The URL can be used to link to this page

Home My WebLink About04-0239KENNETH AUGUSTINE An alleged incapacitated person : IN THE COURT OF COMMON PLEAS : OF CUMBERLAND COUNTY, : PENNSYLVANIA : ORPHANS' COURT DIVISION · NO. -0.2, On the Petition of STEVE AUGUSTINE and JOHN AUGUSTINE CERTIFICATE OF SERVICE I, Marielle F. Hazen, Esquire, certify that on March 8, 2004, I served a tree and correct Copy of the Petition for Appointment of Guardian of the Person and Estate of an Alleged Incapacitated Person in this matteron the parties named below, by depositing same in the United States mail, postage prepaid as follows: Theresa'Augustine 574 W. Chocolate Ave. Hershey, PA 17033 Amanda Augustine 3284 Sequoia Dr. Macungie, PA 18062 Leanna Wickline 3284 Sequoia Dr. Macungie, PA 18062 Jeremy Augustine 3284 Sequoia Dr. Macungie, PA 18062 / Country Meadows 355 S. Sporting Hill Rd. ~Mechanicsburg, PA 17055 The original return receipts are affLxed hereto as Exhibit "A.' Respectfully Submitted, 90:17d 6g ~tV~4 1KI. jo a,%tO..pep~oookt PA I.D. No. 68003 2000 Lingiestown Road Suite 303 Harrisburg, PA 17110 (717) 5404332 · Complete items 1,2, and 3. Also complete item 4 if Restricted Delivery is desired. · Print your name and address on the reverse so that we can return the card to you. · Attach this card to the back of the mailpiece, or on the front if space permits. Id, ¢ b ' J D. Is delivery address different from item 19 []/Yes If YES, enter delivery address below: [] No 3. Service Type [~ertified Mail ' [] Express Mail ', [] Registered ,,J~eturn Receipt for Merchandise [] Insbred Mail [] C.O.D. 4. Restricted Delivery? (Extra Fee) [] Yes 2. Art c e Number . PS Form 3811, August 2001 Domestic Return Receipt 102595o02-M- 1540 · Complete items 1, 2, and 3. Also complete item 4 if Restricted Delivery is desired. · Print your name and address on the reverse so that we can return the card to you. · Attach this card to the back of the mailpiece, or on the front if space permits. 1. Article Addressed to: D. Is delivery address different from item 1 ? . If YES, enter delivery address below: [] No 3. Service Type ,,~ertified Mail [] Express Mail [] Registered _,,,,,~Return Receipt for Merchandise [] Insured Mail [] C.O.D. 4. Restricted Delivery? (Extra Fee) [] Yes 2. Article Number (Transfer from se.ice label) '· Complete items 1, 2, and 3. Also complete item 4 if Restricted Delivery !s desi?ed. · Print your name and address on the reverse so that we can return the card to you: · Attach this card to the back of the mailpiece, or on the front if space permits. 1. Article Addressed to: Ur r ._ ' ' / / : A.. Signature [] Agent ' ~::::~/%~' p Addressee B. Received by ( I C. [~_te df Delivery D. Is detivery address different from it~'~'m ~? ' ~-I Ye/ If YES, enter'delivery address below: [] No 3. Service Type ~L'*Certified Mail [] Express Mail [] Registered ,,,~Return Receipt for Merchandise [] Insured Mail . [] C.O.D. 4. Restricted Delivery9 (Extra Fee) [] Yes 2. Article Number (Transfer from service label) '7~' PS Form 3811, August 2001 Domestic Return Receipt ............ EXI-IIBIT "A" 102595-02-M-1540 i · Complete items 1, 2, and 3. AIs~ complete item 4 if Restricted DeliveQ/is desired. · Print your name and address on the reverse so that we can return the card to you. · Attach this card to the back of the mailpiece, or on the front if space permits. [] Agent [] Addressee D. Is delivery item 17 [] Yes ~f ?_% .¢,~t.e~e~,~%ad~f,.~be~,~ow: No -:~ ...~ , ~ ~ ~ !?" ""'~, MAR i12 0 ~~---~B~ ~ipt for Merchandise ~ Insured Mail D C.O.D. 4. Restricted Delivery? (Extra Fee) [] Yes ' PS Form 3811, August 2001 Domestic Return Receipt 102595-02-M-1540 · Complete items 1, 2, and 3. Also complete item 4 if Restricted Delivery is desired. · Print your name and address on the reverse so that we can return the card to you. · Attach this card to the back of the mailpiece, or on the front if space permits. 1. Article Addressed to: Jress different from item 17 [] If YES, enter delivery address below: [] No 3. Service Type ,,[~ertified Mail [] Express Mail [] Registered .,J~Return Receipt for Merchandise · [] insured Mail [] C.O.D. 4. Restricted Delivery? (Extra Fee) [] Yes 2. ArticleNumber ~:' )~0 ~~ '"" (7'ransferfromservicelabel) PS Form 3811, August 2001 Domestic Return Receipt 102595-02-M-~.52,0 EXHIBIT "A' IN RE: KENNETH AUGUSTINE An alleged incapacitated person \ : IN THE COURT OF COMMON PLEAS : OF CUMBERLAND COUNTY, : PENNSYLVANIA : ORPHANS' COURT DIVISION : : NO. 21-2004-0239 On the Petition .of STEVE AUGUSTINE and JOHN AUGUSTINE PROOF OF SERVICE OF CITATION I, Marielle F. Hazen, Attorney for Petitioners, hereby certify that service of a copy of the Citation and Petition, a copy of which is attached,, was made on Kenneth Augustine, by reading a copy of it to him on Monday, March 22, 2004, at 11:30 a.m. at his current residence located at Country Meadows Assisted Living Facility, Dementia Unit, 355 South Sporting Hill Road, Mechanicsburg, PA 17055. I read the Petition and Citation to the alleged incapacitated person~ and then explained the documents to him, to the maximum extent possible, in language and terms he was likely to understand. ~u Respectfully Submitted, PA I.D. No. 68003 2000 Linglestown Road Suite 303 Harrisburg, PA 17110 (717) 540-4332 IN RE: KENNETH AUGUSTINE AN ALLEGED INCAPACITATED PERSON IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION NO. 21-2004-0239 IMPORTANT NOTICE CITATION WITH NOTICE A petition has been filed with the Court to have you declared an Incapacitated Person. If the Court finds you to be an Incapacitated Person, your rights will be affected, including~ur right to manage money and property and to make decisions. A copy of the petition which has been filed by Steve Augustine and John Augustine 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 April 19 ,2004, at 9:30 A.M. to tell the Court why is 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 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 haveeither limited of full powers to act for you. If the court finds you are totally incapacitated, your leg~tl rights will be affected and you will not be able to make a contract or gift of your money to 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 repre~senting you) the court will still h01d the hearing in your absence and may appoint thle Guardian!requested. · 'Clerk, Orphans' Cou~ Division Cumberland County~ Carlisle, PA My Commission Expires 1st Mon~day, January, 2006 IN RE: KENNETH AUGUSTINE An alleged incapacitated person : IN THE COURT OF COMMON PLEAS : OF CUMBERLAND COUNTY, : PENNSYLVANIA ~ : ORPHANS' COURT DIVISION ;NO. 21-2004-0239 On the Petition~of STEVE AUGUSTINE and JOHN AUGUSTINE NOTICE REGARDING REPRESENTATION OF ALLEGED INCAPACITATED PERSON In-conformity with statute 20 Pa. C.S. Section 5511(a),I please tak.e notice that counsel has not been retained by or on behalf of the alleged incapacitated/pe~son~ and that the hearing to determine this matter is scheduled for April 1~, 2004, at 9:30 a.m. in ~Courtroom #3 in the Cumberland County Courthouse, Carlisle, Pennsylvania. Date Respectfully Submitted,I ar~el~d~. H~en,V'Esq. PA I.D. No. ~8003 · 2000 Lmglestown Road' Suite 303 Harrisburg, ,PA 17110 (717) 540-4332 KENNETH AUGUSTINE An alleged incapacitated person : IN THE COURT OF COMMON PLEAS : OF CUMBERLAND COUNTY, : PENNSYLVANIA : ORPHANS' COURT DIVISION : : NO. 21-2004-0239 On the Petition of STEVE AUGUSTINE and JOHN AUGUSTINE PROOF OF SERVICE OF CITATION I, Marielle F. Hazen, Attorney for Petitioners, hereby certify that service of a copy of thc Citation and Petition, a copy of which is attached, was made on Kenneth Augustine, by reading a copy of it to him on Monday, March 22, 2004, at 11:30 a.m. at his current residence located at Country Meadows Assisted Living Facility, Dementia Unit, 355 South Sporting Hill Road, Mechanicsburg, PA 17055. ! read thc Petition and Citation to thc alleged incapacitated person, and then explained the documents to him, to the maximum extent possible, in language and terms he was likely to understand. Respectfully Submitted, PA I.D. No. 68003 2000 Linglestown Road Suite 303 Harrisburg, PA 17110 (717) 540-4332 IN RE: KENNETH AUGUSTINE AN ALLEGED INCAPACITATED PERSON IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION NO. 21-2004-0239 IMPORTANT NOTICE CITATION WITH NOTICE A petition has been filed with the Court to have you declared an Incapacitated Person. If the Court finds you to be an Incapacitated Person, your rights will be affected, including~ur right to manage money and property and to make decisions. A copy of the petition which has been filed by Steve Augustine and John Augustine 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 April 19 ,2004, at 9:30 A.M. to tell the Court why is 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 yourselfi You also have the right to request that the Court order that an independent evaluation 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 of 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 to 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. Clerk, Orphans Court D~wsion Cumberland County, Carlisle, PA ~ My Commission Expires 1st Monday, January, 2006 IN RE: KENNETH AUGUSTINE An alleged incapacitated person : IN THE COURT OF COMMON PLEAS : OF CUMBERLAND COUNTY, : PENNSYLVANIA : ORPHANS' COURT DIVISION : :NO. 21-2004-0239 On the Petition of STEVE AUGUSTINE and JOHN AUGUSTINE PROOF OF SERVICE OF FINAL ORDER AND STATEMENT OF RIGHTS I, Marielle F. Hazen, Attorney for Petitioners, hereby certify that service of a copy of the Final Order and Statement of Rights, a copy of which is attached, was made on Kenneth Augustine, by reading a copy of it with him on Monday, April 19, 2004, at 10:30 a.m. at his residence located at Country Meadows Assisted Living Facility, Dementia Unit, 355 South Sporting Hill Road, Mechanicsburg, PA 17055. I read the Order and Statement of Rights with the alleged incapacitated person, and then summarized the Order and Statement of Rights in language and terms he was likely to understand. Date Respectfully Submitted, Marielle F. H~n, Esq. PA I.D. No. 68003 2000 Linglestown Road Suite 303 Harrisburg, PA 171 l0 (717) 540-4332 IN RE.' KENNETH AUGUSTINE an incapacitated person On the Petition of STEVE AUGUSTINE and JOHN AUGUSTINE · IN THE COURT OF COMMON PLEAS · OF CUMBERLAND COUNTY, · PENNSYLVANIA · ORPHANS' COURT DIVISION NO. 2004-00239 FINAL ORDER OF COURT APPOINTING PLENARY GUARDIAN ANDNOW, this [Clt~-~ day of 0oD~ ,2004, a hearing in this case having been ! held on April 19, 2004 at C?: J_/...~ ~.t~.m., and it appearing to the Court that KENNETH AUGUSTINE was served with a Citation and Notice of this hearing on March 22, 2004, and the Court finds that the physical or mental condition of KENNETH AUGUSTINE would be harmed by his presence at hearing, and further finds from the testimony: 1. That KENNETH AUGUSTINE suffers from brain damage due to anoxic encephalopathy, a condition which totally impairs his capacity to receive and evaluate information effectively and to make and communicate decisions concerning his management of financial affairs or to meet essential requirements for his physical health and safety. 