HomeMy WebLinkAbout01-0575
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
IN RE:
VIOLET M. TROUT. an
alleged incapacitated
person
No. c2/ "()l - $1 S-
TO: Ms. Violet M. Trout
c/o HCR Manor Care
940 Walnut Bottom Road
Carlisle, Pennsylvania 1 701 3
IMPORTANT NOTICE
CITATION WITH NOTICE
A Petition has been filed with this Court to have you declared an Incapacitated
Person. If the Court finds you to be an Incapacitated Person, your rights will be affected,
including your right to manage money and property and to make decisions. A copy of the
Petition which has been filed by HCR Manor Care is attached.
You are hereby ordered to appear at a hearing to be held in Courtroom # of
the Cumberland County Courthouse, 1 Courthouse Square, Carlisle, Cumberland County,
Pennsylvania, on
_.m. to tell the Court why it should
at
not find you to be an Incapacitated Person and appoint a Guardian to act on your behalf.
To be an Incapacitated Person means that you are not able to
receive and effectively evaluate information and communicate decisions and
that you are unable to manage your money and/or other property, or to
make necessary decisions about where you will live, what medical care you
will get, or how your money will be spent.
At the hearing, you will have the right to appear, to be represented
by an attorney, and to request a jury trial. If you do not have an attorney,
you have the right to request the Court to appoint an attorney to represent
you and to have the attorney's fees paid for you if you cannot afford to pay
them yourself. You also have the right to request that the Court order that
an independent evaluation be conducted as to your alleged incapacity.
If the Court decides that you are an Incapacitated Person, the
Court may appoint a Guardian for you, based on the nature of any condition
or disability and your capacity to make and communicate decisions. The
Guardian will be of your person and/or your money and other property and
will have either limited or full powers to act for you.
If the Court finds you are totally incapacitated, your legal rights
will be affected and you will not be able to make a contract or gift of your
money or other property. If the Court finds that you are partially
incapacitated, your legal rights will also be limited as directed by the Court.
If you do not appear at the hearing (either in person or by an attorney representing
you) the Court will still hold the hearing in your absence and may appoint the Guardian
requested.
By:
Clerk, Orphans' Court
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
IN RE:
VIOLET M. TROUT, an
alleged incapacitated
person
No.
ORDER
AND NOW, this cJo ~ay of
, 2001, upon consideration of
the annexed Petition, IT IS ORDERED, AD] DGED, AND DECREED that a Citation be
issued, directed to Violet M. Trout, to show cause, if any there may be, why she should
not be adjudged an incapacitated person and a plenary guardian be appointed for her;
hearing to be held on the /tffA-dayof 4u~" 2001, at /tJ .'tQ)a.m.!p.m.,
. ~ -
in Courtroom # l of the Cumberland County Courthouse, 1 Courthouse Square,
Carlisle, Cumberland County, Pennsylvania. Said Citation shall be served upon the alleged
incapacitated person, Violet M. Trout, by an adult individual, not a party to the
proceedings who shall execute an affidavit of service, and the same is to be returnable to
the Court on the date and time of said hearing, aforementioned.
Notice of the Petition and hearing shall be given to Violet M. Trout, the alleged
incapacitated person, by either registered or certified mail, return receipt requested, not
less than twenty (20) days prior to the hearing.
BY THE COURT,
].
- I
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
IN RE:
VIOLET M. TROUT, an
alleged incapacitated
person
No.
ORDER
AND NOW, TO WIT, this
day of
, 2001, upon
consideration of the within Petition,
is hereby appointed plenary guardian of the estate and person of Violet M. Trout.
IT IS SO ORDERED:
BY THE COURT,
].
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
IN RE:
VIOLET M. TROUT, an
alleged incapacitated
person
No.
PETITION FOR AD1UDlCA TION OF-INCAPACITY AND APPOINTMENT
OF PLENARY GUARDIAN OF THE ESTATE AND PERSON IN
ACCORDANCE WITH 20 PA C.S.A. SECTION 5511
TO THE HONORABLE, THE JUDGES OF THE SAID COURT:
1. Petitioner, HCR Manor Care (hereinafter referred to as "Petitioner"), is a
health care provider qualified to conduct business in the Commonwealth of Pennsylvania,
and is the residential services provider for Violet M. Trout, the alleged incapacitated
person. Petitioner maintains offices and/or a place of business within the County of York,
located at 940 Walnut Bottom Road, Carlisle, Cumberland County, Pennsylvania 17013.
2. The alleged incapacitated person, Violet M. Trout, having a date of birth of
August 23, 1906, is currently 94 years of age, widowed, and presently maintains her
domicile at 940 Walnut Bottom Road,. Carlisle, Cumberland County, Pennsylvania 1 701 3.
3. . To the best of the Petitioner's knowledge, information and belief, the names
addresses and relationships of the alleged incapacitated person's parents, spouse and/or
adult testate or intestate heirs are' as follows:
Nephew - Frank Eichelberger (Attorney-in-fact)
32 South Hanover Street
Apartment 2
Carlisle, PAl 701 3
Ii
I
I
4. The alleged incapacitated person's functional limitations are: disorientation as
to time and occasionally as to place; non-ambulatory; incontinent; able to speak, but not
into complete a sentence; on a pureed diet as a result of dental deteriorated due to aging;
inability to perform any activities of daily living without substantial assistance.
5. The alleged incapacitated person lacks sufficient capacity to make or
communicate responsible decisions concerning her person or property due to her age and
physical incapacity, more specifically described herein, which has permanently impaired the
alleged incapacitated person's abilities and which requires the care available at a skilled care
facility .
6. Petitioner seeks the appointment of a plenary guardian of the person of
Violet M. Trout due to potential allegations of breach of fiduciary obligation by the alleged
incapacitated person's existing Power of Attorney, and because infirmities of old age and
mental deficiencies impair her ability to receive and evaluate information effectively and
communicate decisions in any way to such a significant extent that she is totally unable to
meet essential requirements for her physical health and safety, and is totally unable to
manage her financial resources.
7. The specific areas concerning which Violet M. Trout is alleged to be
incapacitated are as follows: - .
a. Mental infirmities of old age;
b. Mental disability;
c. Moderately advanced to advanced dementia;
2
d. Atherosclerotic brain disease;
e. Transichemic;
f. Hypertension;
g. Congestive heart failure;
h. Degenerative joint disease; .
i. A-fib;
j. Paranoia; and
k. Anemia.
8. The alleged incapacitated person, upon information and belief, was never a
member of the armed services of the United States.
9 . To approximate value and/or extent of the assets of the alleged incapacitated
person are unknown to the Petitioner.
10. The estimated monthly net income of the alleged incapacitated person from
all sources is unknown to the Petitioner.
1 1 . Because of her mental and/or physical condition, the alleged incapacitated
person is totally unable to manage her financial affairs, property, and business and is liable
to dissipate her property or become the victim of designing persons and lacks the capacity
to make and communicate responsible decisions relating thereto, including the ability to
communicate her need for assistance in these areas.
3
12. Because of her impaired mental and/or physical condition, the alleged
incapacitated person lacks the capacity to make or communicate responsible decisions
concerning her person and is unable to keep herself properly nourished and hydrated,
make her own living arrangements or otherwise tend to the daily necessities of her care.
13. The severity of the alleged incapacitated person's mental and/or physical
condition and the lack of viable, less restrictive alternatives necessitate that a plenary
guardian of her estate be appointed to manage and handle all aspects of the alleged
incapacitated person, specifically including, but not limited to all issues related to her cash,
checks, and any bank or savings accounts held in her name, stocks and bonds, personal
property, real estate, life and other insurance of which she is a beneficiary, entitlement to
any governmental and non-governmental benefit plans, federal, state and local taxes, claims
made or to be made on behalf of her or against her, the execution of documents, entry
into contracts affecting her and the payment of reasonable compensation or costs to
provide services for her.
14. The severity of the alleged incapacitated person's mental and/or physical
condition and the lack of viable less restrictive alternatives necessitate the plenary guardian
of her person be appointed to handle all issues relating to the person of alleged
incapacitated person, specifically hicluding, but not limited to her living arrangements, her
medical and psychiatric care, the administration of medication to her, and the employment
and discharge of physicians, psychiatric, dentist, nurses, therapists, and other professionals
for her physical and mental treatment and care.
4
15. To the extent known by Petitioner, it is averred that the alleged incapacitated
person has executed a durable Power of Attorney, as aforesaid.
1 6. To the extent known by Petitioner, it is averred that the alleged incapacitated
person has not executed an Advance Directive for Health Care or Living Will.
17. To the extent known by Petitioner, it is averred that the alleged incapacitated
person does not have a Will which, inter alia, names the alleged incapacitated person's
existing attorney-in-fact as Executor.
18. Petitioner is without knowledge or information as to whether the alleged
incapacitated person has funds reserved for funeral and burial.
1 9. No reasonable alternatives to the appointment of a guardian of the person
exist, due to the age and physical condition of the alleged incapacitated person, and due to
the allegations of breach of fiduciary obligations by the alleged incapacitated person's
existing Power of Attorney, as outlined above.
20. The Petitioner proposes that this Honorable Court appoint a plenary
guardian of the estate and person of Violet M. Trout, the alleged incapacitated person.
2 1 . The Petitioner requests that the proposed guardian of the estate and person
have no interest adverse to the alleged incapacitated person.
22. No other Court, upon information and belief, has heretofore assumed
jurisdiction in any proceeding to determine the capacity of the alleged incapacitated
person.
23. Upon information and belief, no other guardian has been appointed for the
Estate or the person of the alleged incapacitated person.
5
WHEREFORE, Petitioner respectfully requests that this Honorable Coun award a
I citation directed to Violet M. Trout, the alleged incapacitated person, and to such other
I
I persons as this Honorable Coun may direct to show cause why Violet M. Trout should not
be adjudged a fully incapacitated person, and in need of a plenary guardian of her person
I and estate, and to require notice of this proceeding to such persons as this Honorable
Coun may direct.
Respectfully submitted,
~ /~ 1/0 <~._. _.~
p ~~-,;r ~
aniel F. Wolfson, Esquire /
WOLFSON & ASSOCIA T~, P.c.
267 East Market Street
York, PA 17403
(717) 846-1252
ID No. 20617
Attorney for Petitioner
6
05/23/01 02:50 FAX
[lJ09
VERI FICA TION
~"&"~-;,~,,~~ ""'~,,-o...'" I hereby verlftes that he/she is employed by
HeR Manor Care, 940 Walnut Bottom Road, Carlisle, Pennsylvania (Petitioner herein) as
"'~~,;,,,,-,-s.'" 'K>--~~- of Peddoner's Health Care Facility; and that as such,
she is authorized to make the within verification on Petitioner's behalfj and further that the
facts and statements conuined within the foreloinl Petition for Adludlcation of Incapacity
and Appointment of Plenary Guardian are trUe and correct to the best of hlsll1er
knowledle, information and belief.
