HomeMy WebLinkAbout09-28-07 (2)
ANNUAL REPORT OF
GUARDIAN OF THE PERSON
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COURT OF COMMON PLEAS OF
Cu.",.,.. t&~r....J.... COUNTY, PENNSYL VANIA
ORPHANS' COURT DIVISION
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Estate of
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. an Incapacitated Person
No. ~,.. ,,' - L.{ q ~
I. INTRODUCTION
I if 1). .sJcr -~ . ~ appointed
)4 PIenary[JLimited Guardian of the Person by Decree of -.bJG"A.. E . ~'u....fer. . L
dated 9 -/~ - 0 '=>
~ A. This is the Annual Report for the period from ~A ~ I ;{ ,,( 0 0 ~
'fC-;. to -.Jl~~ .3 I ,~ 00 ~ (the "R'eport Period"); or
o 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,
FormG-03 rev. 10.13.06
Page 1 of4
~
Estate of
~ ?}.
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, an Incapacitated Person
II. PERSONAL DATA
Age of the Incapacitated Person: 73
Date of Birth: 10 - il3 -3.3
III. LIVING ARRANGEMENTS
A. Current address of the Incapacitated Person:
B. The Incapacitated Person's residence is:
o own home I apartment
);i( nursing home
o boarding home I personal care home
o Guardian's home I apartment
o hospital or medical facility
o relative's home (1l8Dle, relationship and address)
Dother:
C. The Incapacitated Person has been in the present residence since
~~ . J../ I ,< DO S . 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
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Page 2 of 4
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Estate of
~'..:.. &-.
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. an Incapacitated Person
D. Name and address ofthe Incapacitated Person's primary caregiver:
~ ~ I..J~
1000 ~ L
~ PA 110/3
IV. MEDICAL INFORMATION
A. The major medical or mental problems of the Incapacitated Person are as follows:
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B. SpecifY what, if any, social, medical, psychological and support services the
Incapacitated Person is receiving:
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V. GUARDIAN'S OPINION
A. It is the opinion of the Guardian of the Person that the guardianship should:
't1. continue
D be modified
D be tenninated
Farm G-03 rev. JO.J3J)6
Page 3 of 4
Estate of
~'L~'
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, an Incapacitated Person
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B. During the past year, the Guardian of the Person has visited thelfncapacitated Person
r; 0 times with the average visit lasting
{
hours, ..3 0 minutes.
The report of a social service organization employed by the Guardian to oversee and
coordinate the care of the Incapacitated Personfor 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.
a/e<9 ( C> 7
Date
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Name ofGwrd~rson (type or print.j T
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H~ ItA
Address
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City.~
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711 - i.3 0 - 0 G.S- 0
Telephone
Form G-03 rev. 10.13.06
Page 4 of4