2. That there are insufficient supports available to assist KENNETH AUGUSTINE in such decisions and that there are no other less restrictive alternative mechanism for decision-making. A TRUE COPY FROM RECORD In Testimony wherof, I hereunto set my hand and the seal of seJd Court al Carlisle, PA [ (-- ~ Clerk of the Orphans C,~~ Cumberland C.,ount~~~:~ 3. That based on the inability of KENNETH AUGUSTINE to receive and evaluate information and to make or communicate decisions, a plenary Guardian of the Person and a plenary Guardian of the Estate are required on a permanent basis. NOW, THEREFORE, based on the clear and convincing evidence supporting the foregoing findings it is ORDERED, ADJUDGED and DECREED that KENNETH AUGUSTINE bc and is hereby adjudged an incapacitated person, and STEVE AUGUSTINE and JOHN AUGUSTINE arc appointed Plenary Permanent Co-Guardians of the Person and Estate. As Plenary Permanent Co- Guardians of the person, STEVE AUGUSTINE and JOHN AUGUSTINE have thc authority to access all KENNETH AUGUSTINE'S medical records, including but not limited to psychiatric records, and to request and/or terminate an out-of-hospital do-not-resuscitate order on behalf of KENNETH AUGUSTINE, in accordance with Pennsylvania law. Further, as Co-Guardians of the person, STEVE AUGUSTINE and JOHN AUGUSTINE shall have the power and authority to serve as personal representatives for all purposes of thc Health Insurance Portability and Accountability Act of 1996, (Pub. L. 104-191), 45 CFR Sections 160 through 164 ("HIPAA"). The Co-Guardians shall bc considered the personal representatives for KENNETH AUGUSTINE'S heath care disclosures under the 2003 federal HIPAA regulations and shall have full authority to review KENNETH AUGUSTINE'S medical records and to execute releases of confidential information from medical providers and insurers or other third party payors. As co-guardians of the estate, STEVE AUGUSTINE and JOHN AUGUSTINE shall have the authority to make distributions from principal for thc payment of care expenses, all medical needs, attorney's fees, and child support pursuant to court order. An Inventory must bc filed within ninety (90) days. A report by the Co-Guardians shall be filed within 12 months and annually thereafter. 0oo°° Bond in the amount of /-~ 0 ~ shall be posted by the Co-Guardians. KENNETH AUGUSTINE, an incapacitated person, has the right to appeal this Order of Court by filing exceptions within ten (10) days of this date or to petition this Court for a review hearing to modify or terminate the guardianship herein established. If KENNETH AUGUSTINE was not presem at this hearing on appointment of a guardian then petitioner shall serve upon and read to KENNETH AUGUSTINE the Statement of Rights, a copy of which is attached to this Order as Exhibit "A", and file proof of such service with this Court within ten days. BY THE COURT: Orphan's Court Division - Court of Common Pleas of No. 00239 of 2004 Estate of Kenneth Augustine BOND-Guardian Bond No. 104314524 Know all Men by these Presents THAT WE, STEVE AUGUSTINE & JOHN AUGUSTINE (Name and address of Guardian, or Cruardiam) 1004 COPPERCREEK DR, MECHANICSBURG, PENNSYLVANIA, 17050 , as principal and Travelere Casualty and Surety Company of America One Tower Square, Hartford, CT, 06183 (Name and address of Surety) ARE HELD AND FIRMLY BOUND unto the COMMONWEALTH OF PENNSYLV~ in the stun of Forty Thousand and 00/100 Dollars, $40,000.00, as surety, lawful money, to be paid to the said Commonwealth; to which payment, well and truly to be made, we bind ourselves, our Heirs, Executors, A~tors, Successors and Assigns and every of them, jointly and severally, firmly by these presents. Sealed with our seals, and dated this 22nd dayof April 2004 Condition of Obligation (1) When One Guardian- The condition of this obligation is that, if the said guardian shall well and truly administer the e~tate accordh~ to law, this obli~tion shall be void; but otherwise it shall remain in force. (2) When Two or More Gum-dians- The condition ofthis oblisation is that, ifthe said guardians or any ofthem shall well and truly administer the estate accord/ng to law, this obligation shall be void as to the guardian or guardiam who shall so ~4mluister the estate; but otherwise it shall remain in force. Sealed and delivered in the Presence of S-6167 (1/02) 30-547 STEV~ ~UG~USTINE & JOHN AUGUSTINE ............... .i.~ 7f~ ............................ SE~ ~Su~ty Compagy of America David T. Rousche, Attorn.ey~in-Fact TI~VELERS CASUALTY AND SURETY COMPANY OF AMERICA TRAVELERS CASUALTY AND SURETY COMPANY FARlV[INGTON CASUALTY COMPANY Hartford, Connecticut 06183-9062 POWER OF ATTORNEY AND CERTIFICATE OF AUTHORITY OF ATTORNEY(S)-IN-FACT KNOW ALL PERSONS BY THESE PRESENTS, THAT TRAVELERS CASUALTY AND SURETY COMPANY OF AMERICA, TRAVELERS CASUALTY AND SURETY COMPANY and FARMINGTON CASUALTY COMPANY, corporations duly organized under the laws of the State of Connecticut, and having their principal offices in the City of Hartford,. County of Hartford, State of Connecticut, (hereinafter the "Companies") hath made, constituted and appointed, and do by these presents make, constitute and appoint: G. Greg Gunn, Theodore W. Mowery, Gary. D. Harshbarger, David T. Rousche, Patricia E. Pierce, of Lemoyne, Pennsylvania, their true and lawful Attomey(s)-in-Fact, ~vith full power and authority hereby conferred to sign, execute and acknowledge, at any place within the United States, the following instrument(s): by his/her sole signature and act, any and all bonds, recognizances, contracts of indemnity, and other writings obligatory, in the nature of a bond, recognizance, or conditional undertaking and any and all consents incident thereto and to bind the Companies, thereby as fully and to the same extent as if the same were signed by the duly authorized officers of the Compames, and all the acts of said A~tomey(s)- in-Fact, pursuant to the authority herein given, are hereby ratified and confirmed. This appomm)ent is made under and by authority of the following Standing Resolutions of said Compames, which Resolutions are now in full force and effect: VOTED: That the Chain'nan, the President, any Vice Chairman, any Executive Vice President, any Senior Vice President, any Vice President, any Second Vice President, the Treasurer, any Assistant Treasurer, the Corporate Secretary or any Assistant Secretary. may appoint Attorneys-in-Fact and Agents to act for and on behalf of the company and may give such appointee such authority, as his or her certificate of authority, may prescribe to sign with the Company's name and seal with the Company's seal bonds, recognizances, contracts of indemmty, and other ~vritmgs obligatory in the nature of a bond, reco~m~izance, or conditional undertaking, and any of said ofricers or the Board of Dtrectors at any time may remove any such appointee and revoke the power given him or hcr. VOTED: That the Chairman, the President, any Vice Chairman, any Executive Vice President, any Senior Vice President or any Vice President may delegate all or any part of the foregoing authority' to one or more officers or employees of this Company', provided that each such delegation is in writing and a copy thereof is filed in the office of the Secretary.'. VOTED: That any bond, recognizance, contract of indemni~', or xwiting obligatory, in the nature of a bond, recognizance, or conditional undertak/ng shall be valid and binding upon the Company when (a) sigued by the President, any Vice Chairtnan, any Executive Vice President, any Senior Vice President or any Vice President, any Second Vice President, the Treasurer, any Assistant Treasurer, the Corporate Secretary. or any Assistant Secretary. and duly attested and sealed with the Company's seal by a Secretary. or Asststant Secretm"y, or (b) duly' executed (under seal, if required) by one or more Attorneys-in-Fact and Agents pursuant to the power prescribed in his or her certificate or their certificates of authority, or by one or more Company officers pursuant to a wTitten delegation of authority.. This Power of Attorney and Certificate of Authority is signed and sealed by facsimile (mechanical or printed) under and by authority of the following Standing Resolution voted by the Boards of Directors of TRAVELERS CASUALTY AND SURETY COMPANY OF AMERICA, TRAVELERS CASUALTY AND SURETY COMPANY and FARMINGTON CASUALTY COMP3aNY, which Resolution is now in full force and effect: VOTED: That the signature of each of the folloWing officers: President, any Executive Vice President, any Senior Vice President, any Vice President, any Assistant Vice President, any Secretm% any Assistant Secretary., and the'~eal of the Company may be affixed by thcsimile to any power of attorney or to any certificate relating thereto appointing Resident Vice Presidents, Resident Assistant Secretaries or Attorneys-in-Fact tbr purposes only of executing and attesting bonds and undertakings and o/her xvntings obligatory, in the nature thereof, and any such power of attorne? or certificate beating such facsimile signature or thcsimile seal shall be valid and binding upon the Company and any such power so executed and certified by such facsimile signature and facsimile seal shall be valid and binding upon the Company in the fi~ture with respect to any bond or undertaking to which it is attached. ~ i i -00 Standardl IN WITNESS WHEREOF, TRAVELERS CASUALTY AND SURETY COMPANY OF AMERICA, TRAVELERS CASUALTY AND SURETY COMPANY and FARMINGTON CASUALTY COMPANY have caused this instrument to be signed by their Senior Vice President and their corporate seals to be hereto affixed this 3rd da), of July 2001. STATE OF CONNECTICUT } SS. Hartford COUNTY OF HARTFORD TRAVELERS CASUALTY AND SURETY COMPANY OF AMERICA TRAVELERS CASUALTY AND SURETY COMPANY FARMINGTON CASUALTY COMPANY George W. Thompson Senior Vice President On this 3rd day of July, 2001 before me personally came GEORGE W. THOMPSON to me known, who, being by me duly sworn, did depose and say: thal he/she is Senior Vice President of TRAVELERS CASUALTY AND SURETY COMPANY OF AMERICA, TRAVELERS CASUALTY AND SURETY COMPANY and FARMINGTON CASUALTY COMPANY, the corporations described in and which executed the above instrument; that he/she knows the seals of said corporations; that the seals affixed to the said instrument are such corporate seals; and that he/she executed the said instrument on behalf of the corporations by authority of his/her office under the Standing Resolutions thereof. My commission expires June 30, 2006 Notary Public Marie C. Tetreault CERTIFICATE I, the undersigned, Assistant Secretary of TRAVELERS CASUALTY AND SURETY COMPANY OF AMERICA, TRAVELERS CASUALTY AND SURETY COMPANY and FARMINGTON CASUALTY COMPANY, stock corporations of the State of Connecticut DO HEREBY CERTIFY that the foregoing and attached Power of Attorney and Certificate of Authority remains in full force and has not been revoked; and furthermore, that the Standing Resolutions of the Boards of Directors, as set forth in the Cer~icate of Authority, are now in force. Sign~ and [iealed at the Home Office of the Company, in the City of Hartford, State of Connecticut. Dated this 2 2nd day of April ,20 04 By Kori M. Johanson Assistant Secretary, Bond 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 IN RE: KENNETH AUGUSTINE : : : An alleged incapacitated person : IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION ORIGINAL Deposition of: Taken by: Before: Date: Place: MICHAEL F. LUPINACCI, M.D. Petitioner Jennifer L. Sirois, Court Reporter, Notary Public March 29, 2004, 4:00 p.m. 4310 Londonderry Road Harrisburg, Pennsylvania APPEARANCES: LAW OFFICE OF MARIELLE F. HAZEN BY: MARIELLE F. HAZEN, ESQUIRE FOR - PETITIONER Reporting Services · 717-258-3657 · 717-258-0383fax courtreporters4u @aol. com 2 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 INDEX TO TESTIMONY DEPONENT EXAMINATION Michael Lupinacci, M.D. By Ms. Hazen NO. (None.) INDEX TO EXHIBITS DESCRIPTION PAGE PAGE 3 3 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 MICHAEL F. LUPINACCI, M.D., called as a witness, being