HomeMy WebLinkAbout01-1180
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iJEG 3 1 2001\l
IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY
NO. I \ EO -- 2()OI ORPHANS' COURT
ESTATE OF BLANCHE M. MANNING
PETITION PURSUANT TO SECTION 5511 OF THE PROBATE, ESTATES
AND FIDUCIARY CODE TO ADJUDICATE BLANCHE M. MANNING TO BE
INCAPACITATED AND TO APPOINT A GUARDIAN FOR HER PERSON AND HER ESTATE
PRELIMINARY DECREE
AND NOW, this . S A~_day of ~/JW ~ ,200~pon consideration
of the annexed Petition, it is ORDERED AN DECREE~ that a heanng on this matter IS set for
the [I tv day of -1j)/J~ ' 20D.t.- in Courtroom No.
. 3 , at / ; 3 J f .M. at the Cumberland County Courthouse, 1
Courthouse Square, Carlisle, Pennsylvania, and that a Citation be issued to Blanche M.
Manning commanding her to show cause why she cannot appear at the aforementioned hearing
pursuant to the Petition of Holy Spirit Hospital to have Blanche M. Manning adjudicated an
incapacitated person and to have plenary guardians appointed for her person and her property.
Notice of the hearing shall be given to Blanche M. Manning in accordance with 20 P.S. S
5511 (a) not less than twenty (20) days prior to the hearing.
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IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY
NO. ORPHANS' COURT
ESTATE OF BLANCHE M. MANNING
PETITION PURSUANT TO SECTION 5511 OF THE PROBATE, ESTATES
AND FIDUCIARY CODE TO ADJUDICATE BLANCHE M. MANNING TO BE
INCAPACITATED AND TO APPOINT A GUARDIAN FOR HER PERSON AND HER ESTATE
.(.,. FINAL DECREE
AND NOW, this 4-- day of Q , 2002, upon consideration
of the Petition of Holy Spirit Hospital and following a hea . it is ORDERED AND DECREED
that Blanche M. Manning is adjudicated an incapacitated person and that Mildred Bell is
appointed as plenary guardian of her person and her property; and no bond shall be required of
the guardian named herein; and that said guardian is hereby authorized to make decisions on
her behalf concerning her medical care and treatment including the admission to nursing
homes, personal care facilities, hospitals and other health care providers as well as to consent
to and authorize her medical treatment; and the guardian is authorized to sell and convey all of
her real property, including that property located at 310 Fulton Street, Enola, East Pennsboro
Township, Cumberland County, Pennsylvania; and that the guardian herein appointed is further
authorized to make future payments of both income and principal for her care and maintenance
as may be necessary including the payment of legal fees, and court costs affiliated with
obtaining this guardianship and all matters related thereto.
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:153152
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IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY
NO. \ \ &0 ORPHANS' COURT 'Z 00 \
ESTATE OF BLANCHE M. MANNING
PETITION PURSUANT TO SECTION 5511 OF THE PROBATE, ESTATES
AND FIDUCIARY CODE TO ADJUDICATE BLANCHE M. MANNING TO BE
INCAPACITATED AND TO APPOINT A GUARDIAN FOR HER PERSON AND HER ESTATE
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The Petition of Holy Spirit Hospital respectfully represents that:
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TO THE HONORABLE, THE JUDGES OF SAID COURT:
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1. Your Petitioner, Holy Spirit Hospital of the Sisters of Christian Charity ("Holy
Spirit Hospital") is an acute care hospital located at 503 North 21st Street, Camp Hill,
Cumberland County, Pennsylvania 17011-2288.
2. Blanche M. Manning is a 93 year old incapacitated female, born on October 8,
1908. She resides alone at 310 Fulton Street, Enola, Cumberland County, Pennsylvania, a
single family residence owned by her. Blanche M. Manning is a widow and has one surviving
child, Glenn J. Manning, who resides at 300 Columbia Drive, Unit #1307, Cape Canaveral,
Florida 32920.
3. Blanche M. Manning was admitted to Holy Spirit Hospital on December 16, 2001
having suffered a seizure. She had recently been discharged to her home from a previous
admission at Holy Spirit Hospital on December 3, 2001. From December 3, 2001 to her most
recent admission on December 16, 2001, she received assistance at home with visiting nurses,
Office of Aging services as well as the support of family members.
4. According to her treating physician, L. Lynne Britton, MD., Blanche M. Manning
is confused, disoriented and exhibits some thinking which borders on delusional, and based
upon a consulting evaluation by a psychiatrist is deemed to be suffering from senile-type
dementia with on-set seizure disorder. Furthermore, the patient is not capable for caring for
herself or making decisions on her own behalf.
5. Blanche M. Manning resides alone and has had significant problems managing
at home without the assistance of her family, the Office of Aging and other in-home service
providers.
6. During her current admission to Holy Spirit Hospital, her treating physician has
determined that she lacks the capacity to make decisions for her own care and is in need of a
guardian.
7. Blanche M. Manning's physicians have recommended that she be placed in a
supervised setting with twenty-four hour care and cannot be left alone. The Office of Aging has
performed an options assessment for placement and also determined she needs placement in a
skilled nursing facility, and she was moved to a nursing home on December 21, 2001.
8. Blanche M. Manning is an incapacitated adult person who needs a court
appointed guardian for her person and her property.
9. It is believed that Blanche M. Manning has a monthly income of approximately
$1,175.00, real property where her home is located which is currently assessed at $71,000.00,
and a small amount of money in a personal bank account.
10. Blanche M. Manning has executed a Will bequeathing all of her estate, with the
exception of some small specific bequests, to her son, Glenn J. Manning who resides in Florida.
In that Will she appoints her nieces, Betty Fleischer and Mildred Bell as co-executors of her
estate.
11. Your Petitioner, Holy Spirit Hospital, is a creditor of Blanche M. Manning, and has
standing to bring this action.
12. Mildred Bell, the niece of Blanche M. Manning, has been assisting her for some
time in managing her affairs and arranging for her health care needs, and is willing to act as
guardian of her person and her property. Attached hereto as Exhibit "A" is an Acceptance by
the proposed guardian, Mildred Bell.
13. Glenn J. Manning has agreed to have Mildred Bell act as guardian of his
mother's property and her person. Attached hereto as Exhibit "B" is a Consent signed by Glenn
J. Manning to have Mildred Bell appointed as the guardian of Blanche M. Manning.
WHEREFORE, your Petitioner prays that a Citation be issued to Blanche M. Manning to
show cause why she should not be adjudged to be incapacitated and a plenary guardian for her
property and person be appointed, and that the Court schedule a hearing on this Petition.
Date:
Davi Luce
Attorney 1.0. #41687
301 Market Street
P.O. Box 109
Lemoyne, PA 17043-0109
Telephone (717) 761-4540
Attorneys for Holy Spirit Hospital
:153152
VERIFICA TION
I, Susan S. Zeigler, ACSW LSW, Director of Social Services of Holy Spirit Hospital of the
Sisters of Christian Charity, verify that the statements made in the foregoing Petition are true and
correct to the best of my knowledge, information and belief. I understand that false statements
herein are made subject to the penalties of 18 Pa.C.S. 94904 relating to unsworn falsification to
authorities.
Dated: I//~ 7/#1
/
IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY
NO. ORPHANS' COURT
ESTATE OF BLANCHE M. MANNING
PETITION PURSUANT TO SECTION 5511 OF THE PROBATE, ESTATES
AND FIDUCIARY CODE TO ADJUDICATE BLANCHE M. MANNING TO BE
INCAPACITATED AND TO APPOINT A GUARDIAN FOR HER PERSON AND HER ESTATE
ACCEPTANCE BY PROPOSED GUARDIAN
Mildred Bell, hereby agrees to accept the appointment of plenary guardian of the person
and estate of Blanche M. Manning, if she is adjudged to be an incapacitated person by the
Cumberland County Orphans' Court.
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~ Mildred ell
Dated: /~~?/t7/
IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY
NO. ORPHANS'COURT
ESTATE OF BLANCHE M. MANNING
PETITION PURSUANT TO SECTION 5511 OF THE PROBATE, ESTATES
AND FIDUCIARY CODE TO ADJUDICATE BLANCHE M. MANNING TO BE
INCAPACITATED AND TO APPOINT A GUARDIAN FOR HER PERSON AND HER ESTATE
CONSENT TO PROPOSED GUARDIAN
Glenn J. Manning, hereby consents to the appointment of Mildred Bell as the plenary
guardian of the person and property of Blanche M. Manning, if she is adjudged to be an
incapacitated person by the Cumberland County Orphans' Court.
~&~n .
Glenn J. anning ~
Dated:
11--1--7-0 (
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IN RE: ESTATE OF BLANCHE MANNING
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
NO. 21-2001-1180
IMPORTANT NOTICE
CITATION WITH NOTICE
A petition has been filed with the Court to have you declared an Incapacitated Person. Ifthe
Court finds you to be an Incapacitated Person, your rights will be affected, including our right to manage
money and property and to make decisions. A copy of the petition which has been filed by HOLY
SPIRIT HOSPITAL OF THE SISTERS OF CHRISITIAN CHARITY ("HOLY SPIRIT") is attached.
You are hereby ordered to appear at a hearing to be held in Court Room No. ~, Cumberland
County Courthouse, Carlisle, Pennsylvania, on FEBRUARY 4 ,2002, at 1:30 P.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
l ,.
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.
