HomeMy WebLinkAbout12-6-78
m THE MAT'IER OF
IN THE COURl' OF <:Ill+m PLFAS OF
CUMBERLAND
CDUNTY, PENNSYLVANIA
. ...
RICHARD B)LLENJX)RF
(nama)
ORPHANS' CDURr DIVISICN
An Alleged Incatpetent
NO.
19
PEl'ITICN FOR APPOINlMENI' OF GUAlIDIAN
The Petition of
Francis X. Bean
, Superintendent of
Whi te Haven Center
, respectfully represents:
1. Your Petitioner has custody of the alleged incanpetent
at White Hawn Center
born al
August 27 ~ 1926
5. The alleged inC'al"petent' s mili tal:y status is:
Never served in armed forces
6. The alleged inC'al"petent' s marital status is:
Never married
7. Those persons, if any, who are the alleged ina:mpetent' s next
of kin and their re1atimship to same, of whan your Petitioner has :kncMledge
are as follows:
Mrs. William BolJ.endorf'
01ay Turnpike Road., Box 460 ~ Route #3
Reading, Pennsylvania 19606
Sister-in-Law
8. No other Court within this CulallLUlWealth of which Petitioner
has knCMledge has appointed a guardian for the alleged incarpetent.
~1R 35-E-l - 9-77
BOOY. 105 PAGE 731
9. The alleged incx::npetent has ina:me consisting of:
(a) Maney due fran
Social Security
. in the arrount of $154. 70
per month
(b) 1vbney due fran
in the anount of $ per
(c)
10. The alleged inccmpetent has assets, real and personal, of
which the Petitioner is aware, in the amount of $ 6,890.74 consisting of:
(a) Monq
held by the Guardian Officer of 1Irl.te
in the amount of $ 5,998.24
as of September 30, 1978 .
HaVeD Center
(b) "Vecchione Refund" monies in the anount of $892.50
title to which is in dispute.
(c)
11. The alleged incanpetent has debts outstanding in the amount
of $5,240.00 , as of Sept_bar 30 , 19..1!!..-., consisting of:
(a) $ 4,347.50 owing to the Carmanwealth of Pennsylvania
as payment for care and maintenance received fran the period April 5
19--12-, to September 30 , 1978 , in accordance with 50 P.S. ~~ 4501 and 4504
and regulations promulgated thereunder.
(b) ~92.50
owing to the COm'Onwealth of Pennsylvania as
payment for care and maintenance rendered between July 11, 1974, and
April 4, 1975,
which relates to the "Vecchione Refund", title to which is
in dispute.
(c)
12. The alleged incarpetent is incapable of handling his
financial affairs for the reasons set forth in the attached Affidavit
and Canpetency Ieport, prepared by
AnthOItY' Haddad
marked as Exhibit A and made a part hereof.
-2-
Bl)OK 105 PAGE 732
MI/1-ffi 35-E-2 - 9-77
$
-':.~
13. S. Marie Piro , Guardian Officer at
the aforesaid insti tuticn, and his successors in office, having no interest
adverse to the alleged incx:upetent, has agreed to act as Guardian if this
Honorable Court shall so appoint. '!he oonsent of the proposed Guardian
to so act is attached hereto and made a part hereof as Exhibit B.
14. If appointed as Guardian, S. Marie Piro
is required to act in cxmpliance with regulations pzanulgated under Court
Order in 5 Pennsylvania Bulletin 931 et seg. (April 19, 1975).
15. In light of these provisions and in furtherance of
Paragraph 7 of the aforesaid regulations, petitioner requests preference
be given to a bank, trust oonpany or other individual willing to accept
appointnent as Guardian.
WHEREFORE, the Petitioner prays that a citation be issued
directing Richard BoJJ.endort , and those
persons, if any, listed in paragraph 7 of this Petition, to shari cause,
if any there be, why he should not
be declared an incxmpetent and a Guardian of the estate cq:pointed, and
why distribution of assets and incxma as paynent of debts listed in
paragrClIi111 should not be made. petiticner further prays that a guardian
ad 1i tern be appointed to act for the alleged incarpetent regarding such
hearing.