duly sworn, was examined and testified as follows: MS. HAZEN: This is the deposition of Dr. Michael Lupinacci regarding Kenneth Augustine, an alleged incapacitated person. Present today are Dr. Lupinacci and myself as well as the court reporter. EXAMI~TION BY MS. HAZEN: Q. Dr. Lupinacci, I have some questions for you. If you don't hear me, please let me know so I can restate it. And if you don't understand a question, please let me know so I can rephrase it. Could you please state your name and professional address? A. It's Dr. Michael Lupinacci. We're at the Bloom Building in Harrisburg, PA. Q. Would you please describe your education, training and background with particular emphasis on your experience in evaluating individuals with incapacities? A. I went to undergraduate in medical school at Georgetown University in Washington D.C. and did my residency in physical medicine and rehabilitation at Baylor College of Medicine in Houston, Texas, and I'm board certified in physical medicine and rehabilitation. I'm the medical director of the brain injury unit at the 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Rehabilitation Hospital of Mechanicsburg, Pennsylvania, and our specialty and the brain injury subspecialty deals particularly with people that have physical and cognitive disabilities related to trauma including traumatic brain injury or nontraumatic brain injury, as is in this case. Q. When did you first examine Ken Augustine? A. I first examined him on December 22nd of '03. Q. Was that because he was a patient at HealthSouth? A. Yes. He was admitted to the brain injury rehabilitation unit that day from acute care having had an anoxic encephalopathy, which is a deprivation of oxygen to the brain after a cardiac arrest. Q. And is that his diagnosis? A. That is his diagnosis, yes. Q. Is that condition a progressive condition? A. What happens with a cardiac arrest after a heart attack is there's a deprivation of oxygen to the brain, and the brain cells, diffusely in many areas of the brain, are injured, sometimes irreversibly injured, which causes difficulties with thinking and memory and judgment, information processing and generally all of our thinking processes can be affected by such a problem. Q. Does Ken Augustine have any physical impairments? 5 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 A. At the present time, he's actually independent with his walking, and he does not have any weakness of his arms or legs; and so physically, he's doing well. Q. You mentioned that'one of the effects of his condition is impairment of judgment. Could you describe his mental impairments focusing specifically on how this has affected him? A. Mr. Augustine's level of impairment of his thinking abilities is in the severe range. His judgment is very severe, severely impaired. He has very tangential thinking on topics; he cannot follow topics to discuss; his memory is severely impaired; his ability to process even basic information is severely impaired; his judgment regarding what is safe or unsafe for him to do at any one time is severely impaired. Q. So, in your opinion, his ability to receive and evaluate information effectively and communicate decisions is impaired to such a significant extent that you would say he is totally unable to manage his financial resources? A. Yes, that's correct. Q. And he's totally unable to meet his essential requirements for physical health and safety? A. Yes, that's also correct. Q. What recommendations would you make concerning services necessary to meet his essential needs for physical 6 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 health and safety? A. At this point, he needs a facility, in the best case scenario, which would be a residential brain injury facility where people like Mr. Augustine could live in a very structured environment with professional help available 24/7 to assist him in his day-to-day care. Q. And what recommendations would you make concerning management of his financial resources? A. Well, it obviously would be best if his financial resources were organized well enough that he could actually be funded for one of these brain injury facilities that would take care of him short term and potentially long term. And someone else would need to be in charge of that? A. Q. Yes. And you don't believe he has the capacity to sign a power of attorney and know what he's signing? A. No, I don't. Q. Do you know of any less restrictive alternatives to a guardianship to provide for his needs? A. No, I don't. Q. What is the likelihood that his level of incapacity will lessen, that his condition will improve? A. The likelihood exists, but I believe it's 7 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 extremely low. Q. So you believe he will need residential care 24 hours a day, 7 days a week for the rest of his life? A. Yes. Q. And you mentioned the residential brain injury facilities, and we discussed that they really are not in existence in Central Pennsylvania so they would have to go towards Philadelphia for those facilities available. If they're not able to find them available, residential brain injury facilities that they can afford, what options do you think are available to the family? A. The only other option is there are some residential brain injury homes in the area, which are group homes, and whether he's able to stay there will a lot depend on whether his behavior, which has been inappropriate at times, can be improved or does improve naturally over time. Q. And if it doesn't, a nursing home may be at least a temporary needed service provider for him? A. Yes. Q. Do you believe that his physical or mental condition would be harmed by his presence in open court? no Yes, I do. And can you just elaborate a little bit on that? Well, Mr. Augustine often, because of his 8 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 thinking difficulties, will be confused and misinterpret information that's presented in front of him, and that can lead to physical agitation and some mild digressiveness. Q. Okay. Is there anything else you think the Court should hear in this matter? A. No, I think we've covered it well. MS. HAZEN: Okay. Then I have no other I thank you for your time, and the family questions. thanks you. (Whereupon, the deposition was concluded at 4:06 p.m.) 9 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 2O 21 22 23 24 25 COMMONWEALTH OF PENNSYLVANIA ) ) SS. COUNTY OF CUMBERLAND ) I, JENNIFER L. SIROIS, a Court Reporter-Notary Public authorized to administer oaths and take depositions in the trial of causes, and having an office in Carlisle, Pennsylvania, do hereby certify that the foregoing is the testimony of MICHAEL F. LUPINACCI, M.D. I further certify that before the taking of said deposition the witness was duly sworn; that the questions and answers were taken down stenotype by the said Reporter-Notary, approved and agreed to, and afterwards reduced to computer printout under the direction of said Reporter. I further certify that the proceedings and evidence are contained fully and accurately in the notes taken by me on the within deposition, and that this copy is a correct transcript of the same. In testimony whereof, I have hereunto inscribed my hand this 7th day of April,/2~,.. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION IN RE: KENNETH AUGUSTINE, an incapacitated person GUARDIAN OF THE ESTATE ANNUAL REPORT [20 Pa.C.S.A. 5521 (c)] FROM ~y,'/ Iq ,2009' TO J'./>~ lC FILE NO. 21-2004-0239 ,200 9~ 1) 2) Iarn the above. I was appointed Guardian by Order of Court dated __ was was not modified by Court Order(s) dated __ Limited fi( Plenary Guardian of the Estate of my ward, named ~oo ~, which (c) Name of Administrator/trix or Executor/tflx (d) Date Guardian of the Person filed the last Annual Report Is the incapacitated person still living? If no, answer the following: (a) Date of Death (b) Place of Death PLEASE ANSWER THE FOLLOWING QUESTIONS WHETHER THE INCAPACITATED PERSON IS LIVING OR DECEASED: 3) My initial Inventory was filed on $ and listed a total estate value of The Inventory listed a total monthly income of $ the following: /o~fl '/',,.. c/,' ~ ¢ ~,'~'/~. comprised of 4) At the beginning date of this reporting period, my initial balance on hand was $ 17~3. o3- 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 C,~,e~..-~,,I,. (I;,.I.,...,/"/~" io 5"' ¢~'"") '/'gg' 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 2 04-Ma~ American Bankers Ins Lewes Trailer Insurance 48.80 05-Ma~ Cingular Wireless Cell Phone 24.17 05-May Citi Cards Credit Card Balance 100.00 10-Ma~ Williams Apothecary Pharmacy needs 5.00 17-Ma}, Lancaster Behavior Dr visit 15.00 11-May Members 1st checking account charge 9.95 20-Ma)/ Patriot News add to sell BMW 24.00 24-Ma~, Pro(,]ress~ve BMW Insurance 103.90 25-May ,S & B Landscaping Lewes Trailer needs 95.00 25-Ma¥ Mid-Atlantic Shore Prop Lewes Trailer land lease 260.00 25-Ma¥ Solutions for Better AgirPersonal needs 54.95 25-May Delaware Electric Lewes Trailer bill 20.00 25-May CobraServ Health Insurance 582.21 25-May Marielle Hazen Legal bill 2784.03 26-Ma¥ Country Meadows Asso, Housing/Pharmacy needs 1577.43 26-Ma¥ Alterra Healthcare Corp Housing needs 3977.91 26-Ma¥ John Augustine repayment of loan 2000.00 26-May Steven Augustine repayment of loan 2000.00 27-May Universal Guarantee court ordered life insurance 50.00 03-Jun Citi Cards Credit Card Balance 2476.47 07-Jun Country Meadows Ass¢ Pharmacy needs 884.45 07-Jun Williams Apothecary Pharmacy needs 330.06 10-Jun Good~/ear Fix BMW (brakes) 242.79 23-Jun Lancaster Behavior Dr visit 15.00 24-Jun Preogressive BMW Insurance 103.90 24-Jun American Bankers Ins Lewes Trailer Insurance 42.04 24-Jun Hedtage medical GrouF Lab work 8.28 24-Jun Lancaster General unpaid bill 7.00 26-Jun Marielle Hazen Legal bill 112.50 28-Jun Alterra Healthcare Corp Housing needs 3977.9( 28-Jun CobraServ Health Insurance 582.21 28-Jun East Petersburg Family Drvisit 15.00 29-Jun Universal Guarantee court ordered rife insurance 50.00 10-Jul Williams Apothecar~ Pharmacy needs 476.85 10-Jul Citi Cards Credit Card Balance 12.37 10-Jul Solutions for Better AgirPersonal needs 54.95 10-Jul Nurses Available supervised care 1355.75 12~Jul Sharon Moshos haircut 15.00 18-Jul Oingular Wireiess outstanding bill 24.17 20-Jul 'Lancaster Behavior Dr visit 15.00 23-Jul Progressive BMW Insurance 103.90 26-Jul Cingular Wireless outstanding bill 10.90 26-Jul Alterra Healthcare Coq: Housing needs 3977.90 26-Jul Marielle Hazen Legal bill 90.00 27-Jul PSECU Credit Card Balance 4013.45 o 7) 2. 3. 4. The present principal assets of my ward are: Description of Asset(s) Present Value 8) TOTAL: The present mount and sources of income for my ward are: Source of Income Amount of Income (indicate whether monthly, quarterly, annually) 3( ?/. ,,a p ~"~ '/'(3 3 o 9) The regular monthly expenses of my ward which I pay are: To Whom Paid /.. 10) ~x~av~o, (circle one)petitioned the Court for permission to invade principal ,o m~f the needs of my ward. (If applicable) The following expenses of my ward have been paid from principal: To Whom Paid Purpose AEflount 4 o 11) I have,ave not~ (circle one) paid myself compensation for services I rendered as guardian. The mount I paid myself totaled $ and was calculated at the following rate: $ per week/month (circle one). 