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HomeMy WebLinkAbout07-07-08 (3)ANNUAL REPORT OF GUARDIAN OF THE PERSON ~._, ~o --- COURT OF OMMON PLEAS OF ` ~ ti~ r ". . ~ = ~ -1 COUNTY, PENNSYLVANIA ~..t ± ~;`=° c~~: ~ '' ( f 1 ~~~' ~`. ORPHANS' COURT DIVISION ~ j -;~~ - ~ _2 -,~ -' - cn Estate of an Incapacitated Person No.~1 " D/ ~ ~~ ~t~ I. INTRODU was appointed ? lenary Limited G dian of the Person by Decree of , J„ dated ~ ,~~ ~ --T A. This is the Annual Report for the period from __~~Z~c..~~ ~ ~ , ~~ to ~~ ~~ (the `Repo Period"); or © B. This is the Final Report for the period from , to (the "Report Period"), and is filed for the following reason: 1. The death of the Incapacitated Person. Date of death: 2. The Guardianship was terminated by the Court by Decree of J., dated For a Final Report, omit SeMions II through IV. Form e-03 rev. lD,13.f16 Page 1 of 4 Estate of , an Incapacitated Person II. PERSONAL DATA Age of the Incapacitated Person: ~~ Date of Birth: ~ 9.J~ III. LIVING ARRANGEMENTS A. Current address of the Incapac/dated Person: ~~~ ~~ ~ ~ ~~Q~ ~ ~ ~,rJQ,~ ~ ~/~ ~ ~ ~~ , B. The Incapacitated Person's residence is: [] own home f apartment (~,Nttr'sing home Q boarding home /personal care Name (~] Guardian's home /apartment hospital or medical facility 0 relative's home (name, relationship and address) Q other: C. The Incapacitated Person has been in the present residence since ~~ - ~ -~ ~O If the Incapacitated Person has moved within the past year, state prior residence and reason(s) for move: ,~,ll Farm G-D3 rev. /0.!3.06 Page 2 of 4 Estate of ~ an Incapacitated Person D. Name and address of the Incapacitated Person's primary caregiver: /doll IV. MEDICAL INFORMATION A. The major medical or mental problems of the Incapacitated Person are as follows: B. Specify what, if any, social, medical, psychological and support services the Incapacitated Person is receiving: ~~~~~~~~ ~~~~/ a~«~ ~~~~~~/ L.d"~ V. GUARDIAN'S OPIh1ION A. It is the opinion of the Guardian of the Person that the guardianship should: continue be modified ~ be terminated Forme-03 rev. 10.!3.06 Page 3 of 4 t Estate of , an Incapacitated Person The reasons for the foregoing opinion are: ~/~ . B. During the past year, the Guardian of the Person has visited the Incapacitated Person -~, times with the average visit lasting ~ hours, minutes. The report of a social service organization employed by the Guardian to oversee and coordinate the care of the Incapacitated Person for the period covered by this Report may be attached to supplement this Report. [ verify that the foregoing informations correct to the best of my knowledge, information and belief; and that this Verification is subject to the penalties of 18 Pa. C.S.A. § 4904 relative to unsworn falsification to authorities. Uate Signature of Guar an of the Person ~~g ~ ~~~~ Name of Guardian of the Person (type or print) ~ ~7 ~ ~a~~ Address ctty stare, ~~, ~`~~ ~~ 5~~~~/ ~ re~eprr ne Form Ci-03 rev. to. t3.06 Page 4 of 4