HomeMy WebLinkAbout08-27-07 (2)
ANNUAL REPORT OF
GUARDIAN OF THE PERSON
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COURT OF COMMON PLEAS OF
C-\)m~~\a.(\ ~COUNTY,PENNSYLVANIA
ORPHANS' COURT DIVISION
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Estate of
N \Co\'€-.. ~\G\.\j~
No. d.o -D~
, an Incapacitated Person
I. INTRODUCTION
~~ Qf\.d ~~ -\-\ \G\ V ctC...-, was appointed
~lenary DLimi~ ,Gpaniian of the Person by Decree of -S . 0 \ er , J.,
dated <6 J-cl..I 2c04> .
),& A. This is the Aor.!',"! Report for the period from <i<; I "" I , ~
to '1S" J..U.l ' ~1- (the "Repo~od"); 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 1 of4
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Estate of N \c.o \ €- -\.A \C\. \JQ1'" ~
. an Incapacitated Person
n. PERSONAL DATA
Age of the Incapacitated Person: \ q
Date of Birth: to- L~-~
In. LIVING ARRANGEMENTS
A. Current address of the Incapacitated Person:
~ OAK.. ~ \~€ Rb
CAv...L-\SLE:, ~ \\0\5 )
(T~c.~~ ~ t-e'S.s : ""~\ t"rAC"-\(.. 2..4>CO w~ \cv\.~ Q.c\
\.. '~.J'W~"\ f>p. \q~lL.
B. The Incapacitated Person's residence IS:
o own home / apartment
o nursing home
o boarding home / personal care home
~ Guardian's home / apartment
o hospital or medical facility
o relative's home (name, relationship and address)
o other:
C. The Incapacitated Person has been in the present residence since ~ l.\ u..s-r-
\C\q 'i
. If the Incapacitated Person has moved within the
past year, state prior residence and reason(s) for move:
Form G-03 rev. 10.13.06
Page 2 of 4
Estateof-N lC.DLG U~\I~ .
. an Incapacitated Person
D. Name and address of the Incapacitated Person's primary caregiver:
""'13....~~"- 5:.+\a)L
2l.,Ob \N.~l;4'\I0\) ~
~lU~~, \C13\L
IV. MEDICAL INFORMATION
A. The major medical or mental problems of the Incapacitated Person are as follows:
N\Co\<2... ~~~('.cl. \r"\~\\.ec.u-\-o.aJl~~.s
\.A;:)~ d \C.\.~f'O\SI.s ~: ~t> I~D I c.\=> , ~~IY\ f
~'" ~ o<..t::> dUe.. -ioCL .~t'e.. ~€r'ehc- ~ .
B. SpecifY what, if any, social, medical, psychological and support services the
Incapacitated Person is receiving:
N'\~ \"=> ('eCe\U\~ 'SoC\a..O ,~\~\caJ)
~~'ccJl.~~P~1 Occup:dno~.~~p~;
~ -\\---e~~ ~cl 2PD -\nJ..\f'l ~ Sk, \ \s '"
CA.C.CDt,cl~:(\ce, \..C~ ~r \9> C\.~ ~f'~" 0':3 tv\~~"K-
~f"\d a.~~~e.C ~ ~~ 1c.c-~r-d'O..r\..s ~I\.d
CON'-~\aV\.~ \la...\'\~ ~l SS~\c\-,
V. GUARDIAN'S OPINION
A. It is the opinion of the Guardian of the Person that the guardianship should:
~continue
o be modified
o be terminated
Form G-03 rev. 10.13.06
Page 3 of 4
Estate of
N \. c..OL~ ~~VAC.
. an Incapacitated Person
The reasons for the foregoing opinion are: ~ \ _,
N \ ~ \<::> ~\<...\\"'\~ ~~\1""e..S.S <:::r\ ~, \t...r ~O~\S I
pu*" \S~~,\ \J~\e.-~~~\€-~~r c~ a..~\N:;,
~ \ ~ \'e.N'A \ C'\S ~f'? ~ 0"",, ~rs ~r 're~ CA..r-e....
a..~o ~,
B. During the past year,'tlIe Guardian of the Person has visited the Incapacitated Person
~ times with the average visit lasting 2::):S hours, -m- minutes.
lSee.. Q-\\o...~ ~u \e-~ \J \SMS ')
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.A. ~ 4904
relative to unsworn falsification to authorities.
<6 { 2..~, 01
Date
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Signature o/Gwmiian o/the Person
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Name a/Guardian of the Person (type or print)
q ~~\~E\<.b
Address
CA~USLF: ~-t::\ \l:)\S
City, State, Zip
\\\-L.<Sfs-So~Co
Telephone
Form 0.03 rev. 10, 13J)6
Page 4 of4
.
Supplement to Annual Report of Guardian of the Person
Person: Nicole Hlavac; Docket Nbr: 06-0608
Following are the details regarding visits to Niki during the August 1, 2006 to August 31,
2007 timeframe.
Trip Visit Visit Duration Notes
Number Start End
1 8/30/07 8/31/07 24 Guardianship Hearing in Carlisle, P A:
Picked Niki up in Philly about 6 p.m. and
returned back to Phill about 6 .m.
2 10/29/07 10/29/07 7 Swapped Summer and Fall Clothes, shopped
for winter coat, boots, etc. and went to dinner
3 12/21/07 12/28/07 169 Father/Co-Guardian picked Niki up at
Melmark and arrived in Carlisle about 3
p.m.; Niki spend Christmas Vacation with
Mom and family. Mom returned Niki back
to Philly just before dinner, approx 4 p.m.
7*24 hrs+ 1
4 3/17/07 3/17/07 6 Stopped on way home from Kelsey's Jr.
01 ics swim meet in NJ
5 5/20/07 5/20/07 3 Stopped on way home from Kelsey swim
meet in Ft Washington just for dinner and
quick shopping; Niki treated to dinner as gift
for Mom's birthda and Mother's Da
6 7/4/07 7/4/07 6 Celebrated birthday, out to lunch and dinner,
summer clothes and snack sho in
Total visits = 6
Total hours = 215
Average Per Visit: 35 hrs and 49 minutes