12) Check the correct response and complete, if appropriate. There will be no need for extraordinary expenditures on behalf of my ward in the next twelve (12) months. There will be a need for extraordinary expenditures on behalf of my ward in the next twelve (12) months because: 13) Check the correct response and complete, if appropriate. __A. My ward receives monthly social security benefits directly. __ B. I am the designated payee to receive my ward's social security benefits. __C. The designated payee of my ward's social security benefits is: Whose address is And is/is not (cimle one) related to my ward as (insert relationship:) __ 5 14) Please note any concerns about the incapacitated person's physical or mental well-being or the finances that the Court should know. 15) I ¥ am__ attached. am not guardian of the incapacitated person's person. If yes, report is I CERTIFY under the penalties of perjury that the information contained in this report is tree and correct to the best of my knowledge, information and belief. 7t'2- 7.?!- Il oe5''' (home) 7/'~-~?o~. (o~y (work) Signature Date Send to: Register of Wills Cumberland County Courthouse One Courthouse Square Carlisle, PA 17013 (717) 240-6345 6 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION IN RE: KENNETH AUGUSTINE, an incapacitated person FILE NO. 21-2004-0239 GUARDIAN OF THE PERSON ANNUAL REPORT [20 Pa.C.S.A. 5521 (c)l FRoM ,200_ To Z/,. ,:00 1) [ amthe above. __ Limited ~¥ Plenary Guardian of the Estate of my ward, named 2) I was appointed Guardian by Order of Court dated /dO~,,pr///~/ ) oo Y', which -- was X~ was~odified by Court Order(s) dated 3) Is the incapacitated person still living? If no, answer the following: (a) Date of Death (b) Place of Death (c) Name of Administrator/trix or Executor/trix (d) Date Guardian of the Person filed the last Annual Rep~, ~, (4 4) If the incapacitated person is still living, answer the following questions: (a) Co) (c) (d) (e) Date Guardian of the Person filed the last Annual Report? Current address of the incapacitated person: Current age: ~ ~' Date of birth of incapacitated person: The incapacitated person's residence is: __ Ward's own residence >c ~ ,9~,',t~,/ L;~,7 __ Hospital or Medical Facility The incapacitated person has been living there since My home/apartment __ Relative's Home Boarding Home /'0~ ,.,' [ do., (0 If moved within the past year, state from where and the reason for the change: I rate hi~er living ~gement ~: Explain: Excellent __ Average ,,/ ,- Below Average 5) (g) I believe he/she is: X~ Content with the living situation Unhappy with the living situation Unaware with the living situation Physical Health (a) Current physical condition of the incapacitated person is: __ Excellent __ Good ?( Fair __ Poor (b) (c) His/her major physical health problems are as follows: /'1 e a~ / / During the past year, his/her physical condition has: Remained about the same. Improved. Explain )( Worsened. Explain ~o~,~.r~ o~ ,~,~'~ (d) During the past year, he/she ece~ved the follow~ng medmal treatment (include check-ups and dental work): Date Ailment Type of treatment Doctor's name 6) Mental Health (a) The incapacitated person's condition is: Excellent __ Good Fair ~ Poor (b) His/her major mental health problems are as follows: (c) During the past year, his/her mental condition has: X Remained about the same. Improved. Explain Worsened. Explain (e) During the past year, treatment or evaluation by a psychiatrist, psychologist or social worker ,~ was was not provided. Such mental health services are briefly described as: Social Activities/Services (a) His/her current social condition is: __ Excellent Good (b) During the past year, his/her social condition has: Remained about the same. Improved. Explain Worsened. Explain Fair X Poor 3 (c) during the past year he/she has participated in the following activities: Recreational Educational Social __ Occupational __ No activities available. __ He/she refuses to participate in any activities. ,)c He/she is unable to participate in any activities. 8) Visitation (a) During the last year, I visited him/her as follows: O^ ce ,o e r m o,, fA/ (c) The average amount of time I spent on each visit was )~ The last time I visited was on 7/~0/o y (date) 9) During the last year I have performed the following activities on behalf of the incapacitatedperson: ]0~,'~ ~,'/f. rl e/,'.rc~--rg'o,~s ~,,'TL~ 10) I believe he/she has the following unmet needs: - The guardianship h" should modification because: (//17/o ~' __ should not be continued without o~o(e~- 6,'~,~r ~',~ff/c/e,.7z J 4 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 the guardian of the incapacitated person's estate. If yes, my report is attached. I CERTIFY under the penalties of perjury that the information contained in this report is tree and correct to the best of my knowledge, information and belief. Name: SX~oe~ /Z~ct~.£~,~ TelephoneSo. ?_~?- 7~/-//gJ- (home) Address: 7t 7 - .To~ - cloYS- .(work) Signature Date Send to: Register of Wills Cumberland County Courthouse One Courthouse Square Carlisle, PA 17013-3387 (717) 240-6345 One Courthouse Square Carlisle, PA 17013 Marjorie A. Wevodau First Deputy Glenda Farner Strasbaugh Register of Wills & Clerk of the Orphans' Court Kirk S. Sohonage, Esquire Solicitor Wanda S. Zeigler Second Deputy OFFICES OF (717) 240-6345 FAX (717) 240-7797 1-888-697-0371 x 6345 l\egister of Wills anb ([Ierk of tbe (!&rpbans' ([ourt (/[ountp of (/[umberIanb October 8, 2007 John Augustine P.O. Box Bainbridge P A 17502 IN RE: Estate of Kenneth Augustine, an incapacitated person File No. 21-04-0239 Dear Sir/Madam: It has come to my attention that you have not filed the guardian reports required by 20 Pa.C.S.A. 9552l(c) in the above captioned guardianship. Enclosed you will find the suggested form ( s). Please mail those reports, along with a check for the filing fee which is $15 payable to the Clerk of Orphans' Court, to the following address within (30) days: Clerk of Orphans' Court One Courthouse Square Carlisle, P A 17013 If you have any questions, please contact your attomey. Respectful! y, ~~~~t.J- Glenda Famer Strasbau& Clerk of the Orphans' Court CC: Marielle F. Hazen, Esquire One Courthouse Square Carlisle, PA 17013 Marjorie A. Wevodau First Deputy Glenda Farner Strasbaugh Register of Wills & Clerk of the Orphans' Court Kirk S. Sohonage, Esquire Solicitor Wanda S. Zeigler Second Deputy OFFICES OF (717) 240-6345 FAX (717) 240-7797 1-888-697-0371 x 6345 l\egister of Wills anb ((Ierk of tbe (!&rpbans' ((ourt ~ount!' of ~umberlanb October 8, 2007 Steve Augustine 1004 Coppercreek Dr Mechanicsburg P A 17050 IN RE: Estate of Kenneth Augustine, an incapacitated person File No. 21-04-0239 Dear Sir/Madam: It has come to my attention that you have not filed the guardian reports required by 20 Pa.C.S.A. S5521(c) in the above captioned guardianship. Enclosed you will find the suggested formes). Please mail those reports, along \vith a check for the filing fee which is $15 payable to the Clerk of Orphans' Court, to the following address within (30) days: Clerk of Orphans' Court One Courthouse Square Carlisle, P A 17013 If you have any questions, please contact your attomey. Respectfully, ~ vt.wJtrMt,~ u Glenda Famer Strasbaugh Clerk of the Orphans' Court CC: Marielle F. Hazen, Esquire Clerk of Orphans' Court of Cumberland County IN RE: KENNETH AUGUSTINE An Incapacitated Person Docket No. 21-2004-0239 ANNUAL REPORT OF GUARDIAN OF THE ESTATE I, Steve Augustine & John Augustine, were appointed plenary guardians of the estate of Kenneth Augustine by Decree of the Honorable Judge George Hoffer. Dated April 19. 2004. This is my annual report for the period from July 16. 2004 to October 16. 2007, ("the Report Period"). I. SUMMARY A. Value of principal assets at the beginning of the Report Period? $ 130.321.54 $ 94.273.53 B. Total amount of income earned during the report period? C. Total Amount of all expenditures made for the care and maintenance of the incapacitated person during the Report Period? 1. From principal $ 102.787.45 $ 94.273.53 2. From income D. Total amount spent for all other purposes during the Report Period? $ 0.00 1. From principal $ 27.534.09 $ 27.534.09 E. Total amounts remaining at the end of the Report Period? 2. From income $ 0.00 Total Income and Principal $ 27.534.09 Q --... o ,"-" . J -J \,;:1 -0 - T'-) a 0"" II. ADDITIONAL INFORMATION A. Principal: 1. Total amount remaining at the end ofthe Report Period? $ 27.534.09 2. How is principal currently invested Savings Account Checking Account Retirement Account $ 25.00 $ 4.569.09 $ 22,940.00 3. Have there been any expenditures from principal during the Report Period Yes If you answered YES, was there Court approval for all expenditures from principal? Yes 4. Did you receive any principal assets during the report period which were not included on the inventory or a prior report filed for the estate? No If you answered YES, did you receive Court approval prior to receiving Additional principal? 5. State the sources and amounts of the additional principal you received: Trailer located in Lewes, Del Retirement Account $ 7.000.00 $ 27.000.00 B. Income: 1. State sources and amounts of income received during the Report Period (i.e., social security, pension, rents, etc.) Lincoln Financial Disability Insurance Social Security Disability Insurance Dividend from stock Interest from savings and checking accounts 2006 Federal Tax refund $ 24.485.52 $ 68,088.00 $ 171.07 $ 210.45 $ 30.00 Total Income received during Report Period $ 92,985.04 2. How is income currently invested? (Please specify, restricted bank accounts, client care account, etc.) Income was used to pay expenses. 3. Specify what payments were made for the care and maintenance of the incapacitated person (i.e., clothing, nursing home, medicine, support, etc.) Assisted living facility Physician/ambulance services/hospital expenses Medicine (pharmacies) Repayment of overpayment of Disability Insurance Federal/State Tax Insurances (life, medical, car) Prepaid funeral expenses Legal expenses Expense to close Credit Card accounts Expense to close Cell Phone account Lewes, Del trailer expenses Misc paperwork expenses (postage, etc.) Tax preparation Direct Child Support payments $ 132.233.13 $ 4.101.19 $ 16.101.69 $ 7.361.63 $ 14.976.00 $ 10.715.19 $ 4.228.00 $ 1.412.83 $ 4.033.14 $ 35.07 $ 15.00 $ 209.42 $ 900.00 $ 849.72 4. Specify what other payments were made during the Report Period. none I verify that the foregoing information is correct to the best of my knowledge, information and belief; and that this verification is subject to the penalties of 18 Pa. C.S.A. 4904 relative to unsworn falsification to authorities. IO!tff!O? Date .~.. Signature of Guardian * FILING FEE $15 MUST ACCOMPANY THIS FILING. Clerk of Orphans' Court of Cumberland County IN RE: KENNETH AUGUSTINE An Incapacitated Person Docket No. 21-2004-0239 ANNUAL REPORT OF GUARDIAN OF THE PERSON I, Steve Augustine & John Augustine, were appointed plenary guardians of the person of Kenneth Augustine by Decree of the Honorable Judge George Hoffer. Dated April 19. 2004. This is my annual report for the period from Julv 16.2004 to October 16.2007, ("the Report Period"). 1. Present age of the incapacitated person: 52 Yrs 2. Current address of the incapacitated person Magnolias of Lancaster 1870 Rohrerstown Rd Lancaster, Pa 17601 3. The incapacitated person's residence is: Boarding homelPersonal care home 4. The incapacitated person has been in the present residence since April 20, 2004. If the incapacitated person has moved within the past year, state change and reason(s) for change ~~-<) C:'::" "::::::1 No Change (J ~XJ - CJ -.J ,"=J '.-) -', 5. Name and address of the incapacitated person's primary care giver: \.0 Timothy J. Labosh, M.D. East Petersburg Family Health Center 5970 S. Lemon St East Petersburg, Pa 17520 ~ --'",-,.- N C) 6. The major medical or mental problems of the incapacitated person are as follows: Brain injury. 