The Incapacitated Person's residence is: 0 own home/apartment �nursing home ❑boarding home/personal care home ❑Guardian's home/apartment [�hospital or medical facility �relative's home (name,relationship and address) other: �'/�_ i � G�P I-,ome, S-}�t��_PC� `� Cv n�t b��[� �., /�� A�so�����;U� -�.r- Q�-� �d c�+��,, Y s �Cn��) C. The Incapacitated Person has been in the present residence since� �- Z�� . If the Incapacitated Person has moved within the past year, state prior residence and reason(s) for move: Fornr G-03 rev.10.13.06 Page 2 of 4 -'��r r . f7 .^�.. � i �� � � C � r rn n ANN�JAb, I�EP�RT OF rn � �. < <�� �� ' GUA�DIAN �F '!"H�' FERSON � � �; � ;'� � _ �� � � r.., c� --� —. -; C? �, � -,r ; :? ',„.' ' , t-- `' � �� � COURT OF CONIMON PLEAS OF ' �; R' r- `" c_� � .� �.0 m�r �CcnC� C(JUiVTY,PErdNSYLVAI�'A r-� ORPHANS' COURT DNISION �;st� of �0 V� l l C� P . �M +�-'�-- , an Incapacitated Person No. a1 - �c� - o�� . � � . . . �. �N r�a�ucTiorr , _ , �..�P n n �-4-C r�r. �o I bc�C�, J2 n n�{-�� (�o� �.��'��was annointed �Plenary�Limited Guardian of the Person by Decree of�,�,,c���' , �., dated �Q � �.C>, I�l�l� � A. This is the Annual Report for the period from ..,0.f�UC�-r`1 � ,�� to �PC�r,n hg.r 3 � , � l i (the "Report Period"); �r � B. This is the Fin�l Report for the period from _, , to _,ii!(the"Report Period"), and is fited for the following reason: 1. The dezt:�of ihe Incapaci�ated Ferson. Date of death: 2. The G>>ardiansr�ip was*�rminate�.' uy i:�u Caiir�by T��cr�.e cf _ 3., d�ted_. ---- - �'�r a FinalReport, ornit 5ection�lithrough�t! Fo,m�-o:, rev.10.13.06 Page I of 4 , ��� . . �Est�e-s� o�e�lr,� P. s rn�-�- , an Incapacitated Person i ' II. PERSONAL DATA Age of the Incapacitated Person: �3 Date of Birth:_ (�G{'� Z3� � 3A' III. LIVING ARRANGEMENTS A. Current address of the Inca acitated P p erson: 3Oo1 O I cl S-k�rle I'IOJS�. (� oaC� ��� �� n� S���n�5 PA' I �('j� B. The Incapacitated Person's residence is: �own home/apartment �nursing home [�boarding home/personal care home [�Guardian's home/apartment [�hospital or medical facility [�relative's home (name, relationship and address) �other: �0�� ►"X�r1�C. s-�-z�'f'f2C� C(�� C - 1 I {� /�T�SrI, ( r �e � � CCvn��rlCcnCt/f'� , 1� -�z�rc(e� C i`�-t�Ze h S) 'I Y C. The Incapacitated Person has been in ttie present residence since �� � � . If the Incapacitated Person has moved within the past year, state prior residence and reason(s)for move: Form G-03 rev.10.13.06 Page 2 of 4 'li � � � — _ _ I _ - _ _ _ _ _,�..� , Es of �—O�J� �(C,� t'• �rn i`�-�— , an Incapacitated Person D. Name and address of the Incapacitated Person's primary caregiver: �{�� � �` � �5� (t�nC� �Qn�'-- �.Ctr � iS1�2 �� ��1� IV. MEDICAL INFORMATION A. The major medical or mental problems of the Incapacitated Person are as follows: P�-o�,�d le�e( o-� rn�n-I� re-i���a-��o,� �r�(�.1�� �l;(�� �nern�0.., ( �/� ��i�h.e S S� ��C C[��1,�22 C-TS U�ns-1�a.c�y �u��- � �CrUCQ��� �-�•r��S, OS�I-eo,poros�S, I� �haS�S � 1�Ur5',-�5 Y B. Specify what, if any, social,medical,psychological and support services the Incapacitated Person is receiving: �QS�Ci 2 n�i C�.� ���J i tiSn S�}�PO�f" 0.�" G.<< �rn1lS �iXCL.� 1n3�2 r� 0.�" U C f�,j t�'��r n G1.-1-i J QS ck v P ro� rcvi,-, ��U1c�,� - �-r�) i,� ('u, t�i� - � � !���CG�C� G15 I�.Q..��-�C� �rpJ�flti- CP��i�- � t.