BY: ~A1J /f? ~~OAL/
-3-
MH/MR 35-E-3 ..... 9-77
6AJK 105 PAGE 733
~ oF ~Vl\NIA
())UNT'i OF wZERNE
.
..
:matter, be~ duly sworn a~ to ~aw, do aepose and state that
, petitioner in this
-
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-----
Iatn
'dbit.e tla'f8n Cent.e1' ___ and that the factS set
forth in the forego~ petition axe tpJe and c:arrect to the best of
1lfJ ~~e, infonnaticn and belief.
of
---
supe1'in'\ienden'\i
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~ 'IO 1\ND ~ BEFO~
ME, 'J1llS II y3- oF
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~i,.,1.' ,. ..'~. ~ 'is.. ~Il P4~O Notary Pubfle
"'u t . ..:... ~li'H~~,,'lUZERNE co.. PA.
':',,1.~~~~ Expires JUly 9, 1979
~iJ.ft-m 35-E-4 - 9-77
v>uGK 105 flleE 734
.AFFIDAVIT
~'lH OF PENNSYLVANIA
ss
0)l.NlY OF LUZERNE
I,
Anthony J. Haddad
, being duly swam
acoording to law, depose and say that I am a PSA II
in the Q..alIlLJl1Wealth of Pennsylvania arployed at White Haven Center
, and I have examined the patient, Richard Bollendorf'
,
an alleged incx:rrpetent, with care and diligence and based upon said
examination and observations am of the opinion that said patient is
inoonpetent to manage hiS,J.i:axCMn affairs for the reascns set forth in the
attached Carpetency Report, and that the facts and opinions contained
therein axe true and oorrect to the best of nw knowledge, infoJ:JOation and
belief.
~ r ___~. /1 ~J 11 .~ J
lLJdJ 'frI-~'-~- f5!J-JL
SVlJ:m 'ID AND SUBSCRIBED BEFORE
ME 'lHIS
/1
DAY OF
a-F~ , 19l1
;/~ C7~
.- No~ Public
S. MARIE PIRO Notary Public
WHITE HAVEN. LUZERNE co., PA.
My Commission .Expires July 9,. 1979
EXHIBIT "A"
llfi/MR 3S-E-S - 9-77
REPORT OF COMPETENCY EXAMINATION
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:\1A,~J: 1:22 )6~) l'J SStI: 165-40-:5938
Drw: 8/'.'/26 ReI: C Sex: M
AI,: 7/%/56 Cumberland Co.
Bl~od fype: 0 Plus/AMBULATORY
Mrs. hillia~ Bollendorl - SIL
Olay turnpike Rd., Box 460, Rt. 83
R e9t1 '1 (f , Penna. 11t>06
D GRAPH PLATE
(_ E }.) IE k?_
DATE
')? 7- I ~"
INSTRUCTIONS: Set forth below your opinion as to whether the patient/resident meets the legal standards of incompetency
Include the medical and factual basis for that opinion. If you have used a competency worksheet (state centers and M R units
only) it can serve as the factual basis for your opinion. Attach a copy to this form. Under Pennsylvania law, a person may be
adjudicated incompetent if he or she, as a result of mental illness, mental retardation, or old age:
(1) is unable to manage his or her property; or
(2) is likely to dissipate that property; or
(3) is likely to become the victim of designing persons; or
(4) lacks sufficient capacity to make or communicate responsible decisions concerning the use and
management of h is or her entitlements.
Your opinion regarding competence must make reference to at least one of these standards. Use as much space as needed and
be as detailed as possible. Medical basis should refer to both diagnosis and its manifestations. Factual basis refers to questions
and answers regarding the four standards above. Please sign on bottom. If additional space is required, use an attached sheet.
/. ~~~ ~ 1-<f-7~ ~
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CONCLUSION: (Please respond Yes or No)
DYes JXJ No
~ Yes 0 No
(2{) Yes 0 No
The patient/resident is capable of managing his/her financial affairs.