7. Specify what, if any, social, medical, psychological and support services the incapacitated person is receiving: Ken receives social support and medication at Magnolias. He sees a physician and psychiatrist as needed. J 8. It is our opinion as guardian of the person that the guardianship should: continue Ken received a sever brain injury during a heart attack in 2003. There is no recovery from this, so Ken will need to be institutionalized for the rest of his life. This will require the continuation of guardianship. 9. During the past year, I have visited the incapacitated person 5 times with the average visit lasting 1 hour. The report of a social service organization employed by the guardian to oversee and coordinate the care of the incapacitated person for the period covered by this report may be attached to supplement this report. I verify that the foregoing information is correct to the best of my knowledge, information and belief; and that this verification is subject to the penalties of 18 Pa. C.S.A. 4904 relative to unsworn falsification to authorities. {O(9(D7 Date ~ Signature of Guardian " FILING FEE $15 MUST ACCOMPANY THIS FILING. Clerk of Orphans' Court of Cumberland County IN RE: KENNETH AUGUSTINE Docket No. 21-2004-0239 An Incapacitated Person ANNUAL REPORT OF GUARDIAN OF THE ESTATE I, Steve Augustine & John Augustine, were appointed plenary guardians of the estate of Kenneth Au ustine by Decree of the Honorable Judge George Hoffer. Dated April 19, 2004. This is my annual report for the period from October 16, 2007 to December 31, 2008, ("the Report Period"). I. SUMMARY A. Value of principal assets at the beginning of the Report Period? $ 27,534.09 B. Total amount of income earned during the report period? $ 34,865.35 C. Total Amount of all expenditures made for the care and maintenance of the incapacitated person during the Report Period? 1. From principal 2. From income D. Total amount spent for all other purposes during the Report Period? E. Total amounts remaining at the end of the Report Period? 1. From. principal 2. From income Total Income and Principal $ 34,703.35 $ 34,865.35 $ 0.00 $ 1,704.88 $ 1,704.88 $ 0.00 $ 1, 704.88 r.~ C7 -0 ~ - r ; C7 -r~ i-~- c~^, _ -r-~ i ~ __' ~ -} ~~ ~ ~ -' GT II. A. B. ADDITIONAL INFORMATION Principal: 1. Total amount remaining at the end of the Report Period? 2. How is principal currently invested Savings Account Checking Account Retirement Account $ 2:5.00 $ 1, 704.88 $ 0.00 3. Have there been any expenditures from principal during the Report Period If you answered YES, was there Court approval for all expenditures from principal? $ 27,534.09 Yes Yes 4. Did you receive any principal assets during the report period which were not included on the inventory or a prior report filed for the (;state? No If you answered YES, did you receive Court approval prior to receiving Additional principal? 5. State the sources and amounts of the additional principal you received: Retirement Account Income: $ 31,363.95 1. State sources and amounts of income received during the Report Period (i.e., social security, pension, rents, etc.) Lincoln Financial Disability Insurance $ 7,755.48 Social Security Disability Insurance $ 26,478.00 Interest from savings and checking accounts $ 31.87 2006 Federal Tax rebate $ 600.00 Total Income received during Report Period $ 34,865.35 2. How is income currently invested? (Please specify, restricted baulk accounts, client care account, etc.) Income was used to pay client care expenses. Specify what payments were made for the care and maintenance of the incapacitated person (i.e., clothing, nursing home, medicine, support, etc.) Assisted living & nursing home facilities Physician/ambulance services/hospital expenses Medicine (pharmacies)/Diapers Federal/State Tax lnsurance (life, bonding insurance for guardians) Misc paperwork expenses (postage, etc.) Tax preparation 4. Specify what other payments were made during the Report Period. none $ 57,493.17 $ 2,394.30 $ 7,276.61 $ 964.00 $ 1120.00 $ 95.43 $ 225.00 I verify that the foregoing information is correct to the best of my knowledge, information and belief; and that this verification is subject to the penalties of 18 Pa. C.S.A. 4904 relative to unsworn falsification to authorities. Date Signature of Guardian * FILING FEE $15 MUST ACCOMPANY THIS FILING. Clerk of Orphans' Court of Cumberland County IN RE: KENNETH AUGUSTINE Docket No. 21-2004-0239 An Incapacitated Person ANNUAL REPORT OF GUARDIAN OF THE PERSON I, Steve Augustine & John Au ustine, were appointed plenary guardians of the person of Kenneth Au ustine by Decree of the Honorable Judge George Hoffer. Dated April 19, 2004. This is my annual report for the period from October 16, 2007 to December 25, 2008, ("the Report Period"). Present age of the incapacitated person: 2 3. 4. 5. Current address of the incapacitated person Claremont Nursing and Rehabilitation Center 53 Yrs 1000 Claremont Rd ~ Carlisle, Pa 17013 ~= ~ ~° "T ` -~ ~ ca ~_~ - ~ ; c-~ =- - The incapacitated person's residence is: ~:_~-~ w ; ; ~ ~ - Nursing home - _. ; ., ~_% '~~ . , -v ~ -. ~-= ~ : ~ _ _,a The incapacitated person has been in the present residence since November 4 X008. If ~ the incapacitated person has moved within the past year , , state change and reason(s) for change Incapacitated person needed a higher level of care that the previous Assisted Living facility could not provide. Name and address of the incapacitated person's primary care giver: I>r. Michael Gawlas, D.O. Good Hope Family Practice 1830 Good Hope Rd Enola, Pa 17025 6. The major medical or mental problems of the incapacitated person are as follows: Brain injury. 7. Specify what, if any, social, medical, psychological and support services the incapacitated person is receiving: Ken receives social support and medication at Claremont. He sees a physician and psychiatrist as needed at the facility. It is our opinion as guardian of the person that the guardianship should: continue Ken received a sever brain injury during a heart attack in 2003. There is no recovery from this, so Ken will need to be institutionalized :for the rest of his life. This will require the continuation of guardianship. 9. During the past year, I have visited the incapacitated person 5 times with the average visit lasting 1 hour. The report of a social service organization employed by the guardian to oversee and coordinate the care of the incapacitated person for the period covered by this report may be attached to supplement this report. I verify that the foregoing information is correct to the best of my knowledge, information and belief; and that this verification is subject to the penalties of 18 Pa. C.S.A. 4904 relative to unsworn falsification to authorities. Date Signature of Guardian * FILING FEE $15 MUST ACCOMPANY THIS FILING. Clerk of Orphans' Court of Cumberland County IN RE: KENNETH AUGUSTINE Docket No. 21-2004-0239 An Incapacitated Person ANNUAL REPORT OF GUARDIAN OF THE ESTATE I, Steve Au~,ustine & John Au ug stine, were appointed plenary guardians of the estate of Kenneth Au ug_ stine by Decree of the Honorable Judge George Hoffer. Dated April 19, 2004. This is my annual report for the period from Januar~1=2009 to December 31, 201i~, ("the Report Period"). I. SUMMARY A. Value of principal assets at the beginning of the Report Period? B. Total amount of income earned during the report period? C. Total Amount of all expenditures made for the care and maintenance of the incapacitated person during the Report Period? 1. From principal 2. From income D. Total amount spent for all other purposes during the Report Period? E. Total amounts remaining at the end of the Report Period? 1. From principal 2. From income Total Income and Principal $ 8,881.82 $ 107,821.44 $ 0.00 $ 102,882.44 $ 7,750.00 $ 6,320.82 $ 6,320.82 $ 0.00 $ 6,320.82 ~' II. A. ADDITIONAL INFORMATION Principal: 1. Total amount remaining at the end of the Report Period? 2. How is principal currently invested Savings Account Checking Account Retirement Account $ 25.00 $ 1,835.40 $ 4,460.42 3. Have there been any expenditures from principal during the Report Period If you answered YES, was there Court approval for all expenditures from principal? $ 6,320.82 Yes Yes 4. Did you receive any principal assets during the report period which were not included on the inventory or a prior report filed for the estate? No If you answered YES, did you receive Court approval prior to receiving Additional principal? 5. State the sources and amounts of the additional principal you received: none B. Income: 1. State sources and amounts of income received during the Report Period (i.e., social security, pension, rents, etc.) Lincoln Financial Disability Insurance $ 55,996.72 Social Security Disability Insurance $ 46,731.80 Interest from savings and checking accounts $ 69.45 Reimbursement (returned & voided checks, refunds, etc) $ 4,214.68 One time cashing of stocks $ 658.79 Federal Tax refund $ 150.00 Total Income received during Report Period $ i 07,821.44 2. How is income currently invested? (Please specify, restricted bank accounts, client care account, etc.) Income was used to pay client care expenses. 3. Specify what payments were made for the care and maintenance of the incapacitated person (i.e., clothing, nursing home, medicine, support, etc.) Assisted living & nursing home facilities Physician/ambulance services/hospital expenses Medicine (pharmacies) Insurance (bonding insurance for guardians) Clothing and Toiletries Misc paperwork expenses (postage, etc.) Tax preparation 4. Specify what other payments were made during the Report Period. Gifts to children & brother $ 98,961.53 $ 1,453.53 $ 777.56 $ 350.00 $ 591.63 $ 86.69 $ 411.50 $ 7,750.00 I verify that the foregoing information is correct to the best of my knowledge, information and belief; and that this verification is subject to the penalties of 18 Pa. C.S.A. 4904 relative to unsworn falsification to authorities. ~ l/lii Date Signature of Guardiali * FILING FEE $IS MUST ACCOMPANY THIS FILING. Clerk of Orphans' Court of Cumberland County IN RE: KENNETH AUGUSTINE Docket No. 21-20(14-0239 An Incapacitated Person ANNUAL REPORT OF GUARDIAN OF THE PERSON I, Steve Augustine & John Au ug stine, were appointed plenary guardians of the person of Kenneth Augustine by Decree of the Honorable Judge George Hoffer. Dated April 19, 2004. This is my annual report for the period from January 1, 2009 to December 31, 20:10, ("the Report Period"). 1. Present age of the incapacitated person: 55 Yrs 2. Current address of the incapacitated person Claremont Nursing and Rehabilitation Center 1000 Claremont Rd Carlisle, Pa 17013 The incapacitated person's residence is: Nursing home 4. The incapacitated person has been in the present residence since November 4, 2008. If the incapacitated person has moved within the past year, state change and reason(s) for change Incapacitated person needed a higher level of care that the previous Assisted Living facility could not provide. 5. Name and address of the incapacitated person's primary care giver: Dr. Michael Gawlas, D.O. Good Hope Family Practice 1830 Good Hope Rd Enola, Pa 17025 6. The major medical or mental problems of the incapacitated person are as follows: Brain injury. 7. Specify what, if any, social, medical, psychological and support services the incapacitated person is receiving: Ken receives social support and medication at Claremont. He sees a physician and psychiatrist as needed at the facility. It is our opinion as guardian of the person that the guardianship should: continue Ken received a sever brain injury during a heart attack in 2003. There is no recovery from this, so Ken will need to be institutionalized for the rest of his life. This will require the continuation of guardianship. 