This verification is made subject to the penalties set forth In 18 Pa. C.S. Section
4904, reladnl to unnvom falslftcation to authorities.
HeR Manor Care:
DATE: <O\\\.\b\
By: "
~~"'~ .~
." .'
05/23/01 02:50 FAX
LlJ09
VERI FICA TlON
~"""~-;,~'-"'-~ ~~CJ...'" , hereby verlftes that he/she is employed by
HeR Manor Care, 940 Walnut Bottom Road, Carlisle, Pennsylvania (Petitioner herein) as
~~~,,~,-s,'" ~~",-- of Petitioner's HealtJl Care Facility; and that as such,
she is authorized to make the within verification on Petitioner's behalf; and funher that the
facn and statements contained within the foreloinr Petition for Adludlcat!on of Incapacity
and Appoinunent of Plenary Guardian are tJ'Ue and correct to the best of hlslher
knowledie, infonnatJon and belief.
This verification is made subject to the penalties set forth In 18 Pa. C.S. Section
4904, reladnr to unsworn falsification to authorities.
HeR Manor Care:
DATE: <C\\\.\b\
By: "
~~~'~
.,' "
r
IN RE:
VIOLET M. TROUT
an alleged incapacitated person
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
N(r- ORPHANS'COURT
21~-575
IMPORTANT NOTICE
CITATION WITH NOTICE
A petition has been filed with this Court to have you declared an Incapacitated Person. If the Court
finds you to be an Incapacitated Person, your rights will be affected, including our right to manage money
and property and to make decisions. A copy of the petition which has been filed by
____DANIEL F. WOLFSON, ESQ. is attached.
You are hereby ordered to appear at a hearing to be held in Court Room No. 3, Cumberland
County Courthouse, Carlisle, Pennsylvania, on Anc:;nS'1' R ,200~, at 10:00 A .M. to
tell the Court why it should not find you to be an Incapacitated Person and appoint a Guardian to act on
your behalf.
To be an Incapacitated Person means that you are not able to receive and effectively
evaluate information and communicate decisions and that you are unable to manage your
money and/or other property, or to make necessary decisions about where you will live,
what medical care you will get, or how your money will be spent.
At the hearing, you have the right to appear, to be represented by an attorney, and
to request a jury trial. If you do not have an attorney, you have the right to request the
Court to appoint an attorney to represent you and to have the attorney's fees paid for you
if you cannot afford to pay them yourself. You also have the right to request that the Court
order that an independent evaluation be conducted as to your alleged incapacity.
If the Court decides that you are an Incapacitated Person, the Court may appoint a
Guardian for you, based on the nature of any condition or disability and your capacity to
, )
,
-
WOLFSON & ASSOCIATES, P.C.
Attorneys at Law
AlTORNEYS
Daniel F. Wolfson
Amy F. Wolfson
Philip C. Warholic
BRANCH OFFICE:
267 East Market Street
Yark, Pennsylvania 17403
8 Manchester Street
Glen Rock, PA 17327
(7 I 7) 235-50 I 4
COUNSEL
Morrison B. Williams
Donald L. Hoage*
PARALEGALS
Margaret L. Burg
Susan K. KostaIas
(71 7) 846-1252
(800) 321-8467
FAX (717) 848-1146
PLEASE FORWARD ALL
CORRESPONDENCE TO
THE YORK OFFICE
e-mail: dfwolfson@debtcollection.net
. Licensed to Practice in Maryland
15 June 2001
Orphan's Court Division
Cumberland County Court House
1 Courthouse Square
Carlisle, PA 17013-3387
IN RE: Isabelle J. Bickel, an alleged incapacitated person
IN RE: Violet M. Trout, an alleged incapacitated person
Dear Clerk:
Please be advised that the undersigned represents the interests of HCR Manor Care in
connection to the above referenced matters. Enclosed please find an original and two (2)
copies of the Petition for Adjudication of Incapacitation and Appointment of Guardian to
be filed in each of the above matters. Also enclosed please find our firm checks in the
amount of $32.00 each which represents payment of your filing fee for the enclosed
Petitions.
It is our understanding that your office will submit the enclosed Petitions to the Court to
schedule a hearing and issue the Citation prior to filing. We are requesting that the Court
appoint a non-interested party to serve as the Guardian of the persons and the estates of
Isabelle J. Bickel and Violet M. Trout. Upon filing the Petitions, kindly return the time-
stamped copies to the undersigned in the enclosed self-addressed, stamped envelope in
order that we may appropriately serve the parties.
'"
'"
Orphan's Court Division
Cumberland County Court House
15 June 2001
Page 2
Thank you for your professional cooperation in this matter. Should you have any questions
or require any additional information, please do not hesitate to contact the undersigned.
Sincerely,
WOL ON & ASSOCIATES, P.c.
~~ ""-.)
t-.V~
A y,. Wolfson, Esquire
AFW/mmm
Enclosure
pc: Sue Gordon, HCR Manor Care (w/enclosure)
r
IN RE:
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 21-01-575 ORPHANS' COURT
VIOLET M. TROUT,
alleged incapacitated
person
IN RE: HEARING DATE
ORDER OF COURT
AND NOW, July 18, 2001, hearing in the above matter has been
continued from August 13, 2001, to August 17, 2001, at 10:00 a.m. in
Courtroom No.3; counsel for the petitioner to notify all interested parties.
By the Court,
P.J.
Daniel F. Wolfson, Esquire
Wolfson & Associates, P.C.
267 East Market Street
York, PA 17403
'-..
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
IN RE:
VIOLET M. TROUT, an
alleged incapacitated
person
No. 21-01-575
RETURN OF SERVICE
\1 ~\.. . \ C ~
On the ~l of ~\"u\ly at ""\ '. ~ ,,;)~.Ip.m., I,
n t\ , served a "Order of Court"
rescheduling the August 13, 01 hearing to August 17,2001, by personal service on
the alleged incapacitated person, VIOLET M. TROUT, at the following address:
Manor Care, 940 Walnut Bottom Road, Carlisle, PA 17013
I verify that the statements made in this return of service are true and correct. I
understand that false statements herein are made subject to the penalties of 10 Pa. C. S. A.
See. 4904 relating to unsworn falsification to authorities.
Date: \J.\.' c:,
I NCit:ric.j 8-:::::1
g~;~~;! ':~";!,:;l'~:Z:'~:i~~ !;;~2i~t~,~~~
"''''('''1'''' , .',,', '--",
I [\;lIV~',' ~),-'I L.~.I...,r~JJ>'~.' ~r.::,.,Vl.fw.
rk.";~i;;;ii~~~~~;A;-J'~:utiCn...;tr~;riCS
SWORN and SUBSCRIBED
to before me this :QL& 11] day
of ~ u.\ J... , 2001.
(J
~
" 'I',
Cb~~, \'l\\~
otary Public
,"
..
,~
~
IN RE:
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 21-01-575 ORPHANS' COURT
VIOLET M. TROUT,
alleged incapacitated
person
IN RE: HEARING DATE
ORDER OF COURT
AND NOW, July 18, 2001, hearing in the above matter has been
continued from August 13, 2001, to August 17, 2001, at 10:00 a.m. in
Courtroom No.3; counsel for the petitioner to notify all interested parties.
By the Court,
P.J.
Daniel F. Wolfson, Esquire
Wolfson & Associates, P.C.
267 East Market Street
York, PA 17403
WOLFSON & ASSOCIATES, P.C.
Attorneys at Law
AIT( II<NI:YS
Ildllil,II:. Wo11s011
^IIIY F Wo11s011
l'llilip ( , Wdrllolic
ImAN( 'II (lFFI( 'I,:
267 East Market Street
York, Pennsylvania 17403
H Milllcll('sl('r Sln'('1
(11('11 Hock, I'^ 17:t!'i
(717) 2:1!)-!)O II
('( II INSI,:I.
MllrrisOl1 I\. Willidllls
I )1l1I; rid I" Ilodl.W ':
I'^I<^I,I:(;^I.S
Mdr~dr<'II" Illlr~
(717) 846-1252
(800) 321-8467
FAX (717) 848-1146
I'/.HASH !-'OHWAWJ !IU
COlmHS/'ONIWNO: n l
TlIH }'( JW..' ( JFF/( 'J:
(.-mail: drwolrson (1I1<!cblcol!cCtiOIl.llcl
1.1<<'II<,,-,IIo,j'ld,IIlI'IJI!\1,ltvl.lllll
I 3 August 200 I
The Honorable George E. Hoffer
Cumberland County Court House
I Courthouse Square
Carlisle, PA 17013-3387
IN RE: Violet M. Trout, an alleged incapacitated person
Cumberland County Orphan's Court No. 21-01-575
Dear Judge Hoffer:
For your records and information, enclosed please find the completed Notification of
Mental Health Commitment which is required to be submitted prior to the hearing in this
matter on August 17, 2001 at 10:00 a.m. Should you have any questions or require any
additional information, please do not hesitate to contact the undersigned.
Sincerely,
FSON & ASSOCIATES, P.c.
112ti:-
AFW /mmm
Enclosure
pc: Orphan's Court Division (w/enclosure)
Sue Gordon, HCR Manor Care (w/enclosure)
WOLFSON & ASSOCIATES, P.C.
Attorneys at Law
AnI )I{NI:VS
1 ),llli,'II' Wllll.~llll
^IIIV I: Wllll~llll
,'I, i !il' (. \ \ "I I" !i,
BI~AN(,II ()(.'(.'I( 'I,:
267 East Market Street
York, Pennsylvania 17403
H M,lI1('1 l\'sll'r SlnTI
(;11'11 P'H'J;, 1'.\ 17T)~'
(717) 2:\;1-;'0 I I
('( >IINSI:I.
MllrtlSlll1 II. Willi"IIIS
I )"11,,101 I.. Illldl.(I'
I '^I{^I.J:< ;^I..'i
M"rl.("n'1 I.. 1\1Irl.(
(717) 846-1252
(800) 321-8467
FAX (717) 848-1146
I'I.HASH f(JU\VIlIUJ !III
(.'O/?UHSI'ONI WNI 'I: n)
'f'I1I:' Y( Jm, I WF/I 'I:
('-lIlail: dfwolfson (Itlclebtcollcction.nel
11"'li',,'rll.,I'I.,.II"'lll\1.II\I,IIHI
I 3 August 200 I
The Honorable George E. Hoffer
Cumberland County Court House
I Courthouse Square
Carlisle, PA 17013-3387
IN
5
Dear Judge Hoffer:
For your records and information, enclosed please find the completed Notification of
Mental Health Commitment which is required to be submitted prior to the hearing in this
matter on August 17, 200 I at 10:00 a.m. Should you have any questions or require any
additional information, please do not hesitate to contact the undersigned.
