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Home My WebLink About07-13-07 <<''' 6814 THE COURTS Form G-03 ANNUAL REPORT OF GUARDIAN OF THE PERSON o '=0 :Bp COURT OE COMMON PLEAS OF (JU"(/UI> ~;r COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION ~{~~ Estate of ~'~o ji. 11.~ No. c/2/-fJ 7- tJ;(txJ , an Incapacitated Person I. INTRODUCTION .x!lJuiU-j2. ~ ~ry 0 Limited Guardian of the Person by Decree of (}.bA.. j , dated '1--/;). - () 7 / ~ This is the Annual Report for the period from ~.. /d--CJ? , to J--/~ /,2. 'cf/1I1 (the "Report Period"); or o B. This is the Final Report for the period from , was appointed , J., 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. Farm G-O] rev. 10.13. 06 Page 1 of 4 PENNSYLVANIA BULLETIN, VOL. 36, NO. 44, NOVEMBER 4, 2006 (=) 'n ,"', c:':) c:::. --.I <- c:= r- w -0 N N 0"'1 THE COURTS 6815 Esmreof J7/l ~ , an Incapacitated Person II. PERSONAL DATA Age of the Incapacitated Person: 11 Date of Birth: r~ If} () III. LIVING ARRANGEMENTS A. Current address of the Incapacitated Person: u" .;J &ktJk ~ ~ nO ~ dtu-.J M#; ~ ~} ~~A, /1<7/1, B. The Incapacitated Person's residence is: o own home / apartment ~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) o other: I I I I I I I i i I I I I I I I j ! I j C. The Incapacitated Person has been in the present residence since I;:) -;2 -0 "-I, , . If the Incapacitated Person has moved within the past year, state prior residence and reason(s) for move: A ~ .zf; ~. Am- t1AdiAMI). fkJgfl4/ ~ lito . ~J.I *~ ~~.~ . -' ,. / ",/$ Form G-03 rev. 10.13.06 Page 2 of 4 PENNSYLVANIA BULLETIN, VOL. 36, NO. 44, NOVEMBER 4, 2006 6816 THE COURTS Estate of ~bt~ /L, /fJ4A fA:.J , an Incapacitated Person D. J2d addre~~~i~ p~mMy c=~ver; 1f,1~~ _Cl .1J;~~~, 7 7 ell IV. MEDICAL INFORMATION A. The major medical or mental problems of the Incapacitated Person are as follows: ~g>>~~7 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: z;r'(ontinue [J be modified [J be terminated Form 0-03 rev. 10.13.06 Page 3 of 4 PENNSYLVANIA BULLETIN, VOL. 36, NO. 44, NOVEMBER 4, 2006 l' THE COURTS 6817 Estate of ~:J' /( A~ . an Incapacitated Person The reasons for the foregoing opioion are: S1~ ~ At- _~ ,/A.-- '4W~4.~'~~~ #;.L,d~~ B. During the past year, the Guardian of the Person has visited the Incapacitated Person 0( f ti~es with the average visit lasting / ~ hours, minutes. ~ /t:ff'--- tid-t7~ 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. 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. S 4904 relative to unsworn falsification to authorities. Date // / Z -. tJ 7 . IItJtL~ J l5~i Name of Guardian of the Person (type or print) 5770 t~'3f. Address tflbb. f? fJ, (111:J- City, State, Zip J (J 6 ~'S' -~4'b l ~ Telephone Form G-03 rev. 10.13.06 Page 4 of 4 PENNSYLVANIA BULLETIN, VOL. 36, NO. 44, NOVEMBER 4, 2006 ,. THE COURTS Form G-02 ANNUAL REPORT OF GUARDIAN OF THE ESTATE ~.CO ~MMONPLEAS OF COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION Estate of ,-,JAIl 0 H, /Jwu;J , an Incapacitated Person No.o?/-O } -/J.2-tJQ I. INTRODUCTION /7 ~ '" ) 4&zu~ f;,' ~ IiJ1Slenary 0 Limited Guard an of the Estate by Decree of dated 14AJ~ ( ;;.2(1) If ~ This is the "'J~ual Report for the period from +-- /..;/ ~ 07w Z. to JV"f /1 J.t01 ' (the "Report Period"); or o B. This is the Final Report for the period from Q -",(."J ;)~ '0 r-- . 