9. During the past year, I have visited the incapacitated person 5 timers with the average visit lasting 1 hour. The report of a social service organization employed by the guardian to oversee and coordinate the care of the incapacitated person for the period covered by this report may be attached to supplement this report. I verify that the foregoing information is correct to the best of my knowledge, information and belief; and that this verification is subject to the penalties of 18 Pa. C.S.A. 4904 relative to unsworn falsification to authorities. ~/ // ~~ Date Signature of Guardian * FILING FEE $IS MUST ACCOMPANY THIS FILING. Clerk of Orphans' Court of Cumberland County IN RE: KENNETH AUGUSTINE Docket No. 21-2004-0239 An Incapacitated Person ANNUAL REPORT OF GUARDIAN OF THE ESTATE I, Steve AuQUStine & John Au ustine, were appointed plenary guardians of the estate of Kenneth Au stine by Decree of the Honorable Judge George Hoffer. Dated April 19, 2004. This is my annual report for the period from January 1, 2009 to December 31, 2010, ("the Report Period"). I. SUMMARY A. Value of principal assets at the beginning of the Report Period? $ 8,881.82 B. Total amount of income earned during the report period? $ 107,821.44 C. Total Amount of all expenditures made for the care and maintenance of the incapacitated person during the Report Period? 1. From principal $ 0.00 2. From income $ 102,882.44 D. Total amount spent for all other purposes during the Report Period? $ 7,750.00 E. Total amounts remaining at the end of the Report Period? $ 6,320.82 1. From principal $ 6,320.82 2. From income $ 0.00 Total Income and Principal $ 5,320.82 Rh,CORI:)h.D O}~h'ICI? <)F RF.C:IS'1'RIiR Oh WII,IS ,,~ 201a FEB 11 '~ cL.r-.xx oI~ ORPI IANS C<)UR'I' CUMBEIt1.~:~Nll COURT', Y,1 II. ADDITIONAL INFORMATION A. Principal: 1. Total amount remaining at the end of the Report Period? 2. How is principal currently invested Savings Account Checking Account Retirement Account $ 25.00 $ 1,835.40 $ 4,460.42 3. Have there been any expenditures from principal during the Report Period If you answered YES, was there Court approval for all expenditures from principal? $ 6,320.82 Yes Yes 4. Did you receive any principal assets during the report period which were not included on the inventory or a prior report filed for the estate? No If you answered YES, did you receive Court approval prior to receiving Additional principal? 5. State the sources and amounts of the additional principal you received: none B. Income: 1. State sources and amounts of income received during the Report Period (i.e., social security, pension, rents, etc.) Lincoln Financial Disability Insurance $ 55.996.72 Social Security Disability Insurance $ 46,731.80 Interest from savings and checking accounts $ 69.45 Reimbursement (returned & voided checks, refunds, etc) $_ 4;214.68 One time cashing of stocks $ 658.79 Federal Tax refund $ 150.00 Total Income received during Report Period $ 107,821.44 2. How is income currently invested? (Please specify, restricted bank accounts, client care account, etc.) Income was used to pay client care expenses. 3. Specify what payments were made for the care and maintenance of the incapacitated person (i.e., clothing, nursing home, medicine, support, etc.) Assisted living & nursing home facilities Physician ambulance serviceslhospital expenses Medicine (pharmacies) Insurance (bonding insurance for guardians) Clothing and Toiletries Misc paperwork expenses (postage, etc.) Tax preparation 4. Specify what other payments were made during the Report Period. Gifts to children & brother $ 98,961.53 $ 1,453.53 $ 777.56 $ 350.00 $ 591.63 $ 86.69 $ 41 I.50 $ 7,750.00 I verify that the foregoing information is correct to the best of my knowledge, information and belief; and that this verification is subject to the penalties of 18 Pa. C.S.A. 4904 relative to unsworn falsification to authorities. Date Signature of Guardian * FILING FEE $15 MUST ACCOMPANY THIS FILING. Clerk of Orphans' Court of Cumberland County IN RE: KENNETH AUGUSTINE Docket No. 21-20(1.4-0239 An Incapacitated Person ANNUAL REPORT OF GUARDIAN OF THE PERSON I, Steve Augustine & John Au ustine, were appointed plenary guardians of the person of Kenneth Au ug_stine by Decree of the Honorable Judge George Hoffer. Dated April 19, 2004. This is my annual report for the period from January 1, 2009 to December 31, 2010, ("the Report Period"). Present age of the incapacitated person: 2. Current address of the incapacitated person Claremont Nursing and Rehabilitation Center 1000 Claremont Rd Carlisle, Pa 17013 3. The incapacitated person's residence is: Nursing home 55 Yrs 4. The incapacitated person has been in the present residence since November 4, 2008. If the incapacitated person has moved within the past year, state change and reason(s) for change Incapacitated person needed a higher level of care that the previous Assisted Living facility could not provide. 5. Name and address of the incapacitated person's primary care giver: Dr. Michael Gawlas, D.O. Good Hope Family Practice 1830 Good Hope Rd Enola, Pa 17025 6. The major medical or mental problems of the incapacitated person are as follows: Brain injury. 7. Specify what, if any, social, medical, psychological and support services the incapacitated person is receiving: RI?CORIiFa ONI~ICI'. OF Rf?G1S1'R}?R <)1~ W'II,1,S 2011 FEB 11 ~~ CI,IsRK OF~ ORP1L~Nti COL'R'1' CU;~1B1?RL,1Nll COURT, PA Ken receives social support and medication at Claremont. He sees a physician and psychiatrist as needed at the facility. 8. It is our opinion as guardian of the person that the guardianship should: continue Ken received a sever brain injury during a heart attack in 2t)03. There is no recovery from this, so Ken will need to be institutionalized for the rest of his life. This will require the continuation of guardianship. 9. During the past year, I have visited the incapacitated person 5 times with the average visit lasting 1 hour. The report of a social service organization employed by the guardian to oversee and coordinate the care of the incapacitated person for the period covered by this report may be attached to supplement this report. I verify that the foregoing information is correct to the best of my knowledge, information and belief; and that this verification is subject to the penalties of 18 Pa. C.S.A. 4904 relative to unsworn falsification to authorities. ~/ // ~r Date Signature of Guardian * FILING FEE $IS MUST ACCOMPANY THIS FILING. IN RE: KENNETH AUGUSTINE : IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA = = ~'~ - ~, :ORPHANS' COURT D:[VISION ~~~~ f, - An incapacitated person : N0.21-04-0239 - :~ `- ,, _. On the Petition of STEVE AUGUSTINE and JOHN AUGUSTINE - ,, :i.: _ . - ~> -, PETITION TO RELEASE BOND AND NOW come Petitioners, STEVE AUGUSTINE and JOHN AUGUSTINE, by and through their attorney, Nicole M. Kerns, Esquire, of Hazen Elder Law, and file the within Petition to Release Bond and in support hereof aver as follows: 1. By Order of this Court dated April 19, 2004, STEVE AUGUSTINE and JOHN AUGUSTINE, were appointed the Permanent Plenary Co-Guardians of the Person and Estate of KENNETH AUGUSTINE. (A copy of the Final Order is attached hereto as Exhibit "A") 2. In the Guardianship Order dated April 19, 2004, a bond in the amount of Forty Thousand Dollars ($40,000.00) was required to be posted by the Co-Guardians. 3. The Co-Guardians secured a Bond through Travelers Casualty and Surety Company of America, Bond Number 104314324. (A copy of the Band is attached hereto as Exhibit "B") 4. KENNETH AUGUSTINE resides in a long term care i~acility and his resources have been depleted to approximately Two Thousand and Four Hundred Dollars ($2,400.00), as KENNETH AUGUSTINE is currently receiving Medical Assistance benefits through the state of Pennsylvania. ~~ . ~ 5. Because there are no longer funds to protect, and because KENNETH AUGUSTINE's remaining funds and his income will need to be applied towards his care, the Co-Guardians need to cancel the guardianship bond. Travelers Casualty and Surety Company of America will not do so without a release from the Court. The insurance company is demanding continued payment of this bond by the Co-Guardians. WHEREFORE, Petitioners respectfully request this Honorable Court to enter an Order releasing the bond in the above-captioned matter. Respectfully Submitted, ~ /Z ~ f ( l Date HAZEN ELDER I.AW Nicole M. Weigel, Es . PA I.D. No. 20682 7 2000 Linglestown F:oad, Suite 202 Harrisburg, PA 17l 10 (717) 540-4332 - Plhone (717) 540-4313 -Fax nwei gel (c~hazenelderlaw. com IN RE: KENNETH AUGUSTINE an incapacitated person IN THE COURT C)F COMMON PLEAS OF CUMI3ERLA1\fD COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION NO. 2004-00239 -, ~~. ~ ~... ~ ~~. ~ ~ O :D 5 'D ' On the Petition of STEVE AUGUSTINE and JOHN AUGUSTINE ~' a~ ~.: i~; ._.. .__. FINAL ORDER OF COURT APPOINTING PLENARY GUARDIAN AND NOW, this ~ day of 2004, a hearing in this case having been held on April 19, 2004 at ~ % yJ`- A.~.m., and it appearing to the Court that KENNETH AUGUSTINE was served with a Citation and Notice of this hearing on Mazch 22, 2004, and the Court finds that the physical or mental condition of KENNETH ALGUSTINE would be harmed by his presence at heazing, and further finds from the testimony: 1. That KENNETH AUGUSTINE suffers from lbrain damage due to anoxic encephalopathy, acondition which totally impairs his capacity to receive and evaluate information effectively and to make and communicate decisions concerning his management of financial affairs or to meet essential requirements for his physical health and safety. 2. That there aze insufficient supports available to assist KENNETH AUGUSTINE in such decisions and that there are no other less restrictive alternative mechanism for decision-making. A TRUE COPY FROM RECORD In 'Testimony wherof, I hereunto set my hand and the seal of ~~ Court Carl e, PA ^This I~t'bav of~ 20 Clerk of the Orphans Cumt~erland C 3. That based on the inability of KENNETH AUGiJSTINE to receive and evaluate information and to make or communicate decisions, a plenary Guardian of the Person and a plenary Guardian of the Estate are required on a permanent basis. NOW, THEREFORE, based on the clear and convincing evidence supporting the foregoing findings it is ORDERED, ADJUDGED and DECREED that KE:[~1NETH AUGUSTINE be and is hereby adjudged an incapacitated person, and STEVE AUGUSTIl'1E and JOHN AUGUSTINE are appointed Plenary Penmanent Co-Guardians of the Person and Estate. As Plenary Permanent Co- Guardians of the person, STEVE AUGUSTiNE and JOHN AUGU5TINE have the authority to access all KENNETH AUGUSTINE'S medical records, including but not limited to psychiatric records, and to request and/or terminate anout-of-hospital do-not-resuscitate order on behalf of KENNETH AUGUSTINE, in accordance with Pennsylvatia law. Further, as Co-Guardians of the person, STEVE AUGUSTINE and JOHN AUGUSTINE shall have the power and authority to serve as personal representatives for all purposes of the Health Insurance; Portability and Accountability Act of 1996, (Pub.L.104-191), 45 CFR Sections 160 through 164 ("HIPAA"). The Co-Guardians shall be considered the personal representatives for KENNETI~ AUGUSTINE'S heath care disclosures under the 2003 federal HIPAA regulations and shall have full authority to review KENNETH AUGUSTINE'S medical records and to execute releases of confidential information from medical providers and insurers or other third party