Sincerely,
WOLFSON & ASSOCIATES, P.c.
Amy F. Wolfson, Esquire
AFW /mm/11
Enclosure
pc: Orphan's Court Division (w/enclosure)
Sue Gordon, HCR Manor Care (w/enclosure)
06/19/01 TUE 13:09 FAX 2406462
--
Cl~/COUNTY COlTRTS
I4J OO~._
$1" 4-131(1-98)
CC\lIMONWEALTH OF i'ENNSY\..'JAHCA
NOTIFICATION OF MENTAL HEALTH COMMITMENT
The Ullil'Onn FireSlTTlS Ad'. fa F"A. C.S. Q:105 ~(4J ~ ttlat it stIaJl be uniawllJffor any pl'!lSOfl adjudlc31ed as an ~ or who hall been in\IClll1'1tarily committeO 10 a IMI1taJ
ins1itution for In~llenl care and 1Ju1rnent under Section 302,303, or 304 of the Mental Health F"rooe<:Iure~ Act of JY/y I), 11)76 (t'.t...S11, No. 143) tQ l1Q'i'ie1O$, IlAIc. manutadl.:re,
CQrltrQl, SillII Of lI'artsfi!!r fi~, This would IndlJde ad"JUCI~ of lncapaci\y ~ 11:1 ;m PaC.SA 55501, P\JlSlIant 10 lI'Ie pennsylvania Mental Healll'l Procadures Ad. SecllorI
109. nctification shall be lIMstnilh!ld "" !he P~/v.ama SWa PoIiCll> by the Judge, meMai heefth revtew olTiccr orccunty mentill /TesJlh and mental nrtan::tation I14mrnl:ltralor Wl'lhln
SEVeN days 01 ~ adjudication, commitment or trNtm..nt by ~t <:laM maillD lI1e Peflf1$ylYanla State PDlle",. Altentlon: Flro.nm Unit, 1800 EllMrton Avenue, Harrisburg,
PA 17110. NO,.E: The I,lnvolopesball t)e m~.d "CONFlOeNTIAL.-
Place an 'X. on eit~er Involuntary Commitmel'lt or Adjudicated Incompetent
INVOLUNTARY COMMITMENT
ADJUDICATED INCOMPETENT
x .
Dale of Involuntary Commitment or Adjudicated Incompetent
INDIVIDUAL INFORMA T~ON (INDIVIDUAL INVOLUNTARILY COMMITT'eO OR ADJUDI~ATED INCOMPETENT)
Trout FIRST Violet K.
LAST NAME MIDDLE
JR., ac.
MAIDEN NAME
Poole
ALIAS
DATE OF BIRTH 08/23/06 SOCIAl. SECURITY NUMBER.
f I wh t 66" WEIGHT 144 lbs.
SEX ema e RAce i e I-IEIGHT
214-16-0835
HAIR gray EYES
blue
ADDRESS
940 Walnut Bottom Road, Carlisle, Pennsylvania 17013
NOTIFICA TION BY (Please print name, address, area code, and phone number of agency or county eourt.)
County Submitting Notification
County Mental He.;ltt~ and Mental Retardation Administrator
County Mental Health Review Officer
Physician
Hospital! Faeility Provfding Treatment! Address
Judge
SIGNATURE OF NOTIFYING OFFICIAL
DATE
Court Case Number
Date of Court Order
J............___~
.L J, ... ~__R__ _ _
NOTIFICATION OF PHYSICIAN'S DETERMINATION THAT NO SEVERE MENTAL DISABILITY EXISTS
The physid:oln shan pttlvide signed confirmation of lt1e delerminalion Ofttle lack of seven;! mental disability follOwing the initial exammaliOn under Secticn 302(b} of the Mental HeaJ1h
PmceclYfe$ Act and pu~nt 10 the Uniform FltflClrms Act. Seclion 6111.1 (g){3), NOfI~ $/'lall /)<II !ransmitted by lhe physidan to the Penn:i)'lvanis Stale PorlQt ~7.'~gh lhe CQI.If'IIIJ
mental "'ulth and ~nt3J retardation admInistrator- or mental heallh review ofllClll'.
Name of Physician (Please print.)
Signature of Physician
Date
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06/19/01 TUE 13:09 FAX 2406462
Cl~/COUNTY COlffiTS
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CCtAMONWE.r.LTH OF nNNSY\..'IIANlA
NOTIFICATION OF MENTAL HEALTH COMMITMENT
Tns UnifOnn. FIlIi!SITT1S Iv:t T. PA C.S. 6105 (OJ(4J ~ lI'Iat it stlaIY be unlawM for atry pollSQn adjudlcaled as an incDmpetent orwl1o I\lI$ been in\f(llunlarily oommitted to a mental
ins1iMion for inpatient care and 1n!stment under Sedion 302, 303, or 304 of the Mentlill Heallh ProcedureB A<;l; or JloIty 9, 19711 (P.I..1S17, No, 143) to l1Q!i!illillill, lISe, lTIaI1utadl.lre.
control. IIIlII or transfer fl"*"", ll1ls would Inc:M1e adjudicdon of IncapaI:i\y ~ lei :lO Pa.C.SA ~!i501. PulSlolanlllO me PBI'll'lt;ylvania Mf:tIlal Healln Proel!!dUI'E!lJ Iv:.t. SeclIoo
109. notification shIlll be !IlInsmiIIed ID Ihs P"""")'M1nU18YM PoIiae by the JUdge, mental hI:~lIh reW:w officer or-county mental hesJlh snd mentsll'etaro'ation ~rnlstralor IIiiillifn
SevaN days 0' 1M adjudication, CQmmllment or lraatment ~ ~l.;lass mail to the Pennsylvania State pollee. Attention: Flro,lIm Unit, 1800 I;'!lmerton AY8n~. Harr1aburg,
PA 17110. HOTE: Tlteenvolope shan be m~ed "COMFlOI:NT1AL.-
Place an 'X' on either Involuntary Commitment or Adjudicated InCQmpelent
INVOLUNTARY COMMITMENT
ADJUDICATED INCOMPETENT
x .
Date of Involuntary Commitment or Adjudicated Incompetent
INDIVIDUAL INFORMA T~ON (INDIVIDUAL INVOLUNTARILY COMMITTEO OR ADJUDI~ATEO INCOMPETENT)
LAST NAME Trout FIRST Violet MIDD!.E M.
JF<.. I!TC.
MAIDEN NAME
Poole
ALIAS
DATE OF BIRTH 08/23/06 SOCIAL. SECURITY NUMBER
f 1 h t 66" WEIGHT 144 lbs.
SEX ema e RACE w i e HEIGHT
214-16-0835
HAIR gray EYES
blue
ADDRESS
940 Walnut Bottom Road, Carlisle, Pennsylvania 17013
NOTIFICATION BY (Please print name, address. area code, and phone number of agency or county eourt.)
County Submitting Notification
Counly Mental Health and Mentl>1 Retardation Administrator
County Mental Health Review Offieer
Physician
Hospital I FaCility Providing Treatment I Address
Judge
SIGNATURE OF NOTIFYING OFFICIAL
DATE
Court Case Number
Date of Court Order
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NOTIFICATION OF PHYSICIAN!S DETERMINATION THAT NO SEVERE MENTAL DISABILITY EXISTS
The p~i~ shan ptl)vide signed oonlirmsliQrl of lt1e decerminalion Of the lad< of $li!V'il1e mental disability follOwing the initial examinaliOn under Seclicn $02(b} of (he Mental HeJ/th
prooeoures ACt and pursuant (a the UnlfOfm J'JreannsAct. Seclion 15111,1 (g){:;l). Natlce $l'1ao ~ tnlnsmftted by the physfdan to tile Penn~vania State PorlCe ~'Z.~t;lh the calmlY
mental health and mentat re13rdalJon ac:ll'l'lini$lra1or or mental he~"th re~lew offie&t.
Name of Physician (Please print)
Signature of Physician
Date
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GENERAL POWER OF ATTORNEY
KNOW ALL MEN BY THESE PRESENTS, that I, VIOLET M. TROUT, of ~04 Center
street, Frederick, Maryland
21701, do hereby constitute and appoint G.
FRANKLIN EICHELBERGER, of 924 Alexander spring Road, Carlisle, Pennsylvania
17013, my true and lawful general Attorney-In-Fact for me, and generally in
my name, place and stead:
1. To enter upon and take possession of any land, buildings, tenements
or other structures, or any part or parts th~reof, that may belong to me, or
to the possession whereof I may be entitled.
2. To ask, coliect and receive any rents, profits, issues or income of
any and all such lands, buil~~ngs, tenelnents or other structures, or of any
part or parts thereof.
3. To make, execute and deliver any deeds, mortgages or leases, whether
wi th or without covenants and warrantit~s, in respect of any such lands,
buildings, tenements or other structures, or of any part or parts thereof,
and to sell and manage any such lands and to manage, repair, alter, rebuild
or reconstruct any buildings, houses or other structures, or any part or
parts thereof, that may now or hereafter be erected upon any such lands.
4. To demand, sue for, collect, recover and receive any goods, claims,
debts, monies, interest and demands;whatsoever now due or that may hereafter
be due or belong to me (including the right to institute any action, suit or
legal proceeding for the recovery of any land, buildings, tenements, or other
structures, or any part or parts thereof, to the possession whereof I may be
entitled), and to make, execute and deliver receipts, releases or other
discharges therefor, under Seal, or otherwise.
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5. To make, execute, endorse, accept and deliver any and all bills of
1
exchange, checks, drafts, notes and trade acceptances; to execute any and all
income tax returns, social Security applications and applications for pension
and retirement benefits and disability benefits of every nature, and any and
all other instruments, papers and documents as my Attorney-In-Fact shall deem
necessary or appropriate; and to enter any safe deposit box in any bank and
to withdraw therefrom any and all property therein contained belonging to me.
6. To pay all sums of money, at any time, or times, that may hereafter
be owing by me upon ,any bill, account, or any bill of exchange, check, draft,
note ,or trade acceptance, made, executed, endorsed, accepted and delivered by
me, or for me, in my name, by my said Attorney-In-Fact.
7. To defend, settle, adjust, compound, submit to arbitration and
compromise all actions, suits, accounts, reckonings, claims and demands,
whatsoever, that now. are, or hereafter shall be, pending between me and any
person, firm or corporation, in such manner and in all respects as my
Attorney-In-Fact shall think fit.
8. To hire accountants, attorneys-at-law, clerks, workmen and others
and to remove them, and appoint others in their place and to pay and allow to
the persons to be so employed such salaries, wages, or other remunerations,
as my Attorney-In-Fact shall thini fit.