�cr� iCtn . i � V. GUARDIAN'S OPINION A. It is the opinion of the Guardian of the Person that the guardianship should: �continue �be modified �be terminated Form G-03 rev.10.13.06 Page 3 of 4 . � I I, E eof �6V� � �0.., s � I , an Incapacitated Person � The reasons for the foregoing opinion are: 1�� 3 . �= kh� he; S;S,�; w S ��� �( lc�.ve�( l-�-e r �PS 4 d P n a I rov � �l I c� .S��t , ' o �, r, I�'e S�c� P n--�c�l � ;,- P cl�� �a s 0.l� �� �a n c�d rn P d �c�� C�,,,,- �,� �i �,�^e d' ec�fz�� c�S,�c� n�e -{� �n S m�c ti -�-vr-no�er� � S r �-��r'OVCPC� (-r Sp `-`�C'OrzlC� � L-(�cJe�( l `S B. Durm the �O`1e c'v�I d mc,�ke UCLrG��Il ' C� S g past year, the Gaardian of the Person has visited�I c p ci a ed`er�n �r- , e� --____times with the average visit lastin N U rnL►'C��,�S �2(,Q/� g�hours �Q � ��e C�:���S �I '------minutes. The report of a social service organizatio �S f��r��a( S�t-�� �.���� „Q ►'�S�C.7enr�( � r�y coordi n a t e t h e c a r e o f t he Incapacitated Person for t h e�erio d covered b t � n e»z p l o y e d b y t he Guar dirrn to oversee and attached to s upp lement this Report. ��- " Q� � (� � y Y h,s Re por t m a y b e L�►m�r �C�� ��r Y � �/l�'�/c j verify that the foregoing information is correct to the be information and belief; and that this Verification is subject to theste am• relative to unsworn falsification to authorities. y�O�'ledge, P lhes of 1 S Pa. C.S.A. § 4904 J�e t l , �U, � �--) _ � Dare ' , '� Q '•`� Sign�ture ofGvar n oftF.e Person� % Na� ' � Jo c G, �l�s vuaratan o,/the Person r„ (•5'f or nrtntJ _"'���1P��� J�'��10 - �aarers '�------_ S h`,re►�c� -}�,�,� P�- ► �, � C:ty State Zrp v � l — << �-io �- 3�� Telephwre Fcrm G-03 rev.10.13,�6 Page 4 of 4 - _ -��. . - -� ANNUAL REPORT OF � � � �� � GUARDIAN OF THE PERSON� g � � `�; '°"''' . G D ` � n' Y=�� � z � JC d �.'� 0 �. � '� -r+ "'rt COURT OF COMMON PLEAS OF (' ° -� � "`" �` o � =-` c� Cu�rv��� r (Qr�C� COUNTY, PENNSYLV� � r- m 0 ORPHANS' COURT DIVISION �'' r�'�'v � � Es of LO�J� ( 10.. �� . S M��-- , an Incapacitated Person No.a �-9c� -oq� i. INTRODUCTION JQnn��� �• W° fb�c'� �J�enni��- Wa��c� �� , wasappointed �.Plena�y�Limited Guardian of the Person by Decree of �C'S�_(� ��� , J., dated .D e c � ?-O, l�1�1 q -iT � A. This is the Annual Report for the period from�v r ,�0� to �t t P�w� bv r ?� i , ZO 1 Z (the "Repor! eriod"); or � B. This is the Final Report for the period from , to , (the"Repo:t Feriod"), and is filed for the following reason: 1. The death of the Incapacitated Person. Date of death: 2. The Guardianship was terminated by the Court by Decree of J., dated Far a Final Report, omit Secteons II through IY. Form G-03 rer.10.13.06 Page 1 of 4 _ _ _ _ _ . ,� . � ' i ES�-of_ (..�,�P i � P S,Y,� , an Incapacitated Person II• PERSONAL DATA Age of the Incapacitated Person:�_ Date of Bi Ili� �n: Oct, Z3 �q� — III. LIVING ARI2AIVGEMENTS A. Current address of the Incapacitated Person: 30� O I c� ��-��,Bu�.Q. Roa�- �o► l � n 5 ��n s p�}- ! �-� i� � � � �- B. Th � e Inca -�' . a.,itated P P erso n s residence is: �own home/apartment [,�nursing home �boarding home/personal care home �Guardian's home/apartment 'i, , �hospital or medical facility relati ' � � ve s home (name, relationship and address) �' �; I„,I �other: G-ro�1 �p�e , IIII� P S��e� � C P�L �C v�.,be�Iq,rC� /p�r�'! � �S.SC�C�i 0.-hGn -�o r �T�.�PC� C;-� Z�ens � C. Th . e.Incapacitated Person has been in the present residence since � q I If the Inca �I�' � pacitated Person has mo�ed within the y past year, state prior residence and reason(s)fo:r inove: �� I� Form G-03 rev.10.13.06 Page 2 of 4 I�I�iI , � . ' i �d 4 _��, r ' Fs af____��g4 ;�}-� , an Inca acitated P P erson D. Name and address of the Incapacitated Person's primary caregiver: c�.