payors. As co-guardians of the estate, STEVE AUGUSTINE and JOI~IlV AUGUSTINE shall have the authority to make distributions from principal for the payment ofcare expenses, all medical needs, attorney's fees, and child support pursuant to court order. An Inventory must be filed within ninety 2 (90) days. A report by the Co-Guardians shall be filed within 12 months and annually thereafter. I Oo Bond in the amount of ~ L~1 ~ I ~ ~~ shall be posted by the Co-Guardians. KENNETH AUGUSTINE, an incapacitated person, has the right to appeal this Order of Court by filing exceptions within ten (10) days of this date or to petition this Court for a review hearing to modify or terminate the guardianship herein established.. If KENNETH AUGUSTINE was not present at this hearing on appointment of a guardian then petitioner shall serve upon and read to KENNETH AUGUSTINE the Statement of Rights, a copy of which is attached to this Order as Exhibit "A", and file proof of such service with this Court within ten days. BY THE COURT: i~"~~ Q_~ BOND-Guardian Orphan's Court Division - Court of Common Pleas of No. 00239 °f 2004 Bond No. 104314324 Estate of Kenneth Augustine Know all Men by these Presents THAT WE, STEVE AUGUSTINE & JOHN AUGUSTINE (Name and address of Guardian, or Guardians) 1004 COPPERCREEK DR, MECHAIVICSBURG, PENNSYLVANIA, 17050 , as principal and Travelers Casaalty and Surety Company of America Oae Tower Square, Hartford, CT, 06183 as surety, (Name and address of Surety) ARE HELD AND FIItMLY BOUND unto the COMMONWEALTH OF PENNSYLVANIA, in the sum of Forty Thousand and 00/100 Dollars, $40,000.00 lawful money, to be paid to the said Commonwealth; to which payment, well and truly to be made, we bind ourselves, our Heirs, Executors, Administrators, Successors and Assigns and every of them, jointly and severally, snnly by these presents. Sealed with our seals, and dated this 2 2nd day of Apri 1 Z 004 Conditt'on of Obligation (1) When One Guardian- The condition of this obligation is that, if the said guardian shall well and truly administer the estate according to law, this obligation shall be void; but otherwise it shall remain in force. (2) When Two or More Guardians- The condition of this obligation is that, if the said guardians or any of them shall well and truly administer the estate according to law, this obligation shall be void as to the guardian o:r guardians who shall so administer the estate; but otherwise it shall remain in force. STE ~ UGUSTINE & JOHN AUGUSTINE Sealed and delivered in the ~' ~ ~ SEAL Presence of ..__ _.._~-_~ __ . ~ ~' ~ -' SEAL ravelers Casualty and Surety Compa of America ~Y ~ __..1~Z~GwJ ~ ~ --___ SEAL' . David T. Rousche, Att~rney-~ir-Fact 5-6167 (1/02) 30-547 TRAVELERS CASUALTY AND SURETY COMPA,YY OF Ali:[ERICA . TRAVELERS CASUALTY AND SURETY COMPANY FARMINGTON CASUALTY COMPANY Hartford, Connecticut 06183-9062 POWER OF ATTORNEY AND CERTIFICATE OF AUTHORITY OF ATTORNEY(S)-IN-FACT ICNOW ALL PERSONS BY THESE PRESENTS, THAT TRAVELERS CASUAL TY AND SURETY COMPANY OF AMERICA, TRAVELERS CASUALTY AND SURETY COMPANY and FAR:ti1INGTON CASUALTY COMPANY, corporations duly organized under the laws of the State of Connecticut, and having their principal offices in the City of Hartford, ...County of Hartford, State of Connecticut, (hereinafter the "Companies") hath made, constituted and appointed, and do by these presents make, constitute and appoint: G. Greg Gunn, Theodore W. Mowery, Gan' D. Harshbarger, David T. Rousche, Patricia E. Pierce, of Lemoyne, Pennsylvania, their true and lawful Attorney(s)-in-Fac:t, with full power and authority hereby conferred to sign, execute and acknowledge, at any place within the United States, the following instrument(s): by his/her sole signature and act, any and all bonds, recognizances, contracts of indemnity, and other writings obligatory in the nature of a bond, recognizance, or conditional undertaking and any and all consents incident thereto and to bind the Companies, thereby as fully and to the same extent as if the same were signed by the duly authorized officers of the Companies. and all the acts of said Attorney(s)- in-Fact, pursuant to the authority herein given, are hereby ratified and confirmed. This appointment is made under and by authority of the following Standing Resolutions o:f said Companies, which Resolutions are now in full force and effect: VOTED: That the Chairman, the President, any Vice Chairman, any Executive Vice President, anv Senior Vice President, any Vice President, any Second Vice President, the Treasurer, any Assistant Treasurer, the Corporate Secretary or any Assistant Secretary may appoint Attorneys-in-Fact and Agents to act for and on behalf of the company and may give such appointee such authority as hiss or her certificate of authority may prescribe to sign with the Company's name and seal with the Companr•`s seal bonds, recoertizances, contracts of indemnity, and other writings obligatory in the nature of a bond, recognizance, or conditional undertaking, and any of said otiicers or the Board of Directors at any time may remove any such appointee and revoke the power given him or her. VOTED: That the Chairman, the President, any Vice Chairman, anv Executive Vice President, any Senior Vice President or any Vice President may delegate all or any part of the foregoins authority to one or more otlicers or employees of this Company, provided that each suet delegation is in writing and a copy thereof is tiled in the othee of the Secretary. - VOTED: That anv bond, recomtizance, contract of indemniR•, or writing obligatory in the natttre of a bond, recognizance, or conditional undertaking shall be valid and binding upon the Company when (a) signed by the President, any Vice Chairman, any Executive Vice President, anv Senior Vice President or any Vice President, any Second Vice President, the Treasurer. any Assistant Treasurer, the Corporate Secretary or any Assistant Secretary and duly attested and sealed with the Company's seal by a Secretary or Assistant Sacretaw, ar `b i duly executed (under seal, if required) by one or more :attorneys-in-Fact and Agents pursuant to the power prescribed in his or her certificate or [heir certificates of authority or by one or more Company otiicers pursuant to a written delegation of authority. This Power of Attorney and Certificate of Authority is signed and settled by facsimile (mechanical or printed) under and by authority of the following Standing Resolution voted by the Boards of Directors of TRAVELERS CASUALTY AND SURETY COMPPuYY OF :~YIERICA, TRAVELERS CASUALTY AND SURETY COMPA~vY and FARMINGTON CASUALTY COMPA,YY, which Resolution is now in full force and effect: VOTED: That the signature of each of the following otiicers: President, any Executive Vice Pre:>ident, any Senior Vice President, any Vice President, any Assistant Vice President, any Secretary, anv Assistant Secretary, and the~seal of the (:ompany may be atiixed by facsimile to any power of attorney or to any certiticate relating thereto appointing Resident Vice Presidents, Resident .assistant Secretaries or Attorneys-in-Fact for purposes only of executing and attesting bonds and undertakings and other writings obligatory in the nature thereof, and any such power of attorney or certificate bearing such facsimile signattue or facsimile seal shall be valid and binding upon the Company and any such power so executed and certified by such facsimile signature and facsimile seal shall be valid and binding upon the Company in the tutttre with respect to any bond or undertaking to which it is attached. . ; -t)1) ltzndardl Ili' WITNESS WHEREOF, TRAVELERS CASUALTY AND SURETY COMPA.N'Y OF AMERICA, TRAVELERS CASUALTY AND SURETY COMPANY and FARMINGTON CASUALTY COMPANY have caused this instrument to be signed b}• their Senior Vice President and their corporate seals to be hereto affixed this 3rd da~• of Jule 2001. STATE OF CON'JECTICUT } SS. Hartford COUNTY OF HARTFORD TY A ~i C,~ ~~ ~ ~ o ~c~~1982~~'a Q~~~,~ x`61 Fr st d.`-'~'FC~"'~.l 37 By George W. Thompson Senior Vice President On this 3rd da}• of Jul}•, 2001 before me personally came GEORGE V~'. THOMPSO)\' to me latown; who. being b~• me duly sworn, did depose and sa}•: that helshe is Senior Vice President of TRAVELERS CASUALTY AND SURETY COMPANY OF AMERICA, TRAVELERS CASUALTY AND SURETY COMPANY and FARMIIVGTON CASUALTY COMPANY, the corporations described in and which executed the above instrument; that he/she knows the seals of said corporations; that the seals affixed to the said instrument are such corporate seals; and that he/she executed the said instrument on behalf of the corporations b~° authorit<• of his/her office under the Standing Resolutions thereof. ~G.TlT~ * ~,~~ # ~~ CERTffICATE TRAVELERS CASUALTY AND SURETY COMPA)\'Y OF AMERICA TRAVELERS CASUALTY AN1D SURETY COMPANY FARNIINGTON CASUALTY COMPANY ~o.nr~. e 3r.~' My commission expires June 30, 200o Notary Public Marie C. Tetre~ault I, the undersigned, Assistant Secretan- of TRAVELERS CASUALTY AND SURET'1' COMPANY OF AMERICA, TRAVELERS CASUALTY AND SURETY COMPANY and FARNiINGTON CASUALTY COMPAII'I', stock corporations of the Stave of Connecticut DO HEREBY CERTffY that the foregoing and attached Power of Attorne}~ and Certificate of Authoriti~ remains in full forcE and has not been revoked; and furthermore, that the Standing Resolution:> of the Boards of Directors, as set fo.~th in the rx~xificate of Authorit}•, are now in force. Signed arxd ~~e~e1 at the Home Office of the Company, in the Cit}• of Hartford, State of Connecticut. Dated this ~ 2nd da~~ of April ,20 04 ~'~1~ a ~ • ~ ~ 19.82' p BY ~~ ~ ~ y ° ~S~r~- s '~--"''~~ 'may 1a~ 6` ~~ ~ ! ~~ y ~ ~` ~_ ~,/ v~~ / /'~.. /vim-(~J -- --- Kori M. Johanson Assistant Secretary, Bond w VERIFICATION I verify that the statements made in this Petition are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. Section 4904, relating to unsworn falsification to authorities. ;~ „~ .,. STEVE AUGUSTINE VERIFICATION I verify that the statements made in this Petition are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. Section 4904, relating to unsworn falsification to authorities. t ~ ./~~'. N AUGUSTINE r IN RE: KENNETH AUGUSTINE An incapacitated person IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION N0.21-04-0239 CERTIFICATE OF SERVICE I, Nicole M. Kerns, Esquire, certify that on thisZ~~ day of~ ~, ~ ( , 2011, I served a true and correct copy of the within Petition to Release Bond on the parties named below, by depositing same in the United States mail, certified mail, postage prepaid as follows: Theresa Augustine 574 W. Chocolate Ave. Hershey, PA 17033 Leanna Wickline 3284 Sequoia Dr. Macungie, PA 18062 Amanda Augustine 3284 Sequoia Dr. Macungie, PA 18062 Jeremy Augustine 3284 Sequoia Dr. Macungie, PA 18062 Respectfully Submitted, HAZEN ELDER LAW 2i rr Dat c~G~ rv~ ~,~e~' Nicole M. Weigel, 1=;s . PA LD. No. 206827 2000 Linglestown Road, Suite 202 Harrisburg, PA 17110 (717) 540-4332 -Phone (717) 540-4313 -Fax nweigel~~hazenelderlaw.com IN RE: KENNETH AUGUSTINE : IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION An incapacitated person : N0.21-04-0239 On the Petition of STEVE AUGUSTINE and JOHN AUGUSTINE FINAL OR~DjER OF COURT AND NOW this ~ day of i (~ ~ , 2011, upon review of the within _.