9. To enter into, make, sign, execute and deliver, acknowledge and
perform any contract, agreement, writing, or thing that may, in the opinion
of my Attorney-In-Fact be necessary or proper, to be entered into, made or
signed,
sealed,
executed, delivered, acknowledged or performed; and
especially should I suffer any illness or accident, physical or mental,
requiring hospitalization or the use of a convalescent home should my present
f
(~
3
residential provisions be inadequate, then I do hereby empower my Attorney-
In-Fact to make all arrangements necessary and proper, in his sole judgment,
to place me in a hospital or convalescent home, executing the necessary
agreements or contracts therefor, and to pay all bills and expenses which
might be incurred, all to the exclusion of any authority over my person or
property by any other person or relative.
10. To buy, receive, lease, accept or otherwise acquire, and to sall,
transfer, pledge, mortgage, hypothecate or 9therwise encumber or dispose of,
any property whatsoever and wheresoever situate, be it real, personal, mixed
and/or intangible, upon such terms as my Attorney-In-Fact shall think proper;
and, in general, to borrow ~~ my behalf, any and all sums of money that my
Attorney-In-Fact shall determine necessary or appropriate in connection with
the management of my affairs.
11. To sell, contract to sell, deed, conveyor otherwise dispose of any
and all real estate that I may own, wherever situate; including especially
that real estate that I own located in the City of Frederick, Frederick
County, Maryland, and being known as 304 Center street, Frederick, Maryland
21701, and in connection with these powers, specifically, I do hereby grant
unto my Attorney-In-Fact the right and power to sign, seal, execute,
acknowledge and deliver any and a,l instruments in writing of any kind and
nature, as may be necessary or convenient, containing such terms and
condi tions as my Attorney-In-Fact may deem advisable, to completely and
effectually complete final settlement under any contract of sale which my
Attorney-In-Fact shall deem appropriate for the sale of any and all of my
real estate, and my Attorney-In-Fact in connection with any such sale shall
have the right to receive full proceeds coming to me as a result of said
f
( ....--.
4
sale, without the necessity of the purchaser or settlement officer to see to
the disposition of the settlement proceeds or the proceeds of any such sale.
12. Under the terms hereof, I do specifically grant unto my.Attorney-
In-Fact the power to borrow on my beha.lf any and all swns of money that my
Attorney-In-Fact shall deem necessary and/or appropriate; and in connection
therewith, I do hereby specifically grant unto my Attorney-In-Fact the power
to collateralize any such loan with any and all of my property of whatever
nature and description and wherever situate. . Additionally, I do specifically
grant unto my Attorney-In-Fact the power to purchase in any amount that my
Attorney-In-Fact shall deem appropriate, United States Treasury bonds, bills,
notes or other obligations, r,edeemable at par, in payment of any and all
Federal Estate taxes that might arise upon my death, with such United States
Treasury obligations being more popularly known as "Flower Bondsll.
13. Intendin9 to grant unto my Attorney-In-Fact full power of
substitution, I do hereby grant unto my Attorney-In-Fact the power to
constitute and appoint, in his place and stead, as his substitute, one
attorney, or more, for him, with full power of revocation vested in my
Attorney-In-Fact.
14. Without, in anywise, limiting the aforegoing, I do grant unto my
Attorney-In-Fact the power general~y to do, execute and perform any other
act, deed, matter or thing, whatsoever, as fully and effectually as I could
do, if personally present; and it is my intention and purpose in executing
this Power of Attorney to grant unto my Attorney-In-Fact the complete power
and authority to bind me in any manner or form by any written and/or oral act
or deed as fully and completely as I myself could do if I were personally
present and acting.
I
(----
5
15. This General Power of Attorney shall not be affected by my
,
disability, and I request that no guardianship proceeding for my property be
commenced in the event of my disability; but in the event any court appoints
a guardian for my person and property, I direct that my Attorney-In-Fact, G.
Franklin Eichelberger, or his appointed substitute or substitutes, shall
serve as guardian, without bond.
16. This General Power of Attorney shall. not be construed by any court
of law or by any other entity or person as a grant unto my Attorney-In-Fact
of a general power ?f appointment, and in the use of this General Power of
Attor,ney my Attorney-In-Fact is prohibited from dealing with any of my
property for less than valuaQle consid2ration.
And I, the said Violet M. Trout, do hereby ratify and confirm all
whatsoever my said Attorney-In-Fact, or his substitute or substitutes, shall
do, or cause to be done, in, or about the premises, by virtue of this General
Power of Attorney.
IN WITNESS WHEREOF, I have hereunto set my hand and seal, in the County
t1):J day of A6a:'-m~ , 1992.
of Frederick, State of Maryland, on this
WITNESS:
~~ W~~
~~ ~, ~EAL)
~Violet M. Trout
ADtvllSSION AGREE~~ENT
CONTRACT BETWEEN PATIENT/RES!DENT AND FACILITY
....~-
lVlanorCare
Health Services
~
,
THIS ADMISSION AGREEMENT (the "Agreement") is entered into this ci)'if QJ. :t\'r,: "s day of
~o..;.I ,19 99 ,between m6nOr lOJLQ. l--1ea/ll-A he'~acllitY"),and
V/~ e _ Tr-o u..-(- (the "Patient/Resident"), and/or
(the "Responsible Party"). As used herein, the term "Patient/Resident" shall also mean the Responsible
Party, if any. The parties agree as follows:
1. Commencement. This Agreement shall begin on the date of admission of the Patient/Resident
to the Facility.
2. Termination of Agreement, Discharge and Transfer.
a. Termination by Patient/Resident. The Patient/Resident may terminate this Agreement by
giving the Facility at least five (5) days advance written notice. The Patient/Resident is responsible
for payment of all charges for five (5) days after notice is given, or until the Patient/Resident actually
leaves the Facility, whichever is last. If the Patient/Resident leaves the Facility (i) before the attending
physician discharges the Patient/Resident, or (ii) against medical advice, the Patient/Resident and
Responsible Party agre~ to assume all responsibility for injury or harm to the Patient/Resident, and
hereby release the Facility, its employees and agents, from all liability connected with such departure.
. b. Termination by Facility. The Facility may terminate this Agreement and discharge the Pat-
ient/Resident upon at least thirty (30) days prior written notice if (1) the Patient/Resident's needs
cannot be met; (2) the Patient/Resident presents a danger to the. health or safety of other indivi-
duals; (3) the Patient/Resident fails to pay charges for supplies or services after notice; (4) the
Patient/Resident's health has improved sufficiently so that the Patient/Resident no longer needs the
services provided; or (5) the Facility ceases to operate. However, the Patient/Resident may be
transferred or discharged upon less than thirty (30) days notice if: (1) an immediate transfer or
discharge is required due to the Patient/Resident's medical needs; (2) the Patient/Resident presents
a threat to the health and safety of individuals in the Facility; or (3) the Patient/Resident has not
resided in the Facility for thirty (30) days. Such notice shall be given as soon as practical. The
Patient/Resident acknowledges receipt from the Facility of materials as to the Patient/Resident's right
to appeal a discharge decision with State authorities and the appeals process. If this Agreement is
terminated and/or the Patient/ Resident is discharged by the Facility, the Responsible Party agrees
to accept custody of the Patient/Resident upon discharge and cooperate with the Facility to facilitate
the Patient/Resident's discharge.
.
3. Responsible Party. The Patient/Resident shall execute Exhibit A regarding Responsible Party
appointment.
4. Fees & Payments. The Patient/Resident is responsible for, and shall pay, the daily rate and
charges for supplemental services and supplies not paid by any third party as described in the Fee
Schedule, attached as Exhibit B, as well as applicable co-insurance and deductible amounts and all
expenses of discharge or transfer.
5. Release of Information. The Patient/Resident hereby authorizes all persons and/or entities to
release all or any part of his/her medical/health records to the Facility. The Patient/Resident also
authorizes the release of records or information to any health care institution to which the Patient/
Resident may be transferred, any provider involved in the care of the Patient/Resident, any third
party payor, including, but not limited to, government and private insurers, or any other person entitled
or authorized to receive such information by law or by the Patient/Resident.
~
MHC.OOB.:ZO (Rev. 7/96) PI! 3
-rr- 1 of 3
IJ z'Xl1ibj-t. 2.
Conditions (collectively referrr-' to as "Conditions") ( -
1. The assets of the Patient/Resident will be ut'i1ized to pay, when due, all costs incurred by
the Patient/Resident at the Facility not co,,:.:red by a third party payor, at the rates set forth
in the Fee Schedule (Exhibit B). The Responsible Party will arrange for the provision of
personal clothing and care supplies as needed or desired by the Patient/Resident and as
required by the Facility.
2. The assets of the Patient/Resident will be utilized to replace any and all furnishings or other
property of the facility, other Patient/Residents or employees of the facility damaged by the
Patient/ Resident.
3. All of the information, including but not limited to that contained on the attached Application
for Residency, dated mo.J;j;: L (j- ,199 9ef ,and which is attached hereto and
made part of this Exhibit aRd of the Admission Agreement, is true and accurate as of this
date and all assets listed in the application are in fact available to the Patient/Resident for
the Patient/Resident's care while at the facility.
4. Neither the Responsible Party nor the Patient/Resident will take action to dissipate or other-
wise transfer the' Patient/Resident's assets and/or assets which are available for the Pat-
ient/ Resident's care so as to prevent such assets from being used to pay for the care of
the Patient/Resident while at the facility.
5. When the assets available to pay for the Patient/Resident's care at the Facility are not
sufficient to pay for the anticipated length of stay, the Responsible Party or Patient/Resident
will so notify the Facility and will file, on behalf of the Patient/Resident, all applications and
other documents necessary or advisable to qualify him/her for all third party payor programs
for which he/she may be eligible, including Medicaid.
6. If the Patient/Resident is a Medicaid Patient/Resident, that Responsible Party or Patient/
Resident will provide financial information regarding monthly credits, increases and decreases
in the Patient/Resident's bank account(s) and other assets to the Facility to enable the
Facility to provide requested data to Medicaid representatives.
7. If the Patient/Resident is covered by a third party payor, the assets of the Patient/Resident
will be utilized to pay extra charges not covered by the third party payor in a timely manner,
.
and to notify the administrator of the Facility of any problem anticipated in paying such charges.
The undersigned understands and acknowledges that the Facility is relying upon the above Conditions
in admitting the Patient/Resident to the Facility and understands and acknowledges that if the above
warranties and representations are not true, or if the abov ovenants and agreements are not
complied with, the Facility will have detrimentally relied upon and the Facility will suffer financial
harm and loss.
MHC.008.20 (Rev. 4/96) PQ 7
2 of 2
. '.
~. Federal Resident Rights
. Resident Responsibilities
. Life Sustaining Treatment Policy
. Medical/Nursing Education
. Dental, Vision and Hearing Services
. Interdisciplinary Care Conference
. Utilization Review Meetings (if applicable)
. Personal Laundry Policy
.~""-.