The patient/resident is incapable of managing his/her financial affairs.
(If Yes, respond to the following question.)
If the patient/resident is incapable, is the patient's/resident's incapability to manage his/her
financial affairs a product and/or manifestation of his/her mental retardation, mental illness,
or old age?
o Competent
.tRJ Incompetent
r~~~~
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SIGNATURE OF APPROVAL BY SUPERINTENDENT
"'.'nNWEALTH 0.. n-' '!"
UEPl\!:'! ~"-~~:l'~ S~- :'~~2L~~-: ~Alf I F ~!![
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COMPETENCY ASSESSMENT INVENTORi
Jalrea ,.
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lSTITUTION ()~_) ~ , --( e
-~TE 3.:2 7- 7 ~
I- (..2- U F-" V ~)
EXAMINER (---).
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~STRUCTIONS ~ I'h'8 admint~tn"ation of' the CCJmpeten:;'y A3se~~ent
i'lfent:O!r7 (CAl.) ~hould (~'~nfom rc:ai"etully to the Q1Tcictitms pJI"O-
tded here.ino The stated que~ti~n~ and tasks are designed to
lie! t jf~)3pcr.ll.~f<':! wiech 'H,tll be used ill determining 'whethelr or not
resider.,to 1~ (~apable r>>! m.anaging his peJr80nal plro'pe:!r'ty and/or is
:l8cepti,b10 't0l the de~&pt:1.cni5 cf others... (Penn~ylvania Bulletin,
9ri1 19, 19751 Volume 5? Numbe~ 17)0
f the ~'eaid:snt Q ~ )l"e~p~nse is cor~e~t 9 pla(Ce the exa\ct numbeir of
'lints in the i!.pa~e p:t'~vide:L One point will be gi.ven for each
~~~~~t ~~~p~n~~, ~~ept where indicatedo The examiner' should
,-ro"id~ t.he R"e;lident q $ patient 98 namejl age9 and cente::"/hospllal
~~~~i a~~!E.~~~i!~~..!.E~p~1!-~A!]l~t_~~~~~!~,'2,._~~..:.~,",~=",-=---,: ..~ .
ART I - SCREENING QUESTIOnS
CORE ~
() 10
.,.:l ~ 0 El: ttl )Jo t' ~: m
(1)' ro .... "1 ..... u. 0 > 0
..... :.l.l CD C/J u "l to 'l~ r
.. ~ '<. e. 0 .. .. .. l....
....... ~. 0.-:: ::r: 0. g
l':i '-; ~ ..... ~_' -3 CO .... 0
...... "1"- '< ""'...... N U
.) ::S..- '0 M -J l':i :u
_ '~'O ..... ([l '-'- ~
ro ..... Q) .. VI l\:l ~ ..
....:) ::s ":J 0" 0" 0"
....:) ;,s <'0 V' :;0
-.L' ~ 0.; 0 H
I . ::n 0 ...~ n
-oJ 0. .... --0 ;:0 e... ;...;
C1.J ..... ..- CD :>:>>
~_.. CD~ .... ~Q
C1' -.:J ::5 C/J n .. 0
O'OJ.::a.'-~ en
ooo>~ (J)H
O'x "1 a:cfO.::q".
.... to IP ..
H:lo C:"1
0"1t'"".... ....
o >~'Cf)o,
.. tJ)...;::S (I) V1
HOP-Xl
::0 ['1:;Q .. H:lo::tt
t+ ...;n 0"-
. OS:tO"
. ~W
~ ..0
~ ~
(J)
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Aek the ind!.:rldual tosta te his/her full name.,
(Sct;:tt>e one (1) poi.nt if full name is given),
Ha 'fa the ir-,di'llidual ltTi te hia/her full name ()
(S~c>~eOJne (1) point if the individual "Ti.tea his name accurately)o
Q 20
.Q.. :, ~
------Individual's Signature
A5k the ir..di:rldual to name the ~wrrent day~ m,cnthll and year,)
(S~~}l"~~~e (1) pcint if' the 1ndi vidual Jl"e~p\ond.3 ~ol'r'e<<:!tly to all three) 0
,.-.