-- n •'«: o_ n,.l,.,...,, r n a ~{ i3__lierel3y_~R$ER ~~1V11 1Vr aVµVV Vl LV11V, E-D-~ LLB _.._ Travelers Casualty and Surety Company of America Bond (Number 104314324) on the-- guardianship of KENNETH AUGUSTINE, is hereby released effective iyrssrp ~~~ ~ l BY THE COURT: J. c~ ~~~ ~:Y, o c ~ -_ _: ~ A ~~ rn ~v~~ ~,, cza O C -" -~ ~ CD C -, ~; -:, ,-~ c;_~ c~ <~-7 L, {~°-i _::: c-, ..: - -r't ~~ C7 ~~ rn ~~ ~~ ORPHANS' COURT DIVISION COURT OF COMMON PLEAS OF In Re: KENNETH AUGUSTINE CUMBERLAND COUNTY PENNSYLVANIA NO. 04-0239 CERTIFICATE OF SERVICE OF ORDER ORDER DATE: 03/26/11 JUDGE'S INITIALS: AHM TIME STAMP DATE: 03/28/11 IN RE: FINAL ORDER OF COURT SERVICE TO: JEREMY AUGUSTINE HAZEN ELDER LAW LEANNA WICKLINE THERESA AUGUSTINE AMANDA AUGUSTINE METHOD OF MAILING: ENVELOPES PROVIDED BY: ® USPS ^ RRR ^ HAND DELIVERED ^ OTHER MAILED: 03/28/1 I ® PETITIONER ^ JUDGE ^ CLERK OF ORPHANS COURT SERVICE TO: METHOD OF MAILING: ^ USPS ^ RRR ^ HAND DELIVERED ^ OTHER MAILED: ENVELOPES PROVIDED BY: ^ PETITIONER ^ JUDGE ^ CLERK OF ORPHANS COURT Clerk of Orphans' Court of Cumberland County IN RE: KENNETH AUGUSTINE Docket No. 21-2004-0239 An Incapacitated Person ANNUAL REPORT OF GUARDIAN OF THE ESTATE I, Steve Au~zstine & John Augustine, were appointed plenary guardians of the estate of Kenneth Augustine by Decree of the Honorable Judge George Hoffer. Dated April 19.2004. This is my annual report for the period from Januarv 1, 2011 to December 31, 2011, ("the Report Period"). I. SUMMARY A. Value of principal assets at the beginning of the Report Period? B. Total amount of income earned during the report period? C. Total Amount of all expenditures made for the care and maintenance of the incapacitated person during the Report Period? 1. From principal 2. From income D. Total amount spent for all other purposes during the Report Period? E. Total amounts remaining at the end of the Report Period? 1. From principal 2. From income Total Income and Principal $ 6,320.82 $ 62,658.22 $ 1 829.86 $ 62.658.22 $ 2,000.00 $ 2,490.96 $ 2,490.96 $ 0.00 $ 2,490.96 '~ ;~, n r-.7 ~ :-..~-, .-- O y ~ ~ . ~ ~'• ~ ~ r- ~f~ l1 ~ ~~ L7~ 1 ~..., T - ~ ~ A `r' ~~ - , ~, ,. II. ADDITIONAL INFORMATION A. Principal: 1. Total amount remaining at the end of the Report Period? 2. How is principal currently invested Savings Account Checking Account Retirement Account $ 25.00 $ 202.96 $ 2.263.00 $ 2.490.96 3. Have there been any expenditures from principal during the Report Period Yes If you answered YES, was there Court approval for all expenditures from principal? Yes 4. Did you receive any principal assets during the report period which were not included on the inventory or a prior report filed for the estate? No If you answered YES, did you receive Court approval prior to receiving Additional principal? 5. State the sources and amounts of the additional principal you received: none B. Income: 1. State sources and amounts of income received during the Report Period (i.e., social security, pension, rents, etc.) Lincoln Financial Disability Insurance $ 39,684.00 Social Security Disability Insurance $ 22.572.00 Interest from savings and checking accounts $ 2.22 Federal Tax refund $ 400.00 Total Income received during Report Period $ 62.658.22 2. How is income currently invested? (Please specify, restricted bank accounts, client care account, etc.) Income was used to pay client care expenses. L1' _ - _ _ 3. Specify what payments were made far the care and maintenance of the incapacitated person (i.e., clothing, nursing home, medicine, support, etc.) Assisted living & nursing home facilities Physicianlambulance serviceslhospital expenses Medicine (pharmacies) Insurance (bonding insurance for guardians) Lawyers fees Clothing and Toiletries Misc paperwork expenses (postage, etc.) Tax preparation 4. Specify what other payments were made during the Report Period. Gifts to children & brother $ 63.506. i 1 $ 0.00 $ 0.00 $ 0.00 $ 602.88 $ 162.65 $ 32.44 $ 184.0(? $ 2,004.00 I verify that the foregoing information is correct to the best of my knowledge, information and belief; and that this verification is subject to the penalties of 18 Pa. C.S.A. 4904 relative to unsworn falsification to authorities. A~3/~o/~ Date Signature of Guardian FII.ING FEE S15 MUST ACCOMPANY TALS Fn,ING. • i Clerk of Orphans' Court of Cumberland County IN RE: KENNETH AUGUSTINE Docket No. 21-2004-0239 An Incapacitated Person ANNUAL REPORT OF GUARDIAN OF THE PERSON I, Steve Augustine & John Aug~sfi~ne, were appointed plenary guardians of the person of Kenneth Augustine by Decree of the Honorable Judge George Hoffer. Dated April 19, 2004. This is my annual report for the period from January 1, 2011 to December 31.2011, ("the Report Period"). 1. Present age of the incapacitated person: 56 Yrs 2. Current address of the incapacitated person no ~.:, _~, ~!-~ . f'.l ~. Claremont Nursing and Rehabilitation Center j "~~ n ~ ~, C ~ ; 1000 Claremont Rd ~ ~„ ~ w - Carlisle, Pa 17013 _ ~ c ~ ~ ~ :_,~ , , _ _.. :.... 3. The incapacitated person's residence is: m ~ `•'~' _. . ~„ a~~ -T, Nursing home 4. The incapacitated person has been in the present residence since November 4, 200$. If the incapacitated person has moved within the past year, state change and reason(s) for change Incapacitated person needed a higher level of care that the previous Assisted Living facility could not provide. 5. Name and address of the incapacitated person's primary care giver: Dr. Michael Gawlas, D.O. Good Hope Family Practice 1830 Good Hope Rd Enola, Pa 17025 6. The major medical or mental problems of the incapacitated person are as follows: Brain injury. 7 Specify what, if any, social, medical, psychological and support services the incapacitated person is receiving: ' 1'~ ,, Ken receives social support and medication at Claremont. He sees a physician and psychiatrist as needed at the facility. 8. It is our opinion as guardian of the person that the guardianship should: continue Ken received a sever brain injury during a heart attack in 2003. There is no recovery from this, so Ken will need to be institutionalized for the rest of his life. This will require the continuation of guardianship. 9. During the past year, I have visited the incapacitated person 3 times with the average visit lasting 30 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. I verify that the foregoing information is correct to the best of my knowledge, information and belief; and that this verification is subject to the penalties of 18 Pa. C.5.A. 4904 relative to unsworn falsification to authorities. ~ 3 /~~ /~ .___ Date Signature of Guardian FILING FEE SIS MUSr ACCOMPANY THIS FILING. Clerk of Orphans' Court of Cumberland County IN RE: KENNETH AUGUSTINE Docket No. ~ 1-2004-0239 An Incapacitated Person ANNUAL REPORT OF GUARDIAN OF THE PERSON I, Steve Au ustine & John Augustine, were appointed plenary guardians of the person of Kenneth Augustine by Decree of the Honorable Judge George Hoffer. Dated April 19,2004. This is my annual report for the period from January 1, 2012 to December 3 L 2012, {"the Report Period"). 1. Present age of the incapacitated person: 2. Current address of the incapacitated person Kenneth past away on May 31, 2012 3. The incapacitated person's residence is: ~ 57 Yrs f A r..µn~ ~'~ ~ ~'~P r ~--, y. ~~. ;; ~. ,` , ; - e .. 4. The incapacitated person has been in the present residence since November 4, 2008. If the incapacitated person has moved within the past year, state change and reason{s) for change Incapacitated person needed a higher level of care that the previous Assisted Living facility could not provide. 5. Name and address of the incapacitated person's primary care giver: Dr. Michael Gawlas, D. (). Good Hope Family Practice 1830 Good Hope Rd Enola, Pa 17025 6. The major medical or mental problems of the incapacitated person are as follows: Brain injury. 7. Specify what, if any, social, medical, psychological and support services the incapacitated person is receiving: Ken received social support and medication at Claremont. He saw a physician and psychiatrist as needed at the facility. $. It is our opinion as guardian of the person that the guardianship should: continue Ken received a sever brain injury during a heart attack in 2003. There was no recovering from his injury, so Ken was institutionalized until his death on I~Iay 31, 2012. This ends the requirement of guardianship. 9. During the past year, I have visited the incapacitated person 3 times with the average visit lasting 30 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. I verify that the foregoing information is correct to the best of my knowledge, information and belief; and that this verification is subject to the penalties of 18 Pa. C.S.A. 4904 relative to unsworn falsification to authorities. 1 / r o 1 ~~~ ~ Date Signature of Guardian ~` FILING FEE SIS MIDST ACCOMPANY THIS FILING. Clerk of Orphans' Court of Cumberland County IN RE: KENNETH ALTGUSTINE Docket No. 21-2004-0239 An Incapacitated Person ANNUAL REPORT OF GUARDIAN OF THE ESTATE I, Steve Augustine & John Augustine, were appointed plenary guardians of the estate of Kenneth Augustine by Decree of the Honorable Judge George Hoffer. Dated Apn~ 119, 2004. This is my annual report for the period from January 1, 2012 to December 31, 2012, ("the Report Period"). This is the last report because Kenneth Augustine past away on May 31, 2012 I. SUMMARY A. Value of principal assets at the beginning of the Report Period? $ 2,471.09 B. Total amount of income earned during the report period? $ 26,339.71 C. Total Amount of all expenditures made far the care and maintenance of the incapacitated person during the Report Period? 1. From principal $ 1,972.09 2. From income $ 26,339.71 D. Total amount spent for all other purposes during the Report Period? $_ 499.00 E. Total amounts remaining at the end of the Report Period? $ -0.00 1. From principal $ 0.00 2. From income $ 0.00 Total Income and Principal $ O.UO~ . -, c~ ~~_ - ,,~ ~-~ ``~ ~"` c _ '~'~~ ~J d __ ~ A... h .:.. ~.~--' .' ` 5 ,_ ~~ II. A. ADDITIONAL INFORMATION Principal: l . Total amount remaining at the end of the Report Period? 2. Haw is principal currently invested Savings Account Checking Account Retirement Account $ 0.00 $ o.oo $ 0.00 3. Have there been any expenditures from principal during the Report Period If you answered YES, was there Court approval for all expenditures from principal? ~ o.oo Yes Yes 4. Did you receive any principal assets during the report period which were not included on the inventory or a prior report filed for the estate? No If you answered YES, did you receive Court approval prior to receiving Additional principal? 5. State the sources and amounts of the additional principal you received: none B. Income: l . State sources and amounts of income received during the Report Period (i.e., social security, pension, rents, etc.) Lincoln Financial Disability Insurance $_ 16,535.00 Social Security Disability Insurance $ 9,745.00 interest from savings and checking accounts $ 0.71 Lancaster General Hospital refund $ 59.00 Total Income received during Report Period $ 26,339.71 2. How is income currently invested? (Please specify, restricted bank accounts, client care account, etc.) Income was used to pay client care expenses. 3. Specify what payments were made far the care and maintenance of the incapacitated person (i.e., clothing, nursing home, medicine, support, etc.} Assisted living & nursing home facilities $ 2b,055.94 Cemetery Fees $ 900.00 Lawyers fees $ 721.31 Clothing and Toiletries $ 215.55 Misc paperwork expenses (postage, etc.) $ 114.00 Tax preparation $ 305.00 4. Specify what other payments were made during the Report Period. Gifts to children & brother $ 499.00 I verify that the foregoing information is correct to the best of my knowledge, information and belief; and that this verification is subject to the penalties of 18 Pa. C.S.A. 4904 relative to unsworn falsification to authorities. t r ~~--- Date Signature of +Guardian * FILING FEE $15 MUST ACCOMPANY THIS FILING.