. Barber /p.."~uty Services
.' " ... Mail Poli~.1
,. Voting Materials
· Photo/Media Events
. Personal Fund Account Procedure
· Tobacco Policy
· Grievance Procedures
. State Resident Rights (if applicable)
14. GOVERNING LAW. THIS AGREEMENT SHALL BE GOVERNED AND CONSTRUED IN
ACCORDANCE WITH THE LAWS AND REGULATIONS OF THE STATE WHERE THE FACILITY IS
LOCATED. TO THE EXTENT ANY PROVISION HEREOF CONFLICTS WITH STATE LAW, STATE LAW
SHALL CONTROL. THE STATE LAW ADDENDUM ATTACHED HERETO AS EXHIBIT D SETS FORTH
ANY DELETIONS FROM OR ADDITIONS TO, THIS AGREEMENT REQUIRED BY STATE LAW, WHICH
AMENDMENTS SHALL BE A PART OF THIS AGREEMENT.
15. Miscellaneous. The provisions of this Agreement shall bind the parties, their respective executors,
administrators, heirs, beneficiaries, and assigns. The waiver by either party of any breach or 'default
of this Agreement shall not operate as a waiver of any subsequent breach or default. The provisions
of this Agreement shall be severable and the invalidity or unenforceability of any provision shall not
affect the validity or enforceability of any other provision. This Agreement and all Exhibits are the
entire agreement and any changes shall be in writing and signed by both parties.
IN WITNESS WHEREOF, the parties hereto have executed this Admission Agreement as of the day
and year above written.
Date
7vVi7luo/ hQk~--
Facility Representative - sfQnature
MHc-ooe-20 (Rev. 4/96) P'J 5
3 of 3
II
I
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
IN RE:
VIOLET M. TROUT, an
alleged incapacitated
person
No. 21-01-575
RRDER
AND NOW, TO WIT, this ~ day of
, 2001, it is hereby
ORDERED and DIRECTED that the Power of Attorney to G. Franklin Eichelberger is
hereby revoked; and Pennsylvania Guardianship Associates, by and through its President,
Brian Brooks, is hereby appointed plenary guardian of the estate and person of Violet M.
Trout.
IT IS SO ORDERED:
BY THE COURT,
J.
J
WOLFSON & ASSOCIATES, P.C.
Attorneys at Law
A TIORNEYS
Daniel F. Wolfson
Amy F. Wolfson
Philip C. Warholic
Donald L. Hoage*
BRANCH OFFICE:
267 East Market Street
Yark, Pennsylvania 1 7403
8 Manchester Street
Glen Rock, PA 17327
(717) 235-5014
PARALEGALS
Margaret L. Burg
Michele M. McHugh
(717) 846-1252
(800) 321-8467
FAX (717) 848-1146
PLEASE FORWARD ALL
CORRESPONDENCE TO
THE YORK OFFICE
COUNSEL
Morrison B. Williams
e-mail: dfwolfson@debtcolIection.net
. Licensed to Practice in MaryJand
2 October 2001
10((
The Honorable George E. Hoffer
Cumberland County Court House
1 Courthouse Square
Carlisle, PA 17
..~~._..
RE: Violet M. Trout, an alleged incapacitated person
Cumberland County Orphan's Court No. 21-01-575
Dear Judge Hoffer:
As previously promised, enclosed please find the original Consent of Proposed Guardian
which has been executed in this matter by Mr. Brooks of the Pennsylvania Guardianship
Association. We are providing this original document to you so that the Court's file may
be complete.
Thank you for your attention to this matter. Should you have any questions or require any
additional information, please do not hesitate to contact the undersigned.
Sincerely,
1R\FSON & ASSOCIATES, P.e.
~,. \ de J
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;; '"rv' ". /u. ~~..
,l'.my ~Olfson, ESquir .
AFW/mmm
Enclosure
pc: HeR Manor Care (w/enclosure)
'I
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
IN RE:
VIOLET M. TROUT, an
alleged incapacitated
person
No. 21-01-575
CONSENT OF PROPOSED GUARDIAN
STATE OF PENNSYLVANIA
s.s.
COUNTY OF
I, Brian Brooks, as President of Pennsylvania Guardianship Association, P.O. Box
7295, Lancaster, Pennsylvania 17604, do hereby certify that I am willing to act as the
guardian for the Estate and person of Violet M. Trout, an alleged incompetent, if the court
shall so appoint.
Further, I do hereby certify that I am not a fiduciary of any Estate in which the
alleged incompetent has an interest, nor have I any interest adverse to the alleged
incompetent.
The facts and opinions contained herein are true and correct to the best of my
knowledge, information and belief.
Notarial Seal
Sharon L. Brooks. Notary Public
CItY of LanCaSter LancaSter County
My CommI8SIOO eXpires Apr. 18, 2~5
Member. PennsylYanlaAssOdatiOO ofNolanes
SWORN and SUBSCRIBED to
before me this _ cJ.d /' day
of /\..(:2t ~ ryl)J.Ul_ ' 2001 .
~ dlr it~
- ~;~,?k' - fp L<.;'7< t ,
- /'J Notary Public
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
INRE:
No. 21-01-575
VIOLET M. TROUT,
An Incapacitated Person
~ ORDEr I ,...
AND NOW, TO WIT, thisl2 da~ of v.N .
, 2002, the Court being
apprized of the matters contained in the annexed Petition For Amended Order Appointing
Guardian, it is hereby ORDERED AND DECREED that, the appointment of the Pennsylvania
Guardianship Association, Inc., as plenary guardian of the person and estate of the incapacitated
person is hereby confirmed, and it is further ORDERED AND DECREED that the guardian shall
be entitled to a reasonable fee for its efforts, which may be paid from the income ofthe
incapacitated person.
BY THE COURT:
l;S'~..)
J.
'jLU:l~)
R l~ t'd S l 81:-1 ZOo
'<~
u::;al:l
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
INRE:
No. 21-01-575
VIOLET M. TROUT,
An Incapacitated Person
PETITION FOR AMENDED ORDER
APPOINTING GUARDIAN
TO THE HONORABLE, THE JUDGES OF SAID COURT:
c-l:S " \ -
AND NOW, this ~ day of r e b{ Vu /y , 2002, comes the Petitioner, Pennsylvania
Guardianship Association, Inc., by and through its attorney, Scott A. Beaverson, Esquire, and
brings the within Petition for Amended Order Appointing Guardian and in support thereof avers
as follows:
1. That your Petitioner, Pennsylvania Guardianship Association, Inc., is a corporation
organized and existing under the laws of the Commonwealth of Pennsylvania with a mailing
address of PO Box 541, York PA 17404.
2. That by Order of September 13,2001, this Honorable Court appointed Petitioner as
plenary guardian of the estate and person of Violet M. Trout.
3. That the only source of income of Violet M. Trout is from medicare funds
administered by the Pennsylvania Department of Public Welfare.
..
4. That in order for a guardian's fees to be regarded as an allowable deduction, the
Pennsylvania Department of Public Welfare requires, inter alia, that the order appointing the
guardian authorize payment of a fee. A true and correct copy of a Policy Clarification issued by
the Pennsylvania Department of Public Welfare is attached hereto as Exhibit "A."
WHEREFORE, Petitioner, Pennsylvania Guardianship Association, Inc., prays your
Honorable Court to amend its order appointing Petitioner as guardian for Violet M. Trout and to
expressly authorize a reasonable fee may be paid to the guardian from the income of the
incapacitated person.
Respectfully submitted,
~()/tb G ~ o../\re 'VIA'I\
Scott A. Beaverson, Esquire
ID #47322
204 North George Street
Suite 200
York PA 17401
(717) 843-8500
FEB-05--02 0~.:45 PM SCOTT A BEAVERSON ESO
.(17:3431-1.9~,
F'.(j",
.
YERlFICA T10;-':
The u11dersigned verifies that the facts contained in the foregoing are true and correct, to
the best of hlslher knowledge, information and belief, Wld understands that false statements
herein are made subject to the penahies of 1 g Pa. C,S. Section 4904, relating to unsworn
falsification to authorities.
PEl'."NSYLV ANIA GUARDIANSHIP
ASSOCIATION, TNe.
Dote: CJ):0;r
-D~
-... -
roo s, President
, ~
. PMN-9761-4S0 - Guardian ~ (Updated 7-19-01)
......'......-
Page I of2
PoUey Clarification - Medical Assistance - NurS'.ing Home Care
P~fN9"614t110
Home I What's New I Manuals I Admin I Forms I F'eedbaoklSearch
Submitted: July 17.2001
Agency: All CAOs
Citations: NeB 450.41{#1)
Subject: Guardian Fees (Updated 7 -19-0 1 )
How should guardian fees be treated when determining the amount which a resident must
pay towards his cost of nursing facility services'?
Response By: T. Johnson
7/19/01
55 Pa Code i 181.452(d) does not allow guardian fees as a deduction when determining a
client's oontribution toward cost of care. Nursing Care Handbook (NCH) instructions do list
guardian fees as an exclusion when determining contribution toward cost of care,
Guardian fees will be allowed as a deduction when determining cont.ibution toward cost of
care as follows:
1. Only the fee paid loa non-profit guardianship service agency will be allowed as a
deduction when detennining contribution toward cost of care. A fee paid to a representative
payee "Will not be an allowable deduction.
*
2. VerifICation of the court order appointing the guardian 31ld establishing the fee must be
provided.
3. The amount of the guardian fee that is allowable as a deduction is the actual fee paid,
subject to a maximum of$l00 per month.
4. If the amount of the guardian fee exceeds $lOO per mont!1, only allow $100 per month:1.'\
the deduction. There is no provision to allow more than $100 per month for an undue
hardship.
PA 162 notices tbat are sent to the recipientlrepresentatlve/guardian/nursing facility must
explain that the amount of the guardian fee is a deduction from the recipient's income when
determining the recipient's contribution toward the cost of ca.re. The CAO worker is
responsible for listing this deduction and subtracting it from the resident's income when
determining contribution toward cost of care.
This clarification replaces PMN9567450 and any other exbting clarifications that deal with
the treatment of guardian fees wr.en determining contribution t.oward cost of care. For
applicants, this policy is effective immediately. For recipients, this policy 1$ not to be
applied until the next cUent conta(!t or at Dext ..edeterminatioQ, whichever Occurs
earlter.
hnp:(/oimwebIMAIN/polclarif/malpmn-9761-450.htIll
8/2/2001
-0 l"Jt,'d
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~
CA In be f/c)ltJ.
IN THE COURT OF COMMON PLEAS OF Ia:-L IIIl J COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
IN RE: VI 6 M fVI. '/~, an incapacitated person FILE NO. .::) I - 0 I - S 7,
.