Ut~
Byl }{p~ 'C ,~J)ALZ1
Clerk, 0 hans' Court Division
Cumberland County, Carlisle, P A
My Commission Expires 1 sl Monday,
January, 2006
LAW OFFICES
JERRY R. DUFFIE
RICHARD W STEWART
C. ROY WEIDNER, JR.
EDMUND G. MYERS
DAVID W DELUCE
RALPH H. WRIGHT, JR
DAVID 1. LANZA
MARK C. DUFFIE
KElRSTEN WALSH DAVIDSON
MICHAEL 1. CASSIDY
ROBERT M. WALKER
JOHNSON, DUFFIE, STEWART & WEIDNER
A Professional Corporation
301 MARKET STREET
P. O. BOX 109
LEMOYNE, PENNSYLVANIA 17043~0109
WEBSITE: www.jdsw.com
HORACE A. JOHNSON
OF COUNSEL
TELEPHONE 717-761-4540
FACSIMILE 717-761-3015
E.MAIL mail@jdsw.com
WRITER'S EXT. NO. 15
E.MAIL dwd@jdsw.com
January 16, 2002
The HonOiable George E. Hoffer
President Judge
Cumberland County Courthouse
1 Courthouse Square
Carlisle, PA 17013-3387
Re: Estate of Blanche M. Manning
Dear Judge Hoffer:
I represent the Petitioner, Holy Spirit Hospital, in the above captioned guardian matter
which is scheduled for a hearing before you on February 4, 2002. I have spoken with members
of the alleged incapacitated person's family and they have requested the court appoint an
attorney to represent Blanche M. Manning. Under the current Guardian Act, the Court may
appoint counsel to represent the alleged incapacitated person and I concur in this request.
Very truly yours,
DWD:kkm:153697
Enclosures
cc: Holy Spirit Hospital
Mildred Bell
~
IN RE:
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
NO. 21-2001-1180
ESTATE OF
BLANCHE M. MANNING
IN RE: APPOINTMENT OF COUNSEL
ORDER OF COURT
AND NOW, January 18, 2002, Robert O'Brien, Esquire is appointed
to represent the alleged incapacitated person at the hearing to be held on
February 4, 2002, in Courtroom No.3 at 1 :30 p.m.
By the Court,
.J.
Robert O'Brien, Esquire
Court-appointed
David W. DeLuce, Esquire
For Holy Spirit Hospital
).1:''1' luj~S f-hA iJL..L Lhl'UJU'..llUN hE..1-0R\
. NAME, (3 \0. u c.. '" e- 'lY'\c... \) \,:) \ ~
S.S'#:\~T- O-O-\\Q.-'. \
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L ~ U Cu \ '\ u........
\ ~ D 5.omer, guardian, etc.) .
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M.A. #:
City/Town: E...~o \ "-
State: \='~ Zip Code: \ ~ ~
This is t
Date:
e above-named individual was assessed through the OPTIONSPAA on:
The. purpose of this Assessment was to determine the most appropriate and least restrictive
level of care necessary to preserve the individual's' welfare and safety. As a result of the
Assessment, the most appropriate level of care was determined to be:
I~I Nursing Facility
Services
A.
1=1
Short-Term
(less than 6 months)
End Date
I~I
Long-Term
(more than 6 months)
B. 1=1 PDA Waiver
C. 1=1 Domiciliary Care
D. 1=1 Personal Care Boarding Home
E. 1=1 Community Services ( Specify)
OPTIONS ASSESSMENT UNIT
Diane Gourley
; PETITIONER'S
J EXHIBIT
. #/
I a ''Il};), 7
NAME:
ADDRESS:
Cumberland County Office of Aging
16 West Hiqh Street
Carlisle PA
. (City) (717) 240_6110(State)
~ ~(T.l.PI'O~. ~umb.r) \ f'\ _ \ 1"'. _ /"........ \"
SIGNATURE:~""~~t..~~ DATE: l~ ~ ~
This Asses.sment Report deals solely with the preliminary level of care determination made by
the OPTIONS Assessment Unit. Upon receipt of your completed Common Application Form
(PA GOOP) the Department of Public Welfare, through the County Assistance Office, will
determine'your financial eligibility for Medical Assistance. That Office will notify you of
their deci'Sion via a Notice .to Applicant Form (PA-l62). An appeal proc.ess will be available
for both .the final level of care determination and the financial eligibility decision.,
n~tails of the appeal process will be outlined in the PA-162 Notification.
(street)
17013
(ZIP)
If you ttl.liilqrec with ~j,th=r tn@ lCVDJ. gf Gin dltlrm1mlt.lon or t.he (I10181tm ID8QI niirdin9
your eligibility for M.A., you may file an appeal subsequent to receipt of notification from
the CAO (via PA-162 B'or-m). In all cases to acc'essthe formal appee.1s process for level of
car1! or financial eligibility, the County Assistance Office must be contacted and the Common
Application Form (PA. GOOP) must be completed and returned to the CAO.
Rev. 7/96
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IN THE COURT OF COMMON PLEAS OF CtJ~(jF~LAN/) COUNTY, PENNSYL VANIA
ORPHANS' COURT DIVISION
.
IN RE:~A'~~r ' an incapacitated person FILE NO. 1/ il)- JOO /
GUARDIAN OF PERSON ANNUAL REPORT
[20 Pa. C.S.A. 5521 (c)]
FROM-fi..L6- 'I ,200~ TO ~ It', 200_.,2..
1. I am the _ Limited V' Plenary Guardian of the Person of my ward, named above.
2. I was appointed Guardian by Order of the Court datedJl~~~t1d~, which was
~as not)nodified by Court Order(s) dated
3. Is the incapacitated person still living? F
If no, answer the following:
(a) Date of Death?
(b) Place of Death?
( c) Name of Administrator or Executor?
(d) Date Guardian of the Person filed the last Annual Report?
4. If the incapacitated person is still living, answer the following questions:
(a) Date Guardian of the Person filed the last Annual Report?
~ /~~ 00.;2. ~~'7n;Y~ ~CL4.C
(b) Current address of the incapacitated person
~~~~~;Jf;~~<L /?&~O
(c) Current age 93 Date of birth of incapacitated person It' /~e /~,R
(d) The incapc;citated person's residence is:
Ward's own residence
~ Nursing Home
_ Hospital or Medical Facility
_ My home/apartment
Relative's Home
= Boarding Home
( e) The incapacitated person has been living there since~. d /6 dl 00/
If moved within the past year, state from where and the reason for the change
~~~~~. ~l
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C.A. . 27
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(f) I rate his/her living arrangement as:
Excellent -X Average _ Below Average
Explain: ~ ~--A..,I~ ~A/hA//1?D4-~~7 ~" ~/Z
-cb.~"'- ..M.t::~ nA?~~~./N4.
(g) I believe he/s e is:
Xcontent with the living situation~ y~~ L"A:..t: ~ ~
--2Lunhappy with the living situation ~aU4.~ ~ ~
_unaware of the living situa~ ~~ tf1/t.~~ .
5. Physical health
(a) Current physical condition of the incapacitated person is:
Excellent Good ~ Fair Poor
(b) Hislher major physical health problems are as follows: C!.h' r.. aVu~ L
. . ~.~~ ~ (~\-~.
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(c) During the past year, hislher physical condition has:~~
. d b th ~~~~~~L2I1;L.
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d E I. ~ ~ 4~~<4J. ~.~,
_ worsene. xp am......bfLL- ')Ii ~~ ~
~Ue,~ -4,... ~~-t;-t . ~~~
(d) Dtiifngtf{e past year~~e following medical treatment (include
check-ups and dental work):
Date
Ailment
Type of treatment
Doctor's name
~& -;:~mu:i~
.If.!/~ /A7 ~~...u..
-<./I';LLL~ -2L~~J~
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6. M:ental Health dl
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(a) The incapacitated person's condition is
excellent _ good
X poor
(b) Hislher major mental health problems are as follows: //J.n..Ad';-'~ /
~~'~.A,. - \"'~.A~'/J~ t?~c1)6"-';'r.r.f.h..d
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(c) During the past year, hislher mental condition has:
remained about the same.
_ Improved. Explain
~~~~;.~~~~~~
(d) Dunng lli~~{y~treatment or ~a~1rO~ ~st, psyc 0 ogist or social
worker _ was _ was not provided. Such mental health services are briefly
described as:
~-:-~~~->~~'~l~A'4A1. )Ii.,!, 'd,/Ab'~.
7. Social Activities / Services
(a) Hislher current social condition is:
excellent _ good
.2L fair
_poor
(b) During the past year, hislher social condition has:
-X- remained about the same. ~ ~ ~
~improved. Explain. ~~ ~~, ~~p./~~
_ worsened. Explain.~~ ' ~ ~
~,~~~
(c) During the past year he/she has participated in the following activities:
- recrea~onal ~LJ/-V//~~_/A~ '-J~h:L~1:' -/A4/ ~~
- educational ..A~./(+./~ ~--~./IrtI.7;,..A> (~NLJ,N"..j "~Lhl--"'~._
_social ~, ~,~~)
_ occupational (7
no activities available.
V" he~efuses to participate in any activities~ r..$ t;;... .
_ he~ is unable to participate in any activities. ~ ~ ~t!
~.-Uu..~~~~
8. Visitation ~c:f2 9' ~~~~ ~ ~
(al.During the east year. I visited himlher as fOIlOW~~~
~AN~'~~..r./~d,:~* ~ ~J
~... ~~)fn;9'r~ ~~ . . .
J . ~ - '~b) The average amount of time I spent on each visit was 4 - __::f ~.