�-,�c �� ���Gt n C� /�I'�J�n � Ca.�-l �S I� I�!� 1 �-o! 3 l�'• MEDI�AL INFOg2MAT�pN A. The major medical or mental problerris of the Incapacitated Person are as follows: t'�o7�nC� (C�► � � rnC�n'�.l �2�raCi.�iOn �Et�D, �h �c�-�i�( he�n �c�. 8��'1C�F'1NSS� �,�rv�Gt.'h C C'0.�rCcC� M��c r� cQ,�►,� U►�s-�a c� � �-�- I�tr�.t'i-�S, �S�eo�Orz�S�S, /�c���,oS,S,��Si�S B. Specif�what, if any, social, medi ac 1,psychological and support services the �ncapacitated Person is receiving: �eS� C��n-�'ci� I'��1�n� Sv(�'-{"ISv��rV i S; Gr� c�� all Whe,n c��l-en�J; c�� UC� �S �-I�e�nGtJ-�i� +'meS, e.x�Pfi �On. - �r� � �S �� Pro�rQn-� r,� C� ��c� �p � ��' �-j as n�d ed �,-�� C(�A�2c � ��;�ct� � - �'. GUARDIAN'S pPINION A. It is the opinion of the Guardian of the Person that the guardianship should: �co�tinue �be modifieci 0 be terminated F�ma G-03 rev.10.13.06 Page 3 of 4 �r-- Es�'of_ �n��Q. (�G� t', s n� �`-�-�, , an Incapacitated Person The reasons for the foregoing opinion are: � (�a�,e -�(���. (.�v�((a, Si n � 1��13� S k n e.�.�.� h e,� S,s�l-e� ��l-r,,.Q med� cc�Q cv,�, C as�ec� m�- P l�cc�-����-►s Slte� p_�p, ��hcec� , C�� i� '�'Zi.ke��.�-C�iCCnS�i '� rha(Ce -" 1--.� . �� !.-��e l(c� . tNe; sec v�e l�e; m� ,-���c.���� e��a�d�e c r S�c�s k v�cw�. �,,�►� I y ��,;s��y (e�`f �ho , B. During the past year,the Guardian of the Person has visited the Incapacitated Person _�,times with the average visit lasting a hours,� (�minutes. �1� me:��S �I��hone Cal(S w� v-�S;�f,e��'a( 5-�--� � Y�V�2vJ � i'2 S�cl�-��'c�,( r��Po�-f5 , � �1 va r"�� �/ The report of a social service organization employed by the Guardian to oversee and / coordinate the care of the Incapacitated Person for the period covered by this Report may be attached to supplement this Report. �n � �� � ��m�rl lQ� ����r� �� I�'l f�-� , I verify that the foregoing information is correct to the best of my knowledge, information and belief; and that this Verification is subject to the penalties of 18 Pa. C.S.A. § 4904 relative to unsworn falsif cation to authorities. -- I���,e l ( Z� � '� Date Si ture of Guardi of the Person " J P r1 n i f-(� �,(� �?('�. ��i'�,S Name of Guardran of the Person(tvpe or prin!) �� �-Sef r� �P Address Sh;rPnr�.n� I�JWn /�ri 1�11 City,Srate,Zip �l 1 '"� D / � `7(e �(� Telephone Form G-03 rev.10.13.06 Page 4 of 4 _ -r-. r ' Es ;,f� �1� ( (�� ;�--�. , an Incapacitated Person D. Name and address of the Incapacitated Person's primary caregiver: � �.�"�C. �` ( /����C�.nC� �'LJ�n �. C'�,� l �S I� �!-�- l �-o( 3 IV. 1V�EDI�AL INF032MAT101V A. The major medical or mental problerris of the Incapacitatzd Person are as f�llows: Pro�n� t�t�� (� I'hC�n'�.� I�'���C.��On G-E�b, I� �c�-�L( he�n ��- g i���d ness, -},�,�ry-,c�-�;c c�ct-��-c�c� M'�C ro C:Q,�ha�, Ur�.S-�eu c� ����" 1tY� r��i S, C)S�2o�OrOS�S, K���,OS�S,��Si�1S B. Specify what, if any, social, medical,psychological and support services the �ncapacitated Person is receiving: �PS� C�Pn�'ci� ���J�n� Sv�J���f 'Su,�PrV� Si G� c�.� cc-�� 'fi'1��S Q t�he�n cz�l-e n cl� n� U C.f� �S �-I�e�n C�t.-�i�eS � ' x�Pfi �Gn. - �r� � � P��raM r� �,rn.p �;�1� i ���IC�-( QS Il�1�Q e��rvc�. C('�' � C� l��Z.L�al� U V. GU�iRDIAN'S OPINION � A. It is the opinion of the Guardian of trie Persou that the gnardianship should: �continue �be modifiecl 0 be terminated Form G-03 rev.10.13.06 Page 3 of 4 N >C) G K ANNUAL REPORT OF z R' GUARDIAN OF THE PERSON c O A r -n COURT OF COMMON PLEAS OF CUm 62.