GUARDIAN OF PERSON ANNUAL REPORT
[20 Pa. C.S.A. 5521 (c)]
FROMd /Is-jea ,200_ TO ~ A7h ,200_
1. I am the _ Limited hlenary Guardian of the Person of my ward, named above.
2. I was appointed Guardian by Order of the Court dated02/IY!od, which was
/ was not modified by Court Order(s) dated ' /
3. Is the incapacitated person still living? UP.-LJ
If no, answer the following: {f
(a) Date of Death?
(b) Place of Death?
(c) Name of Administrator or Executor?
(d) Date Guardian of the Person filed the last Annual. Report?
4. If the incapacitated person is still living, answer the following questions:
F/rJ
(a) Date Guardian of the Person filed the last Annual Report?
Date of birth of incapacitated person
(d) The incapacitated person's residence is:
Ward's own residence
. /' Nursing Home
_ Hospital or Medical Facility
_ My home/apartment
Relative's Home
Boarding Home
( e) The incapacitated person has been living there since 1A~1l ~
If moved within the past year, state from where and the r ason for the change
C.A. - 27
(f) I rate hislher living arrangement as:
Excellent LA verage
Explain:
_ Below Average
(g) I believe he/she is:
~ontent with the living situation
_unhappy with the living situation
_unaware of the living situation
5. Physical health
(a) Current physical condition of the incapacitated person is:
Excellent Good Fair L- Poor
OLlJnaMCf
, ,
( c) During the past year, hislher physical condition has:
-.L'femained about the same.
_ improved. Explain
worsened. Explain
(d) During the past year, he/she received the following medical treatment (include
check-ups and dental work):
Date Ailment Type of treatment
Q11~ /1.JJJu'J ~ ~
Doctor's name
6. Mental Health
(a) The incapacitated person's condition is
excellent ~OOd
_ poor
(b) Hislher major mental health problems are as follows:
.,"
..
(c) Duri~e past year, hislher mental condition has:
- remained about the same.
- Improved. Explain
- Worsened. Explain
(d) During the past year, treatment or evaluation by a psychiatrist, psychologist or social
worker ~ was _ was not provided. Such mental health services are briefly
detbedas: {~dm... udu/ W J1r;/--t.
: m~ aL+-~~ "1 tur ~ ~
7. Social Activities / Services
(a) His/her current social condition is:
excellent ~ood
fair
poor
(b) During the past year, hislher social condition has:
~emained about the same.
- improved. Explain.
- worsened. Explain.
(c) During the past year he/she has participated in the fOllowing activities:
~ recreational
_ educational ~
----.2S(;cial
_ occupational
no activities available.
= he/she refuses to Participate in any activities.
- he/she is unable to participate in any activities.
8. Visitation
(al During the east year. I visited himlher as follows:
(b) The average amount of time I spent on each visit was
(c) The last time I visited was on I/o ~
date
q tJ(tu-4-e/(l/
J J -dO ~
~
,,-- ..
10. I believe he/she has the following unmet needs:
11. The guardianship /:hOuld _ should not be continued without modification
because:
12. Please note any concerns about the Incapacitated person's physical or mental well being or
the finances that the Court should know.
13. I /am _ am not guardian of the incapacitated person's estate. If yes, my report is
attached.
Date:
I certify under the penalties of perjury that the information contained in this report is true
and correct to the best of my knowledge, information and belief.
~j)~
Sfi e of the agar ian of the Person
~;;I(t:';
Name: \f5( I tt f1 fi) Bmv/(~S
Address:PA GUARDIANSHIP ASSOC.
P.O. BOX 7295
Lancaster, PA 17604.7295
. Telephone # (Home) ~ tJ} --l/ (& f
(Work) ct OJ - y (&~
t,
.
OtUrJbvlaN1
IN THE COURT OF COl\1J\10N PLEAS OF COUNTY, PENNSYLVANIA
Orphans' Court Division
In re
V, .() / e + 111. J(ovc.....:f-, an Incapacitated Person
;:)./- DI- S7S
O.c. No.
h/lCt/
" L .~ REPORT
OF
GUARDIAN OF THE ESTATE
1. I,
Br,ctv1 '/') B(C)ob
(Name of Guardian)
P/eY\a~
(Plenary or Limited)
T'\OGL +
, was appointed on . J.. ,/ J S-J c ~
guardian of the Estate of Vi 0 \ ~ +-
who was adjudicated an incapacitated person by
Decree of
, J. dated
This is my alIDual report for the period
~II j- J6~~
I I
to Vdlj 03
2. Summary:
(Transactions limited to Report Period.)
a. Principal Balance on Hand
:1
b. Income Balance on Hand
$
c. Total Distributions for the
Incapacitated Person
$
d. Total Disburser.]wnts
. I "
'.. t.
$
1
, ;
ffiaJfr~
3. Composition ofPlincipal Balance on Hand
Estimated Value
Total
4. Compos-ition of Income Balance on Hand
Estimated Value
Total
5. Distributions Made to or on Behalf of the Incapacitated Person
Estimated Value
Total
2
~
6. Disbursements
Estimated Value
Total
I certify under penalty of perjury that the foregoing infoDllation
is COlTect to the best of my knowledge, infoill1ation and belief.
Date:
t/NJ03
(Signature)
J3(~ OA-n J\ BrvdL~
(Name of Guardian)
(Address)
(City, State, Zip Code)
(117) 29q-4~~
(Telephone Number)
3
PAG~CUS-PAGA Custodial
8/11' 3
ITEMIZED CATEGORY REPORT
1/ l' 0 Through 8/31' 3
Date Num Description
-------- ------ ------------------
6/24' 3 3423 S PLATINUM PLUS FOR
7/ 3' 3 R8377 DEPOSIT
7/ 9 ' 3 3501 MANORCARE CARLISLE
7/30' 3 3559 CREMATION SOCIETY
TOTAL TROUT, VIOLET
TOTAL INCOME
TOTAL INCOME/EXPENSE
Memo
Category
------------- ----------------- - ---------
Clr Amount
CLOTHING TROUT,VIOLET/FINA
SSDI TROUT,VIOLET/SSDI
VIOLET TROUT TROUT, VIOLET/COST
VIOLET M. TRO TROUT,VIOLET/FUNE
Page 2
-134.16
890.00
-760.00
-1,087.00
-736.69
-736.69
-736.69
---------
---------
PAGA_CUS-PAGA Custodial
8/11' 3
ITBMIZED CATBGORY REPORT
1/ l' 0 Through 8/31' 3
Date
Num
Description
Memo
Category
Page 1
-------- ------ ------------------ ------------- ----------------- - ---------
Clr Amount
1/23' 2
2/ 6' 2
3/ 4' 2
3/ 7' 2
3/ 7' 2
3/ 7' 2
3/11' 2
3/12' 2
4/22' 2
4/22' 2
5/16' 2
6/10' 2
6/10' 2
6/17' 2
6/20' 2
7/ 9' 2
8/14' 2
8/19' 2
8/20' 2
8/23' 2
9/16' 2
10/14' 2
10/14' 2
10/14' 2
10/15' 2
11/11' 2
11/12' 2
11/14' 2
12/10' 2
12/11' 2
12/12' 2
1/ 9' 3
1/ 9' 3
1/30' 3
2/ 6' 3
2/ 6' 3
2/18' 3
3/ 4' 3
3/10' 3
3/31' 3
4/ 3' 3
4/ 7' 3
5/ 5' 3
5/ 6' 3
6/ 3' 3
6/ 5' 3
6/12' 3
INCOMB/EXPENSE
INCOME
TROUT, VIOLET
R4839
2196S
2244
R4900
R4901
R4902
2259
2262
2346S
R4975
2433
R5229
R5286
2507
2523S
R5323
2624
RR539
2643S
2646
2697
2743
R5492
R5493
2762S
R5555
2792S
2819
2886
2893S
R5615
2933
2948
R5667
3003S
R5711
3060
R5759
3119
3157 S
R8212
3180
R8265
3271
R8332
3352 S
3378
DEPOSIT SSDI TROUT,VIOLBT/SSDI
PAGA GENERAL ACCOU GDN FEE TROUT,VIOLBT/GUAR
MANORCARE CARLISLE VIOLBT TROUT TROUT, VIOLET/COST
DEPOSIT SSDI TROUT,VIOLET/SSDI
DEPOSIT SSDI TROUT,VIOLET/SSDI
DEPOSIT BANK TRANSFER TROUT, VIOLET/BANK
SCOTT A. BBAVERSON TROUT,VIOLET/LEGA
BRIAN D. BROOKS / REIMBURSTM TROUT,VIOLET/REIM
PAGA GENERAL ACCOU GDN FEE TROUT,VIOLET/GUAR
DEPOSIT SSDI TROUT,VIOLET/SSDI
MANOR CARE CARLISLB VIOLET TROUT TROUT, VIOLET/COST
DEPOSIT SSDI TROUT,VIOLET/SSDI
DEPOSIT SSDI TROUT,VIOLET/SSDI
MANORCARE CARLISLE VIOLET TROUT TROUT, VIOLET/COST
PAGA GENERAL ACCOU GDN FEE TROUT,VIOLET/GUAR
DEPOSIT SSDI TROUT,VIOLET/SSDI
MANORCARE CARLISLE VIOLET TROUT TROUT, VIOLET/COST
DEPOSIT SSDI TROUT,VIOLET/SSDI
PAGA GENBRAL ACCOU GUARDIAN FEE TROUT,VIOLET/GUAR
MANORCARE CARLISLE VIOLET TROUT TROUT, VIOLET/COST
MANORCARE CARLISLE VIOLET TROUT TROUT, VIOLET/COST
MANORCARE CARLISLE VIOLET TROUT TROUT, VIOLET/COST
DEPOSIT SSDI TROUT,VIOLET/SSDI
DEPOSIT SSDI TROUT,VIOLET/SSDI
PAGA GENERAL ACCOU GUARDIAN FEE TROUT,VIOLET/GUAR
DEPOSIT SSDI TROUT,VIOLET/SSDI
PAGA GENERAL ACCOU GUARDIAN FEE TROUT,VIOLET/GUAR
MANORCARE CARLISLE VIOLET TROUT TROUT, VIOLET/COST
MANORCARE CARLISLE VIOLET TROUT TROUT, VIOLET/COST
PAGA GENERAL ACCOU GUARDIAN FEE TROUT,VIOLET/GUAR
DEPOSIT SSDI TROUT,VIOLET/SSDI
MANORCARE CARLISLE VIOLET TROUT TROUT, VIOLET/COST
TRIANGLE TRVELING TROUT,VIOLET/PERS
DEPOSIT SSDI TROUT,VIOLET/SSDI
PAGA GENERAL ACCOU GDN FEE TROUT,VIOLET/GUAR
DEPOSIT SSDI TROUT,VIOLET/SSDI
MANORCARE CARLISLE VIOLET TROUT TROUT, VIOLET/COST
DEPOSIT SSDI TROUT,VIOLET/SSDI
MANORCARE CARLISLE VIOLET TROUT TROUT, VIOLET/COST
PAGA GENERAL ACCOU TROUT,VIOLET/GUAR
DEPOSIT SSDI TROUT,VIOLET/SSDI
MANORCARE CARLISLE VIOLET TROUT TROUT, VIOLET/COST
DEPOSIT SSDI TROUT,VIOLET/SSDI
MANORCARE CARLISLE VIOLET TROUT TROUT, VIOLET/COST
DEPOSIT SSDI TROUT,VIOLET/SSDI
PAGA GENERAL ACCOU INITIAL 1-5/0 TROUT,VIOLET/GUAR
MANORCARE CARLISLE VIOLET TROUT TROUT, VIOLET/COST
878.00
-1,800.00
-6,500.00
878.00
878.00
6,194.97
-141. 00
-2.50
-200.00
878.00
-848.00
878.00
878.00
-748.00
-300.00
878.00
-748.00
878.00
-100.00
-748.00
-748.00
-748.00
878.00
878.00
-200.00
878.00
-100.00
-784.00
-748.00
-100.00
878.00
-748.00
-169.00
890.00
-200.00
890.00
-760.00
890.00
-760.00
-200.00
890.00
-760.00
890.00
-796.00
890.00
-1,000.00
-760.00
&rrhrld
IN mE COURT OF COMMON PLEAS OF. UIIMI COUNTY, PENNSYLVANIA
ORPHANS' COURT DMSION
IN RE: \/, 0 \ -e t llt :T ({w-- ran inca~acitated person
FILE NO. J \-~ 1- 57..5
GUARDIAN OF THE ESTATE ANNUAL REPORT
[20 Pa.C.S.A. 5521 (c)]
FROM ;) l,S J () d- ,200_ TO d. / IS-Iv] ,200_
~ r ~
1) I am the _Limited ~enary Guardian of the Estate of mj wan!, named above.