~~~~~g~ r:::JJ~.s-~GtJ~~
. ~ .n'~' -L - / ~.z.. -rl/C.4.,.I(7 ~ /
---y----- - (c) The last time I visited was on ..:5": // /CJc:L.
date
9. During the last year I have performed the following activities on behalf the incapacitated
person: }cJ~ >t.ev ~~ ~~~.>t.uuk.J?~~~~. ~ ~
~~.~Z;~~~~~.j~A~:::~;=r
-Z;tU.~?- ""'~eM-U~R~ ~~ ~ ~ ~
~~. ~~~~1:0-~~~~
~~~~.
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10. I believe he/she has the following unmet needs:
11. The guardianship K should _ should not be continued without modification
because' - .
>.~ ~~~~JUA-' '/ . ~
12. Please note any concerns about the Incapacitated personts physical or mental well being or
the finances that the Court should know. ~ e:>',,/l~ .h~ ':!ft:~
,n~.h-:"''''''~, ~'4v~..4>Ud"""~'~.>?~"3?;:-;:i"
~~~;~~~~.
13. I V am _ am not 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 true
and correct to the best of my knowledge, information and belief.
Date: ~~ /~ n1~~..2.
~~/~ 1ri;/~>
Signature of the Guardian of the Person
Name:~//
A~~e:,s: a '.' f7f;;;
. Telephone # (Home) f.J'I"'33r2g
(Work)
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IN THE COURT OF COMMON PLEAS OF Clll't8EItLIUJDCOUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
IN RE~~~;' an incapacitated person
FILENO. //itJ - c;lOO I
GUARDIAN OF THE ESTATE ANNUAL REPORT
[20 Pa.C.S.A. 5521 (c)]
FROMJ~ <I ,200~TO~~ /'I ,2oo....l.
1) I am the Limited Y Plenary Guardian of the Estate of my ward, named above.
I was appointed Guardian by Order of the Court dat~~ ~ J()tJ:L which
_was X was not moditied by Court Order(s) dated
2) Is the incapacitated person still living? Yes
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 Report
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
$ '7IJJ~/tf.3u, . ~..~~~...e~
The Inventory listed a total monthly income of $ Id IJtJ. tJ I comprised of the
fol!2wing:
~ 833-0/ ,A'~./~k~.e:6 ~
.. ~(p 7. 00 ~/~J <JR.-<'./--//u?-
4) At the beginning date of this reporting period, my initial balance on hand was
$ .1/ ~/ ,sj> 3 (). 05'"
~ ~~~~~ .~~-<UL~AV
~~ ~ ..<Y--'~"I.Y7CL- 7~ ~ .~4Z-LJ-
~~/V ~-k.e.., ~ of ~~ ,. ~.~.-4:..J
C.A..28~~~' ~~d/~~
~ }O~, ~ ~-Lh:,~ ~p-V
JJ<-'/~-IO()O. ~ ~ 4~~~ $i8fj().()~
"
5) During this reporting period, the following reflects all sources of income (other than
social security) received by me for my ward: (Add additional pages if needed)
Date Received
Source of Income
Amount
1. ~4.4L. ..0'1.. ..A~~lh
2.
3.
4.
5.
6.
TOTAL
6) During this reporting period, the following reflects all payments I have made for my
ward: (Add additional pages if needed)
Date
To Whom Paid
Reason for Payment Amount
1. ~ ...d;1-'./ ..Ao//A,.,.~ ~L(.e.~
2.
3.
4.
5.
6.
TOTAL
7) The present principal assets of my ward are:
Description of Asset
Present Value
1, ~~/?~'~
~ ~
2.
.7..1. ~I R. .3~
,
SOURCES OF INCOME
2/08/02 Sale of cottage in Delta
3/03/02 Railroad Retirement
3/21/02 Sale of 1976 Ford truck for junk
3/29/02 Refund of fire insurance for cottage in Delta
4/01/02 Railroad Retirement
4/19/02 Proceeds of sale of personal belongings in home in Enola
4/22/02 3 small plates sold privately
4/22/02 Refund from TV Cable Co. when disconnected
4/22/02 Deposit for sale of primary home in Enola
5/01/02 Railroad Retirement
5/07/02 Check for balance of sale of primary home in Enola
~~@)~ ~~'ItnJ~
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PAYMENTS MADE FOR WARD
THE MONTH OF FEBRUARY
2/08/02 Paid on outstanding account at Sears
2/08/02 West Shore Oil Heating Budget
2/08/02 ATT&T Lease of Hearing Phone
2/08/02 Patriot News Delivery February
2/08/02 Senior Blue--Health Insurance
2/08/02 Robert 1. Miller Sewer Certification for sale of cottage
2/08/02 O'brien,Baric & Scherer Court appointed attorney for hearing
2/11/02 Personal expenses for Blanche for the month of February
2/11/02 Verizon--Telephone bill for Enola
2/11/02 Sprint-- Telephone at Stonebridge and partial hook-up fee
2/11/02 Union Fidelity--Surgical Insurance
2/13/02 Peco Energy--Electric bill for cottage at Delta
2/14/02 Commerce Bank--Paid on loan for new roof
2/19/02 Stonebridge Health and Rehab Services for Jan. and Feb
2/26/02 Penna American Water--Water bill at Enola
2/28/02 Peco Energy Balance on Electric at Delta
$45,000.00
833.01
75.00
20.00
833.01
8,081.50
24.00
4.95
5.000.00
833.01
49,048.08
'7~. S-~
25.00
150.00
17.66
10.80
54.00
323.79
150.00
200.00
24.91
38.62
28.19
10.98
109.74
6,782.85
22.40
1.04
PAYMENTS MADE FOR WARD
MONTHS OF MARCH, APRIL AND MAY
3/01/02 Commerce Bank--Pay ofIpersonalloan for roof
3/01/02 East Pennsboro Twp--clear lien in Cumberland Cty for
Outstanding sewer and garbage bills
3/05/02 West Shore Oil--Service call 2/20/02
and oil delivery 2/22/02
3/05/02 Comcast--Final cable bill --service ended 3/08/02
3/05/02 PP&L--Electric bill at Enola
3/05/02 Alicia Stine Treasurer--Personal taxes in Enola
3/05/02 Alicia Stine Treasurer--Real Estate Taxes E.Pennsboro
3/06/02 Leon D. Gerlach--Appraisal of31O.00 Fulton St.,Enola
3/13/02 Penn National Ins--Fire Insurance at Enola
3/13/02 Senior Blue--Health Insurance increased for Perry Co
3/13/02 Omnicare Pharmacies--Prescription expenses at Stonebridge
3/13/02 Sprint--Phone at Stonebridge and final hook-up fee
3/14/02 Stonebridge Health and Rehab --March services
3/23/02 West Shore Oil CoOil Burner Repair of 3/09/02
3/23/02 Verizon--Phone bill at Enola
3/23/02 Penna. American Water--Water bill at Enola
4/02/02 Omnicare Pharmacies Prescriptions at Stonebridge for March
4/03/02 East Pennsboro Twp--Sewer and Garbage at Enola
4/03/02 Cash--Blanche personal expenses for April
4/04/02 Patriot News--March delivery of newspaper
4/04/02 PP&L--Electric bill at Enola
4/09/02 Sprint--Phone bill at Stonebridge
4/09/02 Senior Blue--Health Insurance Part payment for May
4/10/02 Postmaster--Book of stamps
4/10/02 Nancy Boyer--Flowers for friends funeral
4/10/02 The Patriot News--Delivery for April
4/15/02 Lourena Steele--Satisfy Lien against house(Lourena paid Blanches
old outstanding tax bill --Recorded in Cumberland County)
4/15/02 Sears--Settlement of Sears account
4/17/02 SecurChoice--Irrevocable Trust to prepay funeral expenses
4/17/02 Lesh Auction--Difference between checks and net proceeds
4/19/02 Stonebridge Health and Rehab-- April care days and x-ray
4/22/02 Penna Amer. Water--Water bill at Enola
4/25/02 Kevin Manning--Wedding gift for grandson
4/29/02 PP&L-- Electric bill at Enola
4/29/02 Orphan's Court--4 certified copies of guardianship
5/06/02 West Shore Oil Co--Oil on budget account
631.23
1,623.09
392.72
9.29
65.75
4.90
212.31
275.00
51. 00
100.00
96.89
40.72
4,187.49
71.14
27.38
23.97
42.98
80.10
125.00
13.50
51.65
26.81
8.00
6.80
25.00
10.80
2,500.00
703.24
5,425.00
451.00
4.163.13
19.49
25.00
39.73
10.00
163.62
PAYMENTS MADE FOR WARD
IN MAY (CONT'D)
5/07/02 John Stansfield--Check over mowers before public sale 25.00
5/10/02 PP&L Electric Utilities--Last bill for Enola 4.11
5/10/02 Senior Blue--Balance of May and all of June premiums 146.00
5/12/02 AT&T--Hearing phone lease payment 17.66
5/13/02 Verizon--April phone service at Enola 24.75
5/14/02 Orphan's Court --To file initial estate account 10.00
5/14/02 Orphan's Court---To file Guardian of Person Initial Report --------10.00
3.
4.
5.
6.
TOTAL
8) The present amount and sources of income for my ward are:
Source of Income
Amount of Income
(Indicate whether monthly,
quarterly, annually)
06 ?CJlJ /~
,
J>.33.~1 /~
/ .
1.~",~.~~
2. )z""~ /A!.A-40....,. ~/A'Y.vA4Z
3.
4.
5.
6.
9) The regular monthly expenses of my ward which I pay are:
To Whom Paid
Amount
1. ~~'/~/-ye. ~....v?T..k ~ ~A'~
2. ~~__~ ~'ji-d.>
#~d~
~~i.~~.