'Tl _ /) ~12 : ~! , J., to (the "Report Period"), and is filed I ! I I I I j I I I for the following reason: 1. The death of the Incapacitated Person. Date of death: Name of Personal Representative: 2. The Guardianship was terminated by the Court by Decree of J., dated Form G-02 rev. 10.13.06 J PENNSYLVANIA BULLETIN, VOL. 36, NO. 44, NOVEMBER 4, 2006 Page 10f5 c:) --'-1 N N -..J 6809 "-.:!l f:"'~:; C_::J --.l <.- L-'- r c...:l -u -il- 6810 THE COURTS Estate of ~~)I ~ , An Incapacitated Person II. SUMMARY A. State the value of the estate reported on the Inventory / CfZJ crO , $ B. State the value(s) of principal assets at the beginning of the Report Period. (Same as Inventory if first Report, otherwise, ending balance from last Report.) $ 1// /f t $ 'i; t)g() . , 3 $ 5/ ~ LfLf I ~ 7 I C. What is the total amount of income earned during the Report Period? D. What is the total amount of income and principal spent for all purposes during the Report Period? E. What are the balances remaining at the end of the Report Period? 1. Principal $ 2. Income $ 3. Total of Principal and Income $ 131~ ~~' .7? I J~, .21 III. ADDITIONAL INFORMATION (If more space is needed, please attach additional pages.) A. Principal 1. How is the principal balance listed above currently invested? (Please specify, e.g., real estate, certificates of deposit, restricted bank accounts, etc.): ~i~.~~ 1ll>SI tt.CCV~ Gold~'l L,V'W ~J::::=?b popUJ (~ r.(nr{tC - ~-euvr UX(J 2. Have there been any expenditures from the principal / during the Report Period? ............................ ~ Yes D No If yes: a. Have all expenditures from the principal been for the sole benefit of the Incapacitated Person? . . . . . . .. cw1'es DNo Form G-02 rev. 10.13.06 Page 2 of5 PENNSYLVANIA BULLETIN, VOL. 36, NO. 44, NOVEMBER 4,' 2006 "r THE COURTS Es~reOfj)~ JI~ b. List pprpose and amount of expenditures: ~~{$~i~f~l~~{ :4Q!oT 6811 , An Incapacitated Person $ f)O I DO $ ~ ,1J6 $ $ c. Was Court approval received prior to expending the principal? ....................... 0 Y es ~ 3. Were additional principal assets received during the Report Period which were not included in the Inventory or a prior Report filed for the Estate? ........... 0 Y es ~ If yes: a. Was Court approval requested prior to receiving the additional principal? . . . , . . . . . . . . . . .. 0 Y es ~ b. State the sources and amounts of the additional principal received: 1/1 J'f- B. Income 1. State sources and amounts of income received during the Report Period (e.g., Social Security, PenB~ts. etcJj .12- '~J f.. Jl ~~~& "~if.DC \ Total income received during Report Period: Form G-02 rev. /0.13.06 $ $ $ $ $ $ $ $ $ $ $ , 'J j ltLocJ. , -) J to I ~ . (9() $ 4-} 01>oL ~ ~ Page 3 of5 PENNSYLVANIA BULLETIN, VOL. 36, NO. 44, NOVEMBER 4, 2006 6812 THE COURTS Esmteof ~ U ~ , An Incapacitated Person 2. How is income currently invested? (Please specify, e.g., restricted bank accounts, client care account, etc.): ~M~O~ ~J C. Expenses for C~re and Maintenance Specify what expenditures were made from the principal and income for the care and maintenance of the Incapacitated p~ clothing, nursing home, medicine, suPPOrt., etc.~ ~ Ii '.' ~ ~~.;~ -4rU '"4 "r D. Other Expenditures Specify what other expenditures were made during the Report Period. (Do not include any items stated in response to question C above.) t//k E. Guardian's Commissions List amounts of compensation pa~d as Guardian's commission and state how amount was determined: I Amount Method of Determination Court Approval Obtained -t?