I was appointed Yuardian by Order of the Court dated .;;) J j ~ (j d- , which
_was ~was not modified by Court Order(s) dated .
2) Is the incapacitated person still living? ~
If no, answer the following:
(a) Date ofIJ"eath
(b) Place of Death
(c) Name of Administrator/trix or Executor/trix
(d) Date Guardian of the Person filed the last Annual Report
PLEASE ANSWER THE FOLLOWING QUESTIONS WHETHER THE
INCAPACITATED PERSON IS LIVING OR DECEASED.
3) My initiallJlventory was filed on ., /-3 / 10.3 and listed a total estate value of
$ - 77~'" C?7. , J
The Inventory listed _ a total monthly income of $ pq 0 .OD comprised of the
following: -A 00 I D1. ~ 4...-9.-e' ~
4) At the ~g date of this reporting period, my initial balance on hand was
$ -q~ .~ .
c.A. - 28
1
Jl& CL1~-a~/^J2
5) During this reporting period, the following reflects all sources of income (other than
social security) received by me for my ward: (Add additional pages if needed)
Date Received
Source of Income
Amount
1.
2.
3.
4.
5.
6.
TOTAL
6) During this reporting period, the following reflects all payments I have made for my
ward: (Add additional pages if needed)
. Date
To Whom Paid
Reason for Payment Amount
1.
2.
3.
4.
5.
6.
TOTAL
7) The present principal assets of my ward are:
Description of Asset
Present Value
1.
2.
3.
4.
5.
6.
TOTAL
8) The present amount and sources of income for my ward are:
Source of Income
Amount of Income
(Indicate whether monthly,
quarterly, annually)
1.
2.
3.
4.
5.
6.
9) The regular monthly expenses of my ward which I pay are:
To Whom Paid
Amount
1.
2.
3.
4.
5.
6.
10) I havelh e not circle one) petitioned the Court for permission to invade principal to
meet the s of my ward.
(If applicable) The following expenses of my ward have been paid from principal:
To Whom Paid
. Purpose
Amount
1.
2.
3.
4.
5.
6.
v ave not ( circle one) paid myself compensation for services I rendered as
dian.
The amount I Paid myself totaled $
calculated at the -fOllowing rate: $
and was
per week/month ( circle one).
12) Check the correct response and complete, if appropriate.
~e will be no need for extraordinary expenditures on behalf of my ward in
the next (12) months.
There well be a need for extraordinary expenditures on behalf of my ward in
the next (12) months because:
13) Check the correct response and complete, if appropriate.
_A. My ward receives monthly social secmity benefits directly.
_B. I am the designated payee to receive my ward's social security benefits.
..
...
/" C. The designated payee of my ward~a1 security benefi~s
;0 fl (5), U 0( 0 J1...tJG p Ss 0 <-
whose address is '
and i~ (circle one) related to my ward as
9tLar~ (insert relati,onship).
14) Please note any concerns about the incapacitated person t s physical or mental well
being or the finances that the Court should know.
15) I / am
report is attached.
am not guardian of the incapacitated person t s person. If yest
I certify under the penalties of perjury that the information contained in this report is
true and correct to the best of my knowledget information and belief.
Name: . BtUAJLf)~J
Address: PA GUARDIANSHIP ASSOC.
P.O.BOX 7295
Lancaster, PA 17604.7295
Telephone No. (Home) ~q9 / Y'~p
(Work) 91"'- <(J .J>
------- -------------------- --------
.
ITEMIZED CATEGORY REPORT
2/ l' 0 Through 2/28' 3
PAGA_CUS-PAGA Custodial Page 1
6/18' 3
Date Num Description Memo Category Clr Amount
INCOME/EXPENSE
INCOME
TROUT, VIOLET
1/23' 2 R4839 DEPOSIT SSDI TROUT,VIOLET/SSDI 878.00
2/ 6' 2 2196S PAGA GENERAL ACCOU GDN FEE TROUT,VIOLET/GUAR -1,800.00
3/ 4' 2 2244 MANORCARE CARLISLE VIOLET TROUT TROUT, VIOLET/COST -6,500.00
3/ 7' 2 R4900 DEPOSIT SSDI TROUT,VIOLET/SSDI 878.00
3/ 7' 2 R4901 DEPOSIT SSDI TROUT,VIOLET/SSDI 878.00
3/ 7' 2 R4902 DEPOSIT BANK TRANSFER TROUT, VIOLET/BANK 6,194.97
3/11' 2 2259 SCOTT A. BEAVERSON TROUT,VIOLET/LEGA -141.00
3/12' 2 2262 BRIAN D. BROOKS / REIMBURSTM TROUT,VIOLET/REIM -2.50
4/22' 2 2346S PAGA GENERAL ACCOU GDN FEE TROUT,VIOLET/GUAR -200.00
4/22' 2 R4975 DEPOSIT SSDI TROUT,VIOLET/SSDI 878.00
5/16' 2 2433 MANORCARE CARLISLE VIOLET TROUT TROUT, VIOLET/COST -848.00
6/10' 2 R5229 DEPOSIT SSDI TROUT,VIOLET/SSDI 878.00
6/10' 2 R5286 DEPOSIT SSDI TROUT,VIOLET/SSDI 878.00
6/17' 2 2507 MANORCARE CARLISLE VIOLET TROUT TROUT, VIOLET/COST -748.00
6/20' 2 2523S PAGA GENERAL ACCOU GDN FEE TROUT,VIOLET/GUAR -300.00
7/ 9' 2 R5323 DEPOSIT SSDI TROUT,VIOLET/SSDI 878.00
8/14' 2 2624 MANORCARE CARLISLE VIOLET TROUT TROUT, VIOLET/COST -748.00
8/19' 2 RR539 DEPOSIT SSDI TROUT,VIOLET/SSDI 878.00
8/20' 2 2643S PAGA GENERAL ACCOU GUARDIAN FEE TROUT,VIOLET/GUAR -100.00
8/23' 2 2646 MANORCARE CARLISLE VIOLET TROUT TROUT, VIOLET/COST -748.00
9/16' 2 2697 MANORCARE CARLISLE VIOLET TROUT TROUT, VIOLET/COST -748.00
10/14' 2 2743 MANORCARE CARLISLE VIOLET TROUT TROUT, VIOLET/COST -748.00
10/14' 2 R5492 DEPOSIT SSDI TROUT,VIOLET/SSDI 878.00
10/14' 2 R5493 DEPOSIT SSDI TROUT,VIOLET/SSDI 878.00
10/15' 2 2762S PAGA GENERAL ACCOU GUARDIAN FEE TROUT,VIOLET/GUAR -200.00
11/11' 2 R5555 DEPOSIT SSDI TROUT,VIOLET/SSDI 878.00
11/12' 2 2792S PAGA GENERAL ACCOU GUARDIAN FEE TROUT,VIOLET/GUAR -100.00
11/14' 2 2819 MANORCARE CARLISLE VIOLET TROUT TROUT, VIOLET/COST -784.00
12/10' 2 2886 MANORCARE CARLISLE VIOLET TROUT TROUT, VIOLET/COST -748.00
12/11' 2 2893S PAGA GENERAL ACCOU GUARDIAN FEE TROUT,VIOLET/GUAR -100.00
12/12' 2 R5615 DEPOSIT SSDI TROUT,VIOLET/SSDI 878.00
1/ 9' 3 2933 MANORCARE CARLISLE VIOLET TROUT TROUT, VIOLET/COST -748.00
1/ 9' 3 2948 TRIANGLE TRVELING TROUT,VIOLET/PERS -169.00
1/30' 3 R5667 DEPOSIT SSDI TROUT,VIOLET/SSDI 890.00
2/ 6' 3 3003S PAGA GENERAL ACCOU GDN FEE TROUT,VIOLET/GUAR -200.00
2/ 6' 3 R5711 DEPOSIT SSDI TROUT,VIOLET/SSDI 890.00
2/18' 3 3060 MANORCARE CARLISLE VIOLET TROUT TROUT, VIOLET/COST -760.00
TOTAL TROUT, VIOLET 1,070.47
TOTAL INCOME 1,070.47
TOTAL INCOME/EXPENSE 1,070.47
"
C vrwherLt'A-Nd
IN THE COURT OF COMMON PLEAS OF..... COUNTY, PENNSYLVANIA
Orphans' Court Division
In re
V/61-e+- fl{ I fOI.A. t-, an Incapacitated Person
O.c. No.
Q. l-D \ -:)'1 S-
./""' .
rf ;VC~L
~;NUAL 1tE1'ORl
OF
GUARDIAN OF THE PERSON
1. I,~{\~n ~ b(bd~,)
20_,
, was appointed on cJ It r / 0 2-
I
guardian of the person of V " (J \ ~ f-
T( 0 uL +
who was adjudicated and incapacitated person by
Decree of
f~-r
This is my eport for the period of
, J. dated
,20_.
;J/d7!03
d / / J In ~
/ /
,20 to
2. Present age of the incapacitated person:
Date of Birth:
years.