~ ~~O
() .
.l...L- 6 0
CUr'~r~n@l Identiti cca tio'n
Mat.er.t.als~ Penny, ni~keljl dime>> qual'teX", half dollaro
Randomly pla~e the coins in front of'the indlvldual and ask~
(a) Sh~~ me the dime
_ (b) Show me the quarter
( ~ ) Show me the ni~kel
{d) Sh,ow me the half dollar
-.:=- (e) Sho'w me the penny
\"S@ttre two (2) p~,i.nts if four C4) OJ!" mOi'e responsea aTe It:OrrelCt L
;.
L7"
2
Mate~ial;9g
(.......... (1 \. 'r~"~n'" U'
VJ1~ oAbJ V~<:'~""'JP
t'6n)J f 1 'IH~ j'
'....~,.; >' an:.1 ():;\€' ,n';)'.Llat billo
Pla<t:e the bi.l1s in f'rlJint of }r,.rJL;I",ldu.al and. a,:J:~c:
_ (a) S.h(~'\~ me the 1t.'~'QI du.JLlialf bfL.U
(b) Whil;;h bill :is W;';);'lf"lt.h the m'Q),\~t.:
( ~) Sht.\'fIt' m~ the ten d!lJi] lag' bill
(d) "rri.t~h bill i3 the t~mal1e~t am'o,unt?
( e ) Show me the f 1 'Ie d,I;),11arr bill
\ S,c;u)I"e tw~' (2) point.4 if (4) ~):r' ;:n[O\)te )1"'e;'p\O)n,~re ~ a:r,e \C:(~n"Jre(~t L
rop her'e>> if the indi'lfidual. ha~ a t.ro.>tal 3'~IO\ll"e (of (~ix (6)b'J~" le~a p<ClirJlts - for items one (l)
====~~~ ~eTen ~__ _-=:~=:_:-=.:-=~-=--.:_._ ._____
ART II - FINANG IAL MANAGEMENT
CORE~
80 If Y'QlU 'ffant.ed to buy a ra.d.io at the l<Q>w,e~t pirl(Q;{e (lea~t expen$ive)j) and aaw three
lrad.io~. maIi"keds> $7,,00 $11,,00$8,001' ~hl'f.;h jf'adi\~ w~uld. Y\OJu. sele~~~1
(S,~rae on.e {l) p!oint if the $70.00 amQ,unt ~.~s ,38 ~e;c:ted).,
90 Gi ve the intii vidual ~ne dolla)f" ($1000) 1m, mixed (~'hai1lge j) and a~k;
(a) If yrtu bought somethlng f,o,lf' 6:5 ~ent;!jl IahiJ"1~' me ho'W mu~h ~hange you would
have left?
RIGHT
WRONG
(b). If a pen~il ~ost;g 25 (cent,s)l fSh,((~ me h~~' mUlCh m.o:!'l.,ey you need 0
. RIGHT
WRONG
-
(~) If' y~u bwght something [fiT' 85 ~Em~$i' h:~~' mu(~h !~hange would you have left?
RIGHT
WRONG
-
{Sl~~e tw~ (2) p,d;rrt~ if all th)te'~ Itf'ms an"t" an.s:'fife1t'~d.
,~~:"'(l~~.lj), 0
.100 It y~'u only had $200000 a m~n.th {t.QI :~per..dJl 'What "~0lUld J"~u. dp~ with thi.8 m!)ney7
(S.cJ:t~;r'e ane (1) pQ.:1nt if the f'.~\llQtfdng thi'ee i{~~:s ali"~ m~mtl~ned~
(1) f!\JQ'dj (2) telothing, (3) hou~1ll'llg;)
li" F'la(~e f'ifty.~t'ifO (~ent<a (quaJf'tell"ll 2 d.ime~j) ni.<gk,~l>, 2 pe:ni1l!ie~) in fr:~nt @!
individual and. a~kj) IiH~"lf mu~h m(Qlney is htn~eK Ii
(S~ore ~ne (1) ~int r~r ~~rre@t ~~ap~n~e)o
____120 Ask the que~ti~n~
If a atr'an,ger' appr,r>a(~hed Y-O,u and a,~ked J"()'iJ f (jJl(~ ten d.OiJllal)~jI '~hat 'w,tliuld yrQlU do?