/t1~.~.~_
~ 6-. O~ ~ '7n<J->
/7.,,6, ~~
/tJ.90 ~~ ~
15'. 00 '-'Z. a...
3. ~ &-'L Md~r~.~
4.~
5. A T9' T j:,4"U'Y~ ~.b~~
6. )o~~
'1. ~~ 05~)
g. ~~~d?G
(~~~~)
~ t). 00
10) I havelhave not (circle one) petitioned the Court for permission to invade principal to L
meet the needs of my ward. ~~~ /.;l.OO.(JO/7"O
~s.S. ~9' '6L~J~ _U<-G~
~ ~pl~~ing expe~s of my ward have been paid from principal:
To Whom Paid
Purpose
Amount
1.
2.
3.
4.
5.
6.
11) I hav~circ1e one) paid myself compensation for services I rendered as
guardian.
The amount I Paid myself totaled $
calculated at the following rate: $
and was
per week/month (circle one).
12) Check the correct response and complete, if appropriate.
There will be no need for extraordinary expenditures on behalf of my ward in
the next (12) months.
There well be a need for extraordinary expenditures on behalf of my ward in
the next (12) months because:
~~~=<L~"/e6
=~ .. m: __=~...r ;::"~N) 0 .::.:;-;.~=
~~. U~~~ u~~d..I~~e~.
4.3) Check the correct response and complete, if appropriate.
~. My ward receives monthly social security benefits directly~ ~
~~fi)~~
_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 (circle one) related to my ward as
(insert relationship).
14) Please note any concerns about the incapacitated person's physical or mental well
being or the finances that the Court should knoW..G"'-:~e. ~~....~'~
~ ~~.J;;;'-""~~.A..d'dJ~~'::;;:: ~ / ~~~ ~~
~ ~~ '--"~~;---Z:b-~~~Z~1:;::;:~aZ ~-
~ ~;J.110~~~~~ ~~l<..~4- ~
15) I ~ am am not guardian of the incapacitated person's person. If yes, ~ ~.
report is attached.
I certify under the penalties of perjury that the information contained in this report is
true and correct to the best of my knowledge, information and belief.
Name:~~~~~//..-L/
A~~~::::.t~ ~~<;z
Telephone No. (Home) i~'I-33J..8
(Work)
G
IN THE COURT OF COMMON PLEAS oICu.A.",f...AcOUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
IN RE: ~ ~ an incapacitated person FILE NO./lltJ-J,btJ I
GUARDIAN OF PERSON ANNUAL REPORT
[20 Pa. C.S.A. 5521 (c)]
FROM~~ IS', 200~ TOJ~ ~lL, 200~
1. I am the _ Limited --X- Plenary Guardian of the Person of my ward, named above.
2. I was appointed Guardian by Order of the Court date~~"(, .J,,~which was
~odified by Court Order(s) dated
3. Is the incapacitated person still living? r~~.J
If no, answer the following:
(a) Date of Death?
(b) Place of Death?
(c) Name of Administrator or Executor?
(d) Date Guardian of the Person filed the last AnnualReport?
4. If the incapacitated person is still living, answer the following questions:
Vh-~G. ~ & ImO
(a) Date Guardian of the Person filed the last Annual Report? ~~
~.~(,i J4/ I J.tJD:L.
(b) Current address of the incapacitated Rerson - , ~
~~J!/~1:~:~~Wa.. /?d-ttJ
(c) Current age 91 Date of birth of incapacitated person /" 109 JlJi
(d) The incapacitated person's residence is:
Ward's own residence
v/ Nursing Home
_ Hospital or Medical Facility
_ My home/apartment
Relative's Home
_ Boarding Home
(e) The incapacitated person has been living there since~4~.. Of I, dl tJO I
If moved within the past year, state from where and the reason for the change
C.A. .27
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(f) I rate his/her living arrangement as:
_ Excellent ----X- Average _ Below Average
Explain: ~~Att~;'. 4.I<JAVA.lL~J~7f1~ ~~
,-<!!-.v#~~AI- ~~ r........ "H;# ~ ~ b;,AI#7j.A;b ""'A--~..NAU
(g) I believe he/she is: ~ ~~ ..zk.~ ~
L content with the living situation ~ ~~ A "'.;'~ ~ ~ ~~
unhappy with the living situation ~,i%,e....,e....u.. .z:~.
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5. Physical health .- fl-'l/f!.l; #~~.;.4.uL. ~~~
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(a) Current physical condition of the incapacitated person is:
_ Excellent ~ Good Fair Poor
(b) His/her major physical health problems are as follows:
.
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C.A.O. ~
(c) During the past year, his/her physical condition has:
remained about the same.
::Z~!r~~~~~: ~~~i~~Z~:~~~.~
(d) During the past year, he/she received the following medical treatment (include
check-ups and dental work):
Date
Ailment
Type of treatment
Doctor's name
~
J.
~-
.v.c y/~ 3
6. Mental Health
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(a) The incapacitated person's condition is
excellent ~~) _ poor
(b) His/her major mental health problems are as follows: (J-/~~ .-.l.l
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(c) During the past year, hislher mental condition has:
remained about the same.
v~~~:::~.i:~f=~~:;~~'~:z:,~.
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(d) During t1re past year, treatment or evaluation by a psychiatrist, psychologist or social
worker ~ was _ was not provided. Such mental health services are briefly
described as:
-. ~~~ :;:~~~~::z;:,:~~ ~~6~~~~
7. Social Activities / Services
(a) His/her current social condition is:
excellent ~ good
fair
_ poor
(b) During the past :year, his/her social condition has: . ~e.
_;emamedabout ~ ~~4l)Al '1,
->L- Improved. Explam. ~
worsened. Explain ... ·
-~~" ~~ ~4U.v,u~
(c) During the past year he/she has partici);fated in the following activities:
V recrea~onaLct..A~-'.,,4~A", ~-AI/~'-'~,
educatIOnal
V ~~~~~ati~;iZ1? ~I~~~~~~ ~::r~'
_ no activities available. ~ II C, ~ ~ ~ aa.e~~
_ he/she refuses to participate in any activiff'es. .
_ he/she is unable to participate in any activities.
8. Visitation
Ca1 During the past year. I visited himlher as follows: ~~ ~
,~,~~~"A~~ ~~~ J;,~~.4~L ~
(b) The average amount of time I spent on each visit was ~41- )f~'~J
(c) The last time I visited was on cA IA'! /o.;g
date
9. During the last year I have performed the following activities on behalf the inca acitated
person: ~.. .
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10. I believe he/she has the following unmet needs:
11. The guardianship ~hould _ should not be continue~ without modification'
because:
12. Please note any concerns about the Incapacitated person's physical or mental well being or
the finances that the Court should know.
13. I ~ am _ am not guardian of the incapacitated person's estate. If yes, my report is
attached.
I certify under the penalties of perjury that the information contained in this report is true
and correct to the best of my knowledge, information and belief.
Date:
~~..t'd<<~~..~~aj
Signature of the Guardian of the Person
Name: Nil"'" ed Be.11
b~~~::~~ :P4~/!f'?~
. Telephone # (Home) 71?.. 334/...5 3~~
(Work) 1!f!t,j..,J .
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IN THE COURT OF COMMON PLEAS oru"..6,..faJeOUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
IN RE~.I-~~~"'7 an incapacitated person
FILE NO.I/A~.tl.4.Q'
GUARDIAN OF THE ESTATE ANNUAL REPORT
[20 Pa.C.S.A. 5521 (c)]
FROM~ 1.5' ,200": To.....?l~...t'l ,200.,3
1) I am the _Limited ~Plenary Guardian of the Estate of my ward, named above.
I was appointe4 Guardian by Order of the Court dated.- ~~~ ~ J.4/).J ~ which
_was ~ was not modified by Court Order(s) dated .
2) Is the incapacitated person still living? ~ ~ ~
If no, answer the following: T
(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 Report j ~.,.t~ "'r~
PLEASE ANSWER THE FOLLOWING QUESTIONS WHE R TIlE
INCAPACITATED PERSON IS LIVING OR DECEASED.
3) My initiallnventory was filed on~ L~0Ut2.3. and listed a total estate value of
$ 71J '1/1. ~&J .
The Inventory listed a total monthly income of $
following: A.,. 7hA"" tt,;, to
9 g 3.0 I "R.~. "'R~t'H,"t,}t
~IIJ?/JD ss..
.I.JtJ". ~ comprised ofj;j
d~tS "i '~_~.3
8' ]8. ~ .J.. ~"C'".,.~
-.9 '7 ~ oil () oS. $.
4) At the beginning date of this reporting period, my initial balance on hand was
$ 78~ J./ 18. .!Jk .
C.A. . 28
"
5) During this reporting period, the following reflects all sources of income (other than
social security) received by me for my ward: (Add additional pages if needed)
Date Received
Source of Income
Amount
1. _ Se~ Att..ehea ~he ~'t
2.
3.
4.
5.
6.
TOTAL
6) During this reporting period, the following reflects all payments I have made for my
ward: (Add additional pages if needed)
Date
To Whom Paid
Reason for Pavment Amount
1. See 4~raeJ,ed sheets
2.
3.
4.
5.
6.
TOTAL
7) The present principal assets of my ward are:
Description of Asset
Present Value
1. :r1il:.t!.I\t!st be"",nr ~).eeK,nt ete,a,lInt
2.
-!I..!, "/ ~ ~ S .:l
3.
4.
5.
6.