3. Living Arrangements:
a. Current Address of the incapacitated person:
b. The incapacitated person's residence is:
own home/apartment
nursing home
foster home
guardian's home/apartment
hospital or medical facility
relative's home:
other:
(relationship)
..
1
c. The incapacitated person has been in the present residence since
If the incapacitated person has moved within the past year, please state change and reason(s) for
change:
d. I rate the incapacitated person's living alTangement as:
excellent average
below average.
Explain:
e. I believe the incapacitated person is:
very content with the living situation.
unhappy with the living situation.
f.
I recommend a more suitable living alTangement for the incapacitated person as follows:
4. Physical Health:
a. The incapacitated person's CUlTent physical condition is:
excellent good fair poor
b. During the past year, the incapacitated person's physical condition has
remained about the same
_ improved
Explain:
r
c. During the past year, the incapacitated person received the following medical treatment (include
check-ups and dental work):
DATE
AILMENT
TREATMENT
DOCTOR
5. Mental Health
a. The incapacitated person's cun-ent mental condition is:
excellent
good
fair
poor
b. During the past year, the incapacitated person's mental condition has
remained about the same
improved. Explain:
c. During the past year, treatment or evaluation bya psychiatrist, psychologist, or social worker
was provided
was not provided
6. Social Activities/ Services
a. The incapacitated person's cun-ent social condition is
excellent
good
fair
poor
b. During the past year, the incapacitated person's social condition has:
remained about the same
improved. Explain:
worsened. Explain:
c. During the past year, the incapacitated person has participated in the following
activities (check where applicable and explain):
recreational:
educational:
social:
_ occupational:
no activities
_ the incapacitated person refused to participate in any activities
_ the incapacitated person was unable to participate in any activities
7. List of Visits
a. During the past year, I visited the incapacitated person as follows:
b. The average amount of time I spent on each visit
Was:
C. The last time I visited the incapacitated person was
On:
8. Activities
During the past year, I perfonned the following activities on behalf of the incapacitated
person:
I believe the incapacitated person has the following unmet needs:
If this is a plenary guardianship of the person, the guardianship /'
should not be reduced to a limited guardianship of the person.
should th.. ~
~~~
I certify under penalty of perjury that the foregoing infoffi1ation is correct to the best of
my knowledge, infoffi1ation and belief.
C>
~ ~ j CA- h b t> ({)(JKJ
Name of Guardian
Address
PA GUARDIANSHIP ASSOC.
P.O.BOX 7295
lancaster, PA 11604-7295
City, State, Zip
_l'1 \ 1) ~ q q - lf57a r
Telephone Number
PAGA_CUS-PAGA Custodial
7/30' 3
ITEMIZED CATEGORY REPORT
1/ l' 0 Through 7/31' 3
Date Num Description Memo Category
-------- ------ ------------------ ------------- -----------------
6/24' 3 3423 S PLATINUM PLUS FOR CLOTHING TROUT,VIOLET/FINA
7/ 3' 3 R8377 DEPOSIT SSDI TROUT,VIOLET/SSDI
7/ 91 3 3501 MANORCARE CARLISLE VIOLET TROUT TROUT,VIOLET/COST
7/30' 3 3559 CREMATION SOCIETY VIOLET M. TRO TROUT,VIOLET/FUNE
TOTAL TROUT,VIOLET
TOTAL INCOME
TOTAL INCOME/EXPENSE
Page 2
Clr Amount
-134.16
890.00
-760.00
-1,087.00
-736.69
-736.69
-736.69
==:======
ITEMIZED CATEGORY REPORT
1/ l' 0 Through 7/31' 3
PAG~CUS-PAGA Custodial Page 1
7/30' 3
Date Num Description Memo Category Clr Amount
-------- ------ ------------------ ------------- ----------------- - ---------
INCOME/EXPENSE
INCOME
TROUT, VIOLET
------------
1/23' 2 R4839 DEPOSIT SSDI TROUT,VIOLET/SSDI 878.00
2/ 6' 2 2196S PAGA GENERAL ACCOU GDN FEE TROUT,VIOLET/GUAR -1,800.00
3/ 4' 2 2244 MANORCARE CARLISLE VIOLET TROUT TROUT,VIOLET/COST -6,500.00
3/ 7' 2 R4900 DEPOSIT SSDI TROUT,VIOLET/SSDI 878.00
3/ 7' 2 R4901 DEPOSIT SSDI TROUT,VIOLET/SSDI 878.00
3/ 7' 2 R4902 DEPOSIT BANK TRANSFER TROUT,VIOLET/BANK 6,194.97
3/11' 2 2259 SCOTT A. BEAVERSON TROUT,VIOLET/LEGA -141.00
3/12' 2 2262 BRIAN D. BROOKS / REIMBURSTM TROUT,VIOLET/REIM -2.50
4/22' 2 2346S PAGA GENERAL ACCOU GDN FEE TROUT,VIOLET/GUAR -200.00
4/22' 2 R4975 DEPOSIT SSDI TROUT,VIOLET/SSDI 878.00
5/16' 2 2433 MANORCARE CARLISLE VIOLET TROUT TROUT,VIOLET/COST -848.00
6/10' 2 R5229 DEPOSIT SSDI TROUT,VIOLET/SSDI 878.00
6/10' 2 R5286 DEPOSIT SSDI TROUT,VIOLET/SSDI 878.00
6/17' 2 2507 MANORCARE CARLISLE VIOLET TROUT TROUT,VIOLET/COST -748.00
6/20' 2 2523S PAGA GENERAL ACCOU GDN FEE TROUT,VIOLET/GUAR -300.00
7/ 9' 2 R5323 DEPOSIT SSDI TROUT,VIOLET/SSDI 878.00
8/14' 2 2624 MANORCARE CARLISLE VIOLET TROUT TROUT,VIOLET/COST -748.00
8/19' 2 RR539 DEPOSIT SSDI TROUT,VIOLET/SSDI 878.00
8/20' 2 2643S PAGA GENERAL ACCOU GUARDIAN FEE TROUT,VIOLET/GUAR -100.00
8/23' 2 2646 MANORCARE CARLISLE VIOLET TROUT TROUT,VIOLET/COST -748.00
9/16' 2 2697 MANORCARE CARLISLE VIOLET TROUT TROUT,VIOLET/COST -748.00
10/14' 2 2743 MANORCARE CARLISLE VIOLET TROUT TROUT,VIOLET/COST -748.00
10/14' 2 R5492 DEPOSIT SSDI TROUT,VIOLET/SSDI 878.00
10/14' 2 R5493 DEPOSIT SSDI TROUT,VIOLET/SSDI 878.00
10/15' 2 2762S PAGA GENERAL ACCOU GUARDIAN FEE TROUT,VIOLET/GUAR -200.00
11/11' 2 R5555 DEPOSIT SSDI TROUT,VIOLET/SSDI 878.00
11/12' 2 2792S PAGA GENERAL ACCOU GUARDIAN FEE TROUT,VIOLET/GUAR -100.00
11/14' 2 2819 MANORCARE CARLISLE VIOLET TROUT TROUT,VIOLET/COST -784.00
12/10' 2 2886 MANORCARE CARLISLE VIOLET TROUT TROUT,VIOLET/COST -748.00
12/11' 2 2893S PAGA GENERAL ACCOU GUARDIAN FEE TROUT,VIOLET/GUAR -100.00
12/12' 2 R5615 DEPOSIT SSDI TROUT,VIOLET/SSDI 878.00
1/ 9' 3 2933 MANORCARE CARLISLE VIOLET TROUT TROUT,VIOLET/COST -748.00
1/ 9' 3 2948 TRIANGLE TRVELING TROUT,VIOLET/PERS -169.00
1/30' 3 R5667 DEPOSIT SSDI TROUT,VIOLET/SSDI 890.00
2/ 6' 3 3003S PAGA GENERAL ACCOU GDN FEE TROUT,VIOLET/GUAR -200.00
2/ 6' 3 R5711 DEPOSIT SSDI TROUT,VIOLET/SSDI 890.00
2/18' 3 3060 MANORCARE CARLISLE VIOLET TROUT TROUT,VIOLET/COST -760.00
3/ 4' 3 R5759 DEPOSIT SSDI TROUT,VIOLET/SSDI 890.00
3/10' 3 3119 MANORCARE CARLISLE VIOLET TROUT TROUT,VIOLET/COST -760.00
3/31' 3 3157 S PAGA GENERAL ACCOU TROUT,VIOLET/GUAR -200.00
4/ 3' 3 R8212 DEPOSIT SSDI TROUT,VIOLET/SSDI 890.00
4/ 7' 3 3180 MANORCARE CARLISLE VIOLET TROUT TROUT,VIOLET/COST -760.00
5/ 5' 3 R8265 DEPOSIT SSDI TROUT,VIOLET/SSDI 890.00
5/ 6' 3 3271 MANORCARE CARLISLE VIOLET TROUT TROUT,VIOLET/COST -796.00
6/ 3' 3 R8332 DEPOSIT SSDI TROUT,VIOLET/SSDI 890.00
6/ 5' 3 3352 S PAGA GENERAL ACCOU INITIAL 1-5/0 TROUT,VIOLET/GUAR -1,000.00
6/12' 3 3378 MANORCARE CARLISLE VIOLET TROUT TROUT,VIOLET/COST -760.00
(. -.
IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY,
PENNSYLVANIA
ORPHANS' COURT DIVISION
IN RE:
VIOLET M. TROUT
NO. 21-01-575
DATE OF APPOINTMENT
02/15/02
INVENTORY OF ASSETS
DATE: 08/11/03
DESCRIPTION
$ AMOUNT
SOCIAL SECURITY (MONTHL Y) 890.00
CUSTODIAL ACCOUNT @ P AGA -736.69
BANK / CHECKING ACCOUNT 00.00
PERSONAL NEEDS ACCOUNT 00.00
PENSION 00.00
TOTAL CASH ASSETS HELD FOR WARD (BY P AGA) -736.69
TOTAL MONTHLY INCOME 890.00
TOTAL MONTHLY COST OF CARE 760.00
TOTAL MONTHLY GUARDIANSHIP FEE 100.00
Narrative:
PAGA was appointed guardian of the person and the estate on 02/15/02.
P AGA has acquired or has documented all known assets for the ward. This wards Social Security
benefits have been redirected to P AGA .
P AGA acquired and disbursed funds on her behalf.
Mr. Trout died on 7/27/03. She had no Real property.
t .
Pennsylvania Guardianship Association Inc.
PAGA
PO Box 7295, Lancaster, P A 17604
(717)-299-4568 I (717)-940-7599
FAX# (717)-299-5540
I certify under the penalties of 18 Pa. C.S. s/s 4904 (relating to unsworn
falsification to authorities) that the information contained in this report is true and
correct to the best of my knowledge, information and belief.
DATE: gl/",03
President
Position