(S;~1)1"e twc> (2) p~int;~, f '~'\l" any l?'e;.:ip,()'ftl':teC'J) '~he)\'~"b.9' the tndi vidual drce;:} n:ot
gi ve m~ney t:iJ the :3tlrangeJr')"
1) 0 F 1.nan'C'~lal _ C :;)'n'~ept~:
(Ask the :tndividual t,jJ expla:!..n the !~ll"::'Q,..'lng;
(a) ~hecking al~(~;ount (any ment:.t.,on 'O,jf ~he\Cidng a<e;(coun,t fU1).(~,t1.,tjnsS'
i", e" i1 payment fl 'Wi thdra\pl'aJL ~.f funds)"
(b) savings a@~ount (~aYing,~ of m'Qnle~ :in a banjq .ir~terelrr.l'!
( ;~.> ~ft@ial se~ult'i ty (a a ~U,ir<ce (\)if' mOlnie" f lZ"~lD F edeifal G\~ve~nm~nt)
:3
. Cti) loans (b!:JJF'Jrowi~) (a meth,~d :of' gett:.ng m,Q\ney :fr~m a aour~e)
'" . (tt) lif'e in,sur'an~e {pa.yment or m(Oinie~ up\o,n death 'l)!' aweY' or beneficiary)
(f) salaFy (wagefS) (mard.e" ear'ned f.\Cl)Ji"'w\)ll'k i(':clDP.leted)
(g) taxea (m,~\ne.y dedu~ted O!" paid to gove.n'.nment f\!Jr (cOIDDlunit.y #erviceB and
g~\ve'iZ"nment support)
(h) postage ~tamps (item b~ught to be used for mailing letters and pa~kages)
(S~OlJ.l"'e two (2) poin;~ it the individual !'e~ponds <coF'Jre~tly to tour (4) ot the
eight (8) itemso
140 If someone It:ame up t(Q) yOlu on the ~t.ll"eet. and wanted you to buy two watches frail them
tor $100000, .N'hat would y<O)u. d~?
(S~~n"e two (2) points if' the individual doat' n~lt buy the watch) 0
c~ 150 PlaICe eighteendollal"5 (tenS) five, 3 one15)}J in fJI"Oint of' individual and ask,
"How mu~h mone7 is l-}ef'e'l"
(Score one (1) po~nt tor co~rect re~pon~e)o
160 The examiner or the unit stafr ah<!)uld ~S)mp1ete t.he following questions by
answering ye~/noo
l~ Doe~ the individual receive m~ney ~egularly?
20 Does the individual give m~ney and/or' possessions away.indiscriminately?
)0 Doel' the individual frequently lose and/or have his/her money and/or
posae~sions atolen? .
~ore one (!)~~nt. Jr.!I~_!,'4.r!.J1J. _~r~J!~Jrk~ . "1}~ 0
NarE~ It. is suggested that a t~tal s~ore or sixteen (16) or more points be used as
a cut-off 8~ore tor rendering an opini~n of c~peten~eo A score of fifteen (15)
or leas points would be used f'or the opinill:tn (Jf in~ompeten~e 0
MATERIAlS LIST~
Co,ina~ 5 penniea; :3 ni~kels; J dime", J quarters; 1 nalf-dollar
Bills: 3 ~ne~; five; ten; t~enty .
Is the re3ident6s inability to handle hie/her m~nie~ and/or' p~aaes~ions a produ~t of his/her
lsability?