TOTAL
8) The present amount and sources of income for my ward are:
Source of Income
Amount of Income
(Indicate whether monthly,
quarterly, annually)
1. Xa,J Jol!Jdt1 7lt-}-.r,..e. me nT
2. SDc.<<1 SeMlt,,1"y
~ sa. J../, /'nlJntA I r
~ ,~. 00 I'1JdlJthr
-411~ -ti.eIJ'-8 .s~e~
3. ~J;A~__r
4.
5.
6.
9) The regular monthly expenses of my ward which I pay are:
To Whom Paid
1. Sit!Jn~ hl-IL~'~ He4/th -I- ';fceAQb.
2. OWJ"'CQ"~ '-Ph4ltomo..au!-S.
3. ...5enUJ" l3/ue )It'd-It}, :rMIII'4nCe
4. Sf,..,,,T - fel'l,,,na( teJe,f)nDhe.
5. AftJI"t .. hea""n1---f),onf(.
6. ~ h eo -PDt,., tJ"t MeUM.
7. HAl,.. oppfJlntrnent 'X.:2..
I. /Ie t, VI ty FUNd. @ ~neh"'IrJ1 e.
Amount
ONN,. #.lOO. fMh)tO
Qff>>VJ.~ /t2IJ./)() f-'" MD..
91..41) PA)no
.t!I
~~ ",,:s.tJtJ flU )10
/?t,1. ~->>e"y.. .s 4no .
jA.ltJ ~ hUJ
/.5.bO JJ.4CJ,
~"."O fHJ" 11J().
I
j
10) I havefhave not (circle one) petitioned the Court for pennission to invade principal to
meet the needs of my ward.
(If applicable) The following expenses of my ward have been paid from principal:
To Whom Paid
Purpose
Amount
1. ~'-"'I- ~14I~~-4N~~.- ~~I~'
~o ~~~~~&fWH~
J~;:'Y.~I. ~Z;~;:~~ - +-~:~~
4.
5.
6.
11) I have€:ve n~circ1e one) paid myself compensation for services I rendered as
guardian. .
The amount I Paid myself totaled $
calculated at the following rate: $
and was
per week/month (circle one).
12) Check the correct response and complete, if appropriate.
There will be no need for extraordinary expenditures on behalf of my ward in
the next (12) months.
pt:J"s, hI",
There well be a need ror extraordinary expenditures on behalf of my ward in
the next (12) months because:
~~~ -4rf'#U~ t:'tI~ .4h
13) CheCK the e&rrect response and complete, if appropriate.
. ~. My ward receives monthly social security benefits directly.
_B. I am the designated payee to receive my ward's social security benefits. 7i,.c~~
, -L:G...e.v.dtf4N~ ~ ~-H~ ~ ~ a4lt!.~
_c. The designated payee of my ward's social security benefits is
whose address is
and is/is not (circle one) related to my ward as
(insert relationship).
14) Please note any concerns about the incapacitated person's physical or mental well
being or the finances that the Court should know. _.............
15) 11 am am not guardian of the incapacitated person's person. If yes,
report is attached.
I certify under the penalties of perjury that the information contained in this report is
true and correct to the best of my knowledge, information and belief.
Name~=~~ _ Telephone No. QIo~ ?/?-tf.!l'i-.33 01.9-
~;S:A · ~;~ (Work)
,
5/03/02
5/20/02
6/01/02
6/03/02
6/18/02
6/19/02
7/01/02
7/01/02
7/16/02
7/17/02
8/01/02
8/01/02
8/22/02
9/03/02
9/03/02
9/18/02
10/03/02
10/03/02
10/16/02
10/25/02
11/01/02
11/01/02
11/25/02
12/0202
12/02/02
12/25/02
1/04/03
1/04/03
1/25/03
2/03/03
2/03/03
INCOME MAY 15 TO FEBRUARY 4
Social Security
Interest @ Commerce Bank
RR Retirement
Social. Security
Verizon Refund
House-Fire Ins Refund
Interest Commerce Bank
RR Retirement
Social Security
Enola Tax Rebate
Interest Commerce Bank
RR Retirement
Social Security
Interest Commerce Bank
RR Retirement
Social Security
Interest Commerce Bank
RR Retirement
Social Security
Interest Commerce Bank
Interest First Nat'l Bank of Newport
RR Retirement
Social Security
Interest First Nat'l Bankk of Newport
RR Retirement
Social Security
Interest First Nat'l Bank of Newport
RR Retirement
Social Security
Interest First Nat'l Bank of Newport
RR Retirement
Social Security
367.00
48.54
833.01
367.00
14.63
22.00
60.23
833.01
367.00
378.01
58.24
833.01
367.00
67.03
833.01
367.00
39.49
833.01
367.00
19.46
73.1 0
833.01
367.00
76.91
833.01
367.00
60.01
838.26
372.00
59.40
838.26
372.00
~
PAYMENTS MADE FOR WARD MA Y 15, 2002 TO FEB 22, 2003
5/15/02 Penna American Water Co 10.70
Billing period 4/15/02 to rnl08/02
5/16/02 West Shore Oil 101.34
Plumbing repair bill for sale of house in Enola
5/17/02 Sears 93.28
Small refrigerator for room at Stonebridge
5/23/02 K-Mart 12.10
Padded underwear and Kleenex
5/25/02 Mutzabaugh's Grocery 2.54
Marshmallows and other candy
5/28/02 The Patriot News 10.80
Daily delivery at Stonebridge
5/29/02 Postmaster 6.80
Book of Stamps
5/30/02 Rite-Aid 7.49
Hearing aid batteries
5/30/02 Mutzabaugh's Grocery 4.41
Zip lock bags and V-8 juice
6/01102 Omnicare Pharmacy 42.98
Meds at Stonebridge
6/01102 The Patriot News 1~50
Daily delivery at Stonebridge
6/03/02 Mutzabaugh's Grocery 12.59
Dog treats, vegetables, sub, grapes
6/05/02 Activity accouont at Stonebridge 20.00
6/12/02 Sprint 32.86
Phone at Stonebridge
6/12/02 Senior Blue 100.00
Health Insurance
6/12/02 Stonebridge 4,062.55
30 care days
6/18/02 Stonebridge 20.00
Personal spending account
6/18/02 K-Mart 3.49
Storage unit for receipts
6/25/02 Quantum Imaging 36.00
X-ray
6/25/02 K -Mart 16.52
TV Remote
PAGE TWO
7/01/02 Mutzabaugh's Grocery 5.36
Jelly and liquid soap
7/01/02 Omnicare Pharmacy 94.33
Meds at Stonebridge .
7/02/02 Commerce Bank 25.5U
Rent Safe Deposit Box
7/16/02 Sprint 31.69
Phone at Stonebrideg
7/16/02 Senior Blue 100.00
Health Insurance
7/19/02 Stonebridge 4.196.87
31 care days
7/22/02 Karns 5.78
Crab cake and half and half
7/24/02 The Patriot News 10.80
Daily Delivery
7/30/02 Audiologic Consultants 29.99
Replace broken hearing aid case
7/30/02 Rite Aid 5.49
Hearing aid batteries
8/03/02 Mutzabaugh's Grocery 10.12
Cat and dog treats,dust pan and brush
8/09/02 AT&T 17.66
3 month lease for hearing phone
8/09/02 Sprint 31.33
Phone at Stonebridge
8/09/02 Omnicare Pharmacy 224.08
Meds at Stonebridge
8/09/02 Mutzabaugh's Grocery 18.52
Fruit,zip-Iok bags,soap,cream
8/09/02 Stonebridge 4,173.31
31 care days
8/09/02 Stonebridge Activity Account 20.00
8/09/02 Stone bridge 10.30
Trip to Senator's baseball game and van
8/09/02 The Patriot News 13.50
Daily delivery
8/09/02 Senior Blue 100.00
Health Insurance
8/18/02 Mutzabaugh's Grocery 13.43
',.
PAGE 3
9/03/02 Omnicare Pharmacy 239.55
Meds at Stonebridge
9/03/02 Stonebridge 20.00
Activity Fund
9/05/02 Rite Aid 7.49
Body spray,3-way bulb,envelopes
9/09/02 Stonebridge 4,050.00
30 care days
9/09/02 Sprint 32.25
Phone at Stonebridge
9/09/02 Senior Blue 100.00
Health Insurance
9/09/02 Postmaster 7.40
Book of stamps
9/09/02 Cash 10.00
Gift for person taking care of the cat she had in Enola
9/09/02 Mutzabaugh's Grocery 6.77
Cat treats and sub
9/13/02 K-Mart 6.65
Air fresheners,zip lok bags
9/22/02 Mutzabaugh's Grocery 15.48
onions,tomatoes,grapes,lebanon balogna.cream cat treats
9/25/02 The Patriot News 10.80
Daily delivery
10/05/02 Rite-Aid 6.88
Halloween decorations for room and door
10/1 0/02 K -Mart 34.46
2 nightgowns, 12 pair of socks
10/12/02 Sprint 36.45
Phone at Stonebridge
10/12/02 Senior Blue 100.00
Health Insurance
10/12/02 Omnicare Pharmacy 69.24
Meds at Stone bridge
10/14/02 Stonebridge Activity Fund 20.00
10/14/02 Stonebridge 4,185.00
31 care days
10/15/02 Mutzabaugh's Grocery 23.84
Pet treats, vegetaables,salt,soda,chicken,bags,grapes
10/15/02 The Patriot News 10.80
Daily Delivery
10/28/02 Mutzabaugh'sGrocery 8.29
Pet treats, bags
10/29/02 Karns 10.11
Double smoked ham
..