- ~. N/11 I dJf( DYes DNo DYes DNo Form G-02 rev. 10.13.06 Page 4 of5 PENNSYLVANIA BULLETIN, VOL. 36, NO. 44, NOVEMBER 4, 2006 THE COURTS 6813 Estate of ~~~/ II ~ , An Incapacitated Person F. Counsel Fee List amounts paid as counsel fee, and indicate whether Court approval was obtained. jmount k' . 1($()jJ~jJb1f L~I tffd./ / Ai l ~JY Court Approval Obtained ,vIA-DYeS DNo / DYes DNo 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. ~ 4904 relative to unsworn falsification to authorities. ~fJ/! cR~1 (J/OI/G X 8at) Ks Name of Guardian of the Estate (type or print) 5770 (!a+her/~~ S.t, HPk,~ f1{.. /7// d- City, State, Ip ('1117 5 i5- Lf15/ (, Telephone Address Form G-02 rev. 10.13.06 Page 5 of5 PENNSYLVANIA BULLETIN, VOL. 36, NO. 44, NOVEMBER 4, 2006 ! L r i ! f 1;- u i 6818 THE COURTS Form G-04 GUARDIAN'S INVENTORY (! um~rl M ('QOUNTY,PENNSYLVANIA COURT OF COMMON PLEAS OF ORPHANS' COURT DMSION Estate of 2t ~ . t)~ .} an ~capacitated Person ~ . ' a Minor No. bL/-tJ7 - O;)(J() 1. Real Estate: (Location, by whom occupied and rental terms, if applicable) Sub-Totalfor Real Estllte: 2. (~operty: ~' ~/--t.Llnt,y ~ , 3. Jointly Held Property: (Sel forth real and ptnOlfllI propv1)l owMti by tire InctlpQcil4led Perso" JOIN11. Y witlr 011)1 ollter peTSOII(S). Slate wltellter held as _IS by tire elflirelies: if "01. whether lhe righl of survivorship existt.) JoiIItJy Helit Property Form G-04 rl!Y. 10./3.06 o .'-=;:O , ~].1 ':~p Estimated Val~TI -c./^) _^ .:=:=C;. '.') () --- -. -._ '__: ~ l -r-I '-~;::; . :J--1 Estimated Value: / ()lJ > tIC) Estimated Value: --G- Page 1 of2 PENNSYLVANIA BULLETIN, VOL. 36, NO. 44, NOVEMBER 4, 2006 r--_' ~ C:j --' c_ c:: r- w .....,., ~ -- ::.!!: N N (J"\ --- THE COURTS 6819 Estate of :Inez. H. Dau-l S an Incapacitated Person , } .a--MffiOf 4. Anticipated Assets: Estimated Value: (Set forth property of any kind expected to be acquired hereafter. together with anticipated date of acquisition.) Property Anticipated Date of Acquisition AlO (lit!- Sub- Total for Personal Estate: (Attach additional sheets ifnecessary) TOTAL OF ITEMS 1,2,3, and 4: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ii.jA't1 n52 If// v{..! "00 ~ j I '-T'i ~-: () ("- r--..~ ~::) (~:~ -.. L (- r= Commonwealth of Pennsylvania : (), , I.. 1 I]: 5S. County of Lt-1Vl~'}'. {l11..t:K-n lit; &~ 'Q~:i 'J I '. '(j}jj(q, - , says that the foregoing is a full, true and complete Ou"dum ~ H" " Inventory of the Estate of ,\-,' ,LJOAU/J), the aforesaid Incapacitated Person ~; and that all of the information set forth herein is true and correct to the best of the -0 ~ w N N 0'1 Guardian's knowledge and belief. I verify that the statements made in this ) Inventory are true and correct. I under- ). stand that false statements herein are ) made subject to the penalties of ) 18 Pa.C.S. S 4904 relating to unsworn ) falsification to authorities. ) ~;.~. Attorney for Guardian: oiJau {dJ K. f{;z~ Supreme Court 1.D. No.: f Address: Rh.0Jo. :(. C)(A'llJ1 I ;J#-ilOJ1.. [lIE [:jrlp,J!e.. - PO~~I:'f~_ ~/X,tlPA: f7!O<j-JPIf, Telephone: (7/--37;;- 7__ F 07711 G-04 rev. 10. I3. 06 Page 2 of2 PENNSYLVANIA BULLETIN, VOL. 36, NO, 44, NOVEMBER 4, 2006 r~----- r....- ,JUL 11. .... ~ R!'10IJNT C) z -"", ::::i 0 ;( Z ~ (/) w II. 0 0 0 t. ..J UJ <( ~ :2 \U -' 0 <{ u:: Z 0 ~ ~ Z UJ ococ 0 wW f-f- B Z(/) -<{ -0 0:2 " Zf- '" '" <{(/) " 00 ~ UJ i='t '" ;; (/)W () WO 0 :> :2Z N a: g~ c:: UJ OC=' CO (/J :J O(/) E c -' LL~ CO <{ oOC e -" t- WO LL ....: (/J -0 0 (/)LL " ~ ='w > CO 0- >0; wo " C') vi co- > ~ E ::i :;cO 0 :2[ LL (/J 0-