Ye~
)<
No
~'"tU, I -'-CJ0L.~J-
).. SlgnatW"t'I Cer'ti~,. Psychologist or Psychiatrist)
. r ( \ II (\
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Dat.e
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IN THE MATTER OF
IN THE ORPHANS' COURT OF
Rich~rd Rollendorf
Cumberland
COUNTY.
An Alleged Incompetent
No.
of 19
COMMONWEALTH OF PENNSYLVANIA,
ss. :
COUNTY OF
.An thony J. Haddad
, being duly sworn
according to law, deposes and say that
.
1. He is a lic~h~ed-or licensable, practicing
psychologist, who is employed at the State Center or Mental
Retardation Unit known as White HaveD Center
located
at White Haven, Pennsylvania
where on October 5
, 1978 , he examined a resident therein,
viz: (Name) Riehard' Bollendorf
(Age) 152 , (Sex) If
-who was admi tted from Permhurst State School and Hos'Pi tal
on Julv 2
, 19....2Q.., with a history of profound
mental retardation
At the examination of the following symptoms were observed
(1) poor comprehension (2)inability to count or recognize money (3) lack: of'
appropriate social judgement (4) inappropriate verbal expression
from which the diagnosis made is: p profound mental retardation
~
..
4,
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., ,,'" '..
". '
wi th a prognosis as follows: poor prognosis vi th regard to
independent functioning
2. On the basis of the foregoing history and
examination, the affiant is of the opinion that
Richard
"because of mental infirmities of old age, mental illness,
mental deficiency, drug addiction or inebriety, is unable to
manage his property, or is liable to dissipate it or become
the victim of designing persons," and is, therefore, incompetent.
-~worn to and subscribed
before me this ~ day
of Dc~ ' 19i?
~)~.
~~t~~~~~~
Al.l(;E nM"'~SK y
WHITf HAVEN BORa . NOTARY PUBLIC
AIr COMMISSION ~PI~ESUZERNECOUNTY, PA..
4 · 23.1919
-2-
./
CINSENT OF PK>POOED GUARDIAN
I, S. Marie Piro , Ouardian Officer
of White Haven Center , do hereby certify that I
and nw successors in office are willing to act as Guardian for the
estate of Richard lbllendorf , an alleged incarpetent, if
the Court shall so appoint.
Further, I do hereby certify that I am not a fiducicuy of
any estate in which the alleged incorpetent has an interest, nor have
I any interest adverse to the alleged inoatpetent.
rrhe facts and opinions contained herein are true and correct
to the best of nw knowledge, infonnation and belief.
~ h~~:. O~J
~
EXHIBIT liB II
Mi/MR 35-E-6 - 9-77
IN THE MATTER OF
IN THE ORPHANS' COURT OF
Richard Bollendorf
Cumberland
COUNTY.
An Alleged Incompetent
No.
of 19
COMMONWEALTH OF PENNSYLVANIA,
ss. :
COUNTY OF
R 1bd..W- ~ QQ
, being duly sworn
according to law, deposes and say that
1. He is a regularly licensed, practicing physician
who is employed at the hospital or institution known as
lu~~~
w-Lh ~~- CJc--
~ \
located at
he examined a patient therein,
where on ~ V ' 19'[k,
viz: (Name)~, ~,
(Age) S ~ , (Sex) m
2. As a result of this examination it is the opinion
of the affiant that:
A. Said patient is in such physical or mental
condition that he/she is capable of appearing in court
and his/her presence in court will not endanger others
in the court room.
OR
~ Because of the physical or mental condition of
said patient, his/~ welfare would not be promoted by
his/~presence in Court, and/or his/h&:r.- presence might
endanger others in the court room.
Sworn to and subscribed
~~W~ Oo..gc!O I
before me this ~ ~ day
of Oe r ' 194J.
~~~~. "
(f'lJl!!!!80~ . Nor-4R'f
CoIOtISS/O,., UGH, illlEN, PfJSI.1C
QpllifS 'Nt COuN
f.,... ~ p~
.., . 1919 ~