-tQnd COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION Estate of Lo JQ, b. P"(I.1 S csw-44t— an Incapacitated Person No.-2-1- qt.- -095 1. INTRODUCTION JQttiti �; l%)o�bae� •l Cu�;�t� IA1o[�ack (�> wasappointed ICI Plenary CLimited Guardian of the Person by Decree of_We;S 14 D ILr J., dated bPC . 201 (999 171 A. This is the Annual Report for the period from to (the "Report Period"); or M(B. This is the Final Report for the period from TaR• ( 2O 13 to J U 20 2-6i3 (the "Report Period"), and is filed for the following reason: 1. The death of the Incapacitated Person. Date of death: U ly 2�I 2013 T 2. The Guardianship was terminated by the Court by Decree of J., dated For a Final Report, ontit Sections II through IV. Form G-03 rev./0.13.06 Pagel of 4 Estate of [0`. f . S an Incapacitated Person H. PERSONAL DATA Age of the Incapacitated Person: Date of Birth: III. LIVING ARRANGEMENTS A. Current address of the Incapacitated Person: B. The Incapacitated Person's residence is: own home/apartment ®nursing home ®boarding home/personal care home []Guardian's home/apartment hospital or medical facility relative's home (name, relationship and address) []other: C. The Incapacitated Person has been in the present residence since . If the Incapacitated Person has moved within the past year, state prior residence and reason(s) for move: Form G-03 rev.10.13.06 - Page 2 of 4 Estate of Lzgdto— l • sm'4.4 — an Incapacitated Person D. Name and address of the Incapacitated Person's primary caregiver: IV. MEDICAL INFORMATION A. The major medical or mental problems of the Incapacitated Person are as follows: B. Specify what, if any, social, medical, psychological and support services the Incapacitated Person is receiving: V. GUARDIAN'S OPINION A. It is the opinion of the Guardian of the Person that the guardianship should: continue 0 be modified M(be terminated Form G-03 rev. 10.13.06 Page 3 of Estate of LOJ¢-1 JO'— 'S r an Incapacitated Person The reasons for the foregoing opinion are: D44e a6 8,eo't� -7[7012,013 B. During the past year, the Guardian of the Person has visited the Incapacitated Person 2S-,--times with the average visit lasting 2- hours, minutes. also lead Probabj2,7 oV, loo phone, ca9QS wtproviijp s At's The report of a social service organization employed by the Guardian to oversee and rte' coordinate the care of the Incapacitated Person for the period covered by this Report may be `S I i attached to supplement this Report. ©h F �.� prSdr> (�, I verify that the foregoing infonnation is correct to the best of my knowledge, information and belief; and that this Verification is subject to the penalties of 18 Pa. C.S.A. § 4904 relative falsification to unsworn falsi 'c/ation to authorities. Z8, Date Si nure ofGt rdian of the P(elson �n1Cti�P� Jenn;k'- Wolbgr.4 v S Name oofGGuardiCCan ofthe Person(type orprint) C�FX.7 V�il� r1 iJQ� Address _� ^ ir /a„r .7// p� City,State,Zp �7- 0) 761-3W, ¢/¢phone Form G-03 rev.10.13.06 Page 4 of ; . RECEIPT FOR PAYMENT LISA M. GRAYSON, ESQ. Receipt Date : 8/05/2014 Cumberland County - Orphans Court Receipt Time : 11 :29 : 08 One Courthouse Square Receipt No . : 1055675 Carlisle, PA 17013-3387 SMITH LOUELLA P File Number: 1996-00975 --- Paid By Remarks : JENNIFER BOWES DMB ------------ -------- ---- Receipt Distribution ----- --- ---- ------------ Fee/Tax Description Payment Amount Payee Name ANNUAL RPT GRD PER 15 . 00 CUMBERLAND COUNTY GENERAL FUN Check# 462 $15 . 00 Total Received. . . . . . . . . $15 . 00