PAGE 4
11 /0 1/02 Mutzabaugh's Grocery 6.12
Fruit,cottage cheese,bags,cat treats
11/06/02 Omnicare Pharmacy 72.12
Meds at Stonebridge
11/07/02 Commerce Bank 85.00
Open Safe Deposit Box
11/07/02 Stonebridge 4.050.00
30 care days
11/07/02 Senior Blue 100.00
Health Insurance
11/07/02 Mutzabaugh's Grocery 13.00
Chicken,grapes,bagsj uice,sub
11/10/02 AT&T 17.66
3 month lease hearing phone
11/11/02 Sprint 34.59
Phone at Stonebridge
11/13/02 Rite Aid 4.79
Cat treats and tape
11/20/02 Johnson,Duffie,Stewart & Weidner 25.00
Telephone conference concerning taxes
11/21/02 The Patriot News 13.50
Daily delivery
11/29/02 Mutzabaugh's Grocery 27.89
Vegetables,bags,balogna,salad,cat and dog treats
12/07/02 Sprint 35.81
Phone at Stonebridge
12/07/02 Senior Blue 96.00
Health Insurance
12/07/02 Omnicare Pharmacy 152.74
Meds at Stonebridge
12/08/02 Rite Aid 14.20
Christmas tree for room
12/09/02 Rite Aid 10.54
Resinol ointment
12/09/02 Mutzabaugh's Grocery 12.11
Fruit, vegetables,salad
12/09/02 Stonebridge 4,942.00
31 care days
12/14/02 Cash 25.00
Christmas gift for son
12/14/02 Co-pay for doctor visit 10.00
12/14/02 Mutzabaugh's Grocery 13.25
Soda,Qtips,snacksjelly,half and half,cat treats
12120/02 Mutzabaugh's Grocery 8.59
Grapes,onions,cat treats
,.
PAGE 5
12/21/02 Mutzabaugh's Grocery 4.21
Hair spray,kleenes,fruit
12/27/02 Mutzabaugh's Grocery 12.99
Assorted groceries
12/28/02 Rite Aid 7.49
Hearing aid batteries
12/28/02 The Patriot News 10.80
Daily delivery
12/29/02 Rite Aid 6.35
TV remote batteries
12/30/02 K-Mart 9.52
New TV remote
1/05/03 Mutzabaugh's Grocery 4.95
Cat treats,kleenes,tomato juice
1/06/03 The Patriot News 10.80
Daily delivery
1/09/03 Sprint 85.04
Regular monthly fee plus move to a new room
1/09/03 Omnicare Pharmacy 94.56
Meds at Stonebridge
1/09/03 Mutzabaugh's Grocery 10.05
Potatoes,onions,hamJelly
1/10/03 Dollar Tree 7.42
Valentine decorations for room
1/22/03 Stonebridge 4,981.47
31 care days
1/28/03 Rite Aid 3.92
Tape
1/30/03 Mutzabaugh's Grocery 7.40
Assorted groceries
2/03/03 Omnicare Pharmacy 71.66
Meds at Stonebridge
2/06/03 Mutzabaugh's Grocery 14.02
Salad,kleenex,grapes,ham,chicken
2/06/03 Sprint 34.41
Phone at Stonebrildge
2/06/03 Senior Blue 96.00
Health Insurance
2/07/03 AT&T 17.66
Lease for hearing phone
2/07/03 Stonebridge 4,476.05
28 care days
2/09/03 Mutzabaugh's Grocery 10.77
Groceries,cat treats, napkins
2/14/03 Mutzabaugh.s Grocery 10.73
4 S :'> t' ..j Q d Gs. T'U ~ e. I--i e ~
.
PAGE 6
2/19/03 Mutzabaugh's Grocery 20.58
Groceries assorted
2/19/03 Rite Aid 7.49
Hearing aid batteries
2/20/03 Big Lots 6.09
St Patricks Day and Easter decorations for room
2/22/03 The Patriot News 10.80
Daily delivery
2/22/03 Postmaster 7.40
Book of stamps
IN THE COURT OF COMMON PLEA. S OF ~,~,t~,~,ia,t,t COUqNTY, PENNSYLVANIA
ORPH_&NS' COURT DIVISION
, an incapacitated person
FILE NOd/ooO. doo /
GUARDIAN OF PERSON ANNUAL REPORT
[20 Pa. C.S.A. 5521 (c)]
FROM~_t~ riff, 2002 TO t~d~_~, 200_-9"
1. I am the ~ Limited __~Plenary Guardian of the Person of my ward, named above.
2. I was appointed Guardian by Order of the Court dated ~_.~, wh/ch was
~odified by Court Order(s) dated
3. Is the/-ncapacitated person still living?
If no, answer the following:
(a) Date of Death?
(b) Place of Death?
(c) Name of Administrator or Executor?
(d) Date Guardian of the Person filed the last Annual. Report?
4. If the incapacitated person is still living, answer the following questions:
(a) Date Guardian of the Person filed tt3e last Annual Report? ~.~_./.,..
(b) Current address of the incapacitated person
(c) Current age ?ox~ Date ofbirth of incapacitated person
(d) The incapacitated person's residence is:
~ Ward's Own residence
. )<" NursLug Home
~ Hospital or Medical Facility
My home/apartment
Reiative's Home
Boarding Home
(e) The incapacitated person has been living there since ~ ,~/ ,4. Oo/
If moved w" ' ' '
mhin the oast year, state fi-om where and the reason for the change
C,A. - 27
(f) I rate his/her Living arrangement as:
~ Excellent X Average ~ Below Average
(g) I be '~eve he/she is: ~
..~.,4.content with the living situation ~,~,.,
.... unhappy with the living situation
. unaware o.f the living situation
5. Physical health ~ ~ ~ ~ ~ ~.~_t~,~2r~ _,,,~
(a) Current physical condition of the incapacitated person is'
~ Excellent .~ Good Fair _ Poor ,
(b) His/her mhjor physical health problems are as ~ollows:
(c) Dm-ing the past year, h/s/her physical condition has:
remained about the same '~'~--~--~.,-~ .~~
.hq improved. Explain. - ......... ' '"'~'~
~ worsened. Ex¢lam~
(d) During the past year, he/she received the foilowiug medical t~-earrnent (include
check-ups a.nd dental work):
Date ,~ilment Type of treatment Doctor's name
6. Mental Health
(a) The incapacitated person's condition is ,
excellent ~ good . poor
(b) His/her major mental health problems are as follows: A~'~~~/j
(c) Dur/ng the past year, his/h~r mental condition has:
remained about the same.
~ Improved. Explain
~ Worsened. Explain ~
(d) During the past year, treat/~ent or evaluation by a psychiatrist, psychologist or social
worker _,3<" was was not provided. Such mental health services are briefly
described as: ~
7. Social Activities / Services
(a) His/her current social condition is:
~ excellent ~ good
fair
_ poor
(b) During the past year, his/her social condition has:
~ remained about the same.
~ improved. Expl~,,~,~,,,
_ worsen, ed. Explain,~_&Z~-_.,_,
(c) During the past year he/she has participated in the following activities:
~ recreational
-_.~_~ educational
.~ social .
---- occupations ~' '
es av; .
~ he/she is unable to participate in any activities.
8. Visitation
;
(b) The average amount of'" ' ' c~'2~-'-"-~------"
~me I spent on each visit was / - ////~ ~x°~ II
(c) The last t/me I visited was on ~'5" '. "" '-~'~"-"~'- _ 11
10. I believe he/she has the following ummet needs:
11. The gnard.ianship /should __ should not be continued without modification
12. Please note a~y concerns about the.Incapacitated person's physical or mental well being o.
the finances that the Court should know. ~
1B I X,// am am not g-aardian of the/ncapacitated person's estate. If yes, my report is
attached.
I' certify under the penalties of perjury that the information coma/ned in ti-tis report is true
and correct to the best of my knowledge, information and belief.
Date:
Signatt~e of the Guard/an of the Person
· Telephone # (~ome) (Work)
IN THE COURT OF COMMON PLEAS OF~[~I~'~COLrNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
, an incapacitated person
GUARDIAN OF THE ESTATE ANNUAL REPORT
[20 Pa.C.S.A. 552I (c)]
,2o0d o
I) I am the _~Limited... ~Plenary Guardian of the Esta~ of my ward, named above.
I was appointed/Guardian by Order of the Court dated ~,~-~.. ~/. ~.tgghl, which
was v/ was not modified by Court Order(s) dated
2) Is the incapacitated person still living?
If no, answer the following: ~'
(a) Date of Death
Co) Place of Death
(c) Name of Administrator/tflx or Executor/tflx
(d) Date Guardian of the Person filed the last Annual Report
PLEASE ANSWER THE FOLLOWING QUESTIONS
INCAPACITATED PERSON IS LIVING OR DECEASED.
initial
Inventory
was
filed
on,~/q. ,.~0~ and listed a total estate value of
The Inventory listed a total monthly income of $
following:
/~d. ~ / comprised of the
wow ~' ~r-
,~o,q, o 0,,
4) At the beginn/ng date of this reporting period, my initial balance on hand was
s)
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
2.
3.
4.
5.
6.
TOTAL
6) During this reporting period, the following reflects all payments I have made for my
2.
3.
4.
5.
6.
7)
ward: (Add additional pages if needed)
Date To Whom Paid
Reason for Payment
Amount
The present principal assets of my ward are:
Description of Asset
TOTAL
Present Value
o
TOTAL
8) The present mount and sources of income for my ward are:
Source of Income
Amount of Income
(Indicate whether monthly,
quarterly, annually)
o
9) The regular monthly expenses of my ward which I pay are:
To Whom Paid
Amount
---cJL~~#h
IN THE COURT OF COMMON PLEAS OF COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
IN RE: ~4ZChe~LMWUOf' an incapacitated person
FILE NO./I,ft). :J.COI
GUARDIAN OF PERSON ANNUAL REPORT
[20 Pa. C.S.A. 5521 (c)]
FROM ~. / ,200!t' TOIf'/vL, .:ltJ,200S-
I. I am the Limited /' Plenary Guardian of the Person of my ward, named above.
2. I was appointed Guardian by Order of the Court dated ..:l/c}'I,/;}:J. ' which was
was not modified by Court Order(s) dated
3. Is the incapacitated person still living?
If no, answer the following:
/kA/
~'""<
(a) Date of Death?
(b) Place of Death?
(c) Name of Administrator or Executor?
(d) Date Guardian of the Person filed the last Annual Report?
j",}
-'-I
-'1~'
,
__I
4. If the incapacitated person is still living, answer the following questions:
C:'J
C.)
(a) Date Guardian of the Person filed the last Annual Report? if/:;h~dO. 4{){) 'I
(b) Current address 0 the incapacitate person
'd~O~
'O,;l 6
/6 lOR IO?
(c) Current age
9ft:>
Date of birth of incapacitated person
(d) The incapacitated person's residence is:
,hard'S own residence
Nursing Home
_ Hospital or Medical Facility
_ My home/apartment
Relative's Home
Boarding Home
(e) The incapacitated person has been living there since ~ . d / , 0100 /
If moved within the past year, state from where and the reason for the change
C.A. .27
.:r-.
10) I have/have not (circle one) petitioned the Court for permission to invade principal to
meet the needs of my ward.
(If applicable) The following expenses of my ward have been paid from principal:
To Whom Paid Purpose Amount
o
1)
I
hav~ircle one) paid myself compensation for services I rendered as
guardian.
The amount I Paid myself totaled $
calculated at the following rate: $
and was
per week/month (circle one).
12) Check the correct response and complete, if appropriate.
/'"'/There will be no need for extraordinary expenditures on behalf of my ward in
the next (12)months. ~ ~ ~ ~ ~ ~,
~ There well be a need for extraordinary expenditures on behalf of my ward in
the next (12) months because:
13) Check the corre · ~ ~. t,".
A. My ward receives monthly social security benefits directly.
· I am the designated payee to receive my ward's social security
14)
~C. The designated payee of my ward's social security benefits is
whose address is
and is/is not (circle one) related to my ward as
(insert relationship).
Please note any concerns about the incapacitated person's physical or mental well
being or the finances that the Court should know.
15) i v/ am
am not guardian of the incapacitated person's person. If yes,
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: ~ Telephone No. (Home).~/~o
Add,~re,ss: , (Work)
·
NOTICE TO APPLICANT
BENEFIT
,ISTANCE
:CK
)ICAL
ISTANCE
)D
MPS
{SING HOME CARE
&L OTHER
~CES [] (Specie)
)LLOWlNG PERSONS ARE INCLUDED
NAME
DEPARTMENT OF PUBLIC WELFARE
PERRY COUNTY ASSISTANCE OFFICE
SOUTH CHURCH STREET
P, O, BOX 277
NEW BLOOMFIELD, PENNSYLVANIA 17068
LIGIBLE ELiGN(~iBTLE PENDING 717 ' 582'2127
After the first check which may be a special amount you will receive $
[] Twice a Month [] Once a Month [] In the Mail [] At the Bank
You will receive $ for the month(s) of lhen you will receive food stamps in the amount of $
a month from to [] In the Mail [] At the Bank
Level of care authorized you are expected to pay $ a month toward your care.
[] Your medical assistance I.D. card will be mailed to you [] You have a patient pay liability of
$ for the period beginning and ending __ [] Effective Date
NAME
~:~[~]~-~-~`~`~:~:~f~-1:~:~:~[~1~k1E~]a~:~aie~et~;~[~:~#~1~1~:~[~1 Regulation I Reason Code
MF~T)ICAL ASSISTANCE ~ BEEN AUTHORIT~F,D IN THE /~/~/V CATEGORY
E C 'n E pAY E,',Cr TOW V COST OF IS En crrv
YOUR MONTHLY PATIENT PAY AMOUNT IS STATED BELOW. PLEASE [~,ORT .ALL
CHA~NGES- TO YOUR CASEWORKER WITRIN 7 DAYS. CHANGES IN ME _I)-~CAL c~
E,%PENSES SHOULD BE REPORTED TO T]IE NURSING HOME. A COPY OF THIS NOTICE
WILL BE SENT TO THE NURSING HOME. $5 PA CODES 151.452 & 181.453~'
GROSS ~NCOME: J--~r~e
PERSONAL ALLOWANCE:
SPOUSAL DEDUCTION: 't~
SPOUSAL DEDUCTION:
ASST. I FOOD I MED. I SOC,
/ I
HOME M. ALXrT. DEDUCTION: ('~ ~'~.
A.,%rOUNT YOU PAY THE HOME;
HOME M. AINT. DEDUCTION:
PAY THE HONIE:
THE NURSING HOME WILL DEDUCT THE FOLLOWING MEDICAL EXPENSES FROM YOUR
MONTHLY PAYMENT:
MEDICARE:
THE NURSING HOME WILL DEDUCT OTHER MEDICAL EXPENSES IF YOU VERIFY THE
EXPENSE TO THEM.
RECORD NUMBER CAT CTR DIG DIST I
I
/ /'//'- Worke~'s~igfi~tu~e ~
"Dat~ Telephone Number
LEGAL HELP IS AVAILABLE AT
CENTRAL PENNSYLVANIA LEGAL SERVICES
13 NORTH CARLISLE STREET
NEW BLOOMFIELD, PENNSYLVANIA 17068
717 - 582-2171
INCOME FEBRUARY 4, 2003 TO APRIL 30, 2004
2/25/03
3/03/03
3/03/03
3/25/03
4/03/03
4/03/03
4/07/03
4/25/03
5/03/03
5/03/03
5/25/03
6/03/03
6/03/03
6/25/03
7/03/03
7/03/03
7/25/03
8/03/03
8/03/03
8/25/03
9/03/03
9/03/03
9/25/03
10/03/03
10/03/03
10/25/03
11/03/03
11/03/03
11/25/03
12/03/03
12/03/03
12/25/03
1/03/04
1/03/04
1/07/04
1/25/04
2/03/04
2/03/04
2/05/04
2/25/04
3/03/04
Interest at First National Bank of Newport
RR Retirement
SS
Interest ~ First National Bank of Newport
RR Retirement
SS
Insurance rebate
Interest ~ First National Bank of Newport
RR Retirement
SS
Interest ~ First National Bank of Newport
RR Retirement
SS
Interest ~ First National Bank of Newport
RR Retirement
SS
Interest ~ First National Bank of Newport
RR Retirement
SS
Interest ~ First National Bank of Newport
RR Retirement
SS
Interest ~ First National Bank of Newport
RR Retirement
SS
Interest ~ First National Bank of Newport
RR Retirement
SS
Interest ~ First National Bank of Newport
RR Retirement
SS
Interest ~ First National Bank of Newport
RR Retirement
SS
Hearing aid refund
Interest ~ First National Bank of Newport
RR Retirement
SS
Refund for returned floor lamp at Boscov's
Interest ~ First National Bank of Newport
RR Retirement
54.27
838.26
372.00
45.40
838.26
372.00
14.30
42.89
838.26
372.00
36.56
838.26
372.00.
32.2~
838.2~
372.0~
22.2!~.~'
838.26
372.~
20.84'-.
838.2~6
372.00
16.83
838.26
372.00
12.19
838.26
372.00
10.29
838.26
372.00
6.60
847.70
379.00
1,850.00
4.62
847.00
379.00
38.15
5.84
847.70
3/03/04
3/25/04
4/03/04
4/03/04
4/25/04
SS
Interest ~ First National Bank of Newport
RR Retirement
SS
Interest at First National Bank of Newport
379.00
4.73
847.70
379.00
4.94
PAYMENTS MADE FOR WARD FEBRUARY 23, 2003 TO APRIL 30, 2004
2/26/03
2/26/03
2/26/03
2/26/03
2/26/03
2/26/03
2/27/03
3/05/03
3/06/03
3/11/03
3/11/03
3/11/03
3/11/03
3/12/04
3/18/03
3/18/03
3/20/03
4/05/03
4/07/03
4/07/03
4/08/03
Rite Aid 13.84
Resinol Ointment
Mutzabaugh's 4.36
Grapes, chicken, tomatoes
Orphan's Court of Cumberland County 10.00
Filing annual estate reports
Orphan's Court of Cumberland County 10.00
Filing annual guardianship report
Pa Dept of Revenue 794.00
2002 Income Tax
R. William Wire 435.00
Preparation of Income Tax of 2002
Postmaster 2.26
Postage for filing income tax and Orphan's Court reports
Mutzabaugh' s 24.27
Groceries
Senior Blue 96.00
Health Insurance 4/01/03 to 4/30/03
Kams 3.38
Baking soda and Jelly
Rite Aid 7.49
Hearing aid batteries
Mutzabaugh' s 19.70
Assorted groceries
Sprint 33.43
Phone ~ Stonebridge
Mutzabaugh' s 4.00
Grapes and cottage cheese
Omnicare Pharmacies 71.66
Meds ~ Stonebridge
Stonebridge Health and Rehab 4,898.28
Private pay room and board
The Patriot News 13.50
Delivery daily paper 3/01/-3/31/03
Senior Blue 96.00
Health Insurance 5/01/03 to 5/31/03
Cash 25.00
Birthday gift to Son
Sprint 32.98
Phone ~ Stonebridge
Stonebridge Health and Rehab 4,788.28
Private pay room and board
4/08/03
4/09/03
4/25/03
4/25/O3
5/03/03
5/06/03
5/06/03
5/06/03
5/12/03
5/12/03
5/17/03
5/27/03
5/27/03
5/28/03
6/03/03
6/03/03
6/06/03
6/06/03
6/07/03
6/12/03
6/12/03
6/18/03
6/26/03
Stonebridge Health and Rehab
Activity Fund
Omnicare Pharmacies
Meds ~ Stonebridge
Stonebridge Health and Rehab
Activity fund and transport
The Patriot News
Through 4/26/03
Rite Aid
Hearing aid batteries
Sprint
Phone ~ Stonebridge
Senior Blue
Health Ins 6/01/03 to 6/30/03
Stonebridge Health and Rehab
Private Pay Room and board ~ Stonebridge
ATT&T Consumer Lease
5/02/03 to 8/02/03 Hearing Phone
Omnicare Pharmacies
Meds ~ Stonebridge
Mutzabaugh' s
Assorted Groceries
The Patriot News
Through 5/31/03
Mutzabaugh' s
Assorted Groceries
Mobile Optometry LLC
New bifocal lenses
Omnicare Pharmacies
Meds ~ Stonebridge
Mutzabaugh's
Assorted Groceries
Stonebridge Health and Rehab
Private pay room and board
Senior Blue
Health Insurance 7/01/03 to 7/31/03
Postmaster
Book of stamps
Rite Aid
Incontinence Pads
Sprint
Phone ~ Stonebridge
Mutzabaugh' s
Groceries, cat litter and food
Mutzabaugh' s
Cat supplies and Chicken
5.00
73.60
25.00
10.80
6.99
32.86
96.00
4,960.96
17.66
73.60
27.95
13.50
13.65
96.00
81.91
12.48
4.756.56
96.00
7.40
15.99
32.66
33.01
9.51
6/26/03
7/01/03
7/03/03
7/03/03
7/03/03
7/07/03
7/07/03
7/07/03
7/07/03
7/10/03
7/10/03
7/14/03
7/15/03
7/19/03
7/22/03
7/31/03
8/02/03
8/05/03
8/07/03
8/07/03
8/07/03
8/07/03
8/07/03
Rite Aid
Incontinence Pads
The Patriot News
Through 6/28/03
Mutzabaugh' s
Groceries
Penna Neurological Assoc
Office visit co-pay
The Patriot News
Through 7/26/03
Senior Blue
Health Insurance 8/01/03 through 8/31/03
Sprint
Phone ~ Stonebridge
Stonebridge Health and Rehab
Private pay room and board T.V. and Hair
Mutzabaugh's
Groceries, stapler and staples
Mutzabaugh' s
Groceries
Omnicare Pharmacies
Meds ~ Stonebridge
Mutzabaugh's
Groceries
Rite Aid
Incontinence pads
Walmart
Sneakers and pads
Mutzabaugh' s
Chicken and groceries
Mutzabaugh' s
Groceries
Walmart
2 packs of 42 incontinence pads
Mutzabaugh's
Groceries
Mutzabaugh' s
Groceries
CVS Pharmacies
2 packs incontinence pads
Sprint
Phone ~ Stonebridge
Senior Blue
Health Insurance 9/01/03 through 9/30/03
Omnicare Pharmacies
Meds ~ Stonebridge
15.99
10.80
11.83
10.00
10.80
96.00
32.60
4,936.51
9.41
6.46
260.91
11.09
15.99
18.80
11.75
14.44
23.94
9.14
5.73
19.98
32.74
96.00
289.02
8/13/03
8/15/03
8/15/O3
8/19/03
8/22/03
8/23/03
8/26/03
8/29/03
8/30/03
9/08/03
9/09/03
9/09/03
9/17/03
9/17/03
9/10/03
9/22/03
9/23/03
10/03/03
9/25/03
10/06/03
10/06/03
10/06/03
10/18/03
ATT&T Consumer Lease
8/02/03 to 11/02/03 Hearing Phone
Walmart
Groceries
Mutzabaugh' s
Groceries
Sign Pro
Utensils
Stonebridge Health and Rehab
Private pay Room and Board
The Patriot News
Through 8/30/03
Mutzabaugh' s
Groceries
Target
2 packs of hearing aid batteries
Mutzabaugh' s
Groceries
Senior Blue
Health Ins 10/01/03 through 10/31/03
Sprint
Phone ~ Stonebddge
Stonebridge Health and Rehab
Private pay room and board
Giant
Cat food and jelly
K-Mart
Envelopes, tablet, peeler
Mutzabaugh' s
Groceries
Omnicare Pharmacies
Meds ~ Stonebridge
CVS Pharmacies
3 packs incontinence pads
Mutzabaugh's
Groceries
The Patriot News
Through 9/30/03
Sprint
Phone ~ Stonebridge
Stonebridge Health and Rehab
Private pay room and board
Senior Blue
Health insurance 11/01/03 through 11/30/03
Omnicare Pharmacies
Meds ~ Stonebridge
17.66
12.51
5.58
7.05
4,924.50
13.50
3.96
11.99
6.29
96.00
32.50
4.779.00
8.61
6.23
7.53
257.50
32.97
22.58
10.80
33.96
4,929.50
96.00
244.84
10/19/03
10/24/03
10/25/03
10/27/03
11/02/03
11/07/03
11/07/03
11/09/03
11/09/03
11/10/03
11/11/03
11/18/03
11/21/03
11/26/03
11/26/03
12/08/03
12/08/03
12/12/03
12/14/03
12/13/03
12/15/03
12/23/03
12/24/03
Mutzabaugh' s
Groceries
The Patriot News
Through 10/25/03
Mutzabaugh' s
Groceries
Postmaster
Stamps
Omnicare Pharmacies
Meds ~ Stonebridge
Senior Blue
Health Ins 12/01/03 to 12/31/03
Sprint
Phone ~ Stonebridge
Stonebridge Health and Rehab
Private pay room and board
Mutzabaugh' s
Groceries
Audiologic Consultants
Office visit co-pay and deposit on hearing aid
AT&T Consumer Lease
Lease on hearing 11/02/03 to 02/02/04
Mutzabaugh' s
Groceries
The Patriot News
Though 11/27/03
Audiologic Consultants
Digital hearing aid for severe hearing loss
Mutzabaugh' s
Groceries
Senior Blue
Health Insurance 01/01/04 to 01/31/04
Glenn J Manning
Christmas girl for son
K-Mart
Socks and underwear
Sprint
Phone ~ Stonebridge
Onmicare Pharmacies
Meds ~ Stonebridge
Rite Aid
Resinol ointment
Stonebridge Health and Rehab
Private pay room and board
Mutzabaugh' s
Groceries
12.02
10.80
13.19
7.40
244.84
96.00
34.13
4,779.00
7.31
40.00
17.66
6.78
13.50
1,975.50
23.15
96.00
25.00
24.96
34.03
244.84
14.68
4,757.00
24.46
1/09/04
1/14/04
1/19/04
1/1904
1/20/04
1/20/04
1/24/04
1/24/04
1/25/04
2/02/04
2/05/04
2/05/04
2/17/04
2/18/04
2/18/04
2/18/04
2/18/04
2/28/04
3/03/04
3/04/04
3/04/04
3/09/04
Mutzabaugh's 15.74
Groceries
Senior Blue 96.00
Health Ins 2/01/04 to 2/28/04
Mutzabaugh's 19.08
Groceries
Radio Shack 10.99
Heating Aid Batteries
Stonebridge Health and Rehab 10.00
Activity Fund
Rite Aid 8.25
Book-keeping supplies
Omnicare Pharmacies 6.14
Meds ~ Stonebridge
The Patriot News 10.80
Dally delivery
Boscov' s 38.15
Bedside floor lamp
Mutzabaugh's 7.07
Groceries
Mutzabaugh' s 20.45
Groceries
Omnicare Pharmacies 106.46
Meds ~ Stonebridge
Mutzabaugh' s 18.67
Groceries
Senior Blue 106.00
Health Ins 3/01/04 to 3/31/04 (Raise in rates)
Stonebridge Health and Rehab 5.00
Activity fund
Stonebridge Health and Rehab 1,090.70
Room and Board
Mutzabaugh's 7.36
Groceries
Mutzabaugh' s 10.12
Groceries
Stonebridge Health and Rehab 2,314.18
Room and board
Rite Aid 5.29
Door Decoration
Mutzabaugh' s 22.40
Groceries
Senior Blue 88.00
4/01/04 to 4/30/04 Change in rotes retroactive to last month
Will be 97.00 from now on
3/09/04
3/10/04
3/17/04
3/17/04
3/22/04
3/30/04
4/06/04
4/06/04
4/12/04
4/14/04
4/25/04
4/29/04
4/29/04
4/29/04
Mutzabaugh' s
Groceries
Postmaster
Stamps
Mutzabaugh' s
Groceries
Stonebridge Health and Rehab
Activity fund
Mutzabaugh' s
Groceries
Mutzabaugh's
Groceries
Glenn Manning
Birthday Gif~ Son
Mutzabaugh's
Groceries
Mutzabaugh' s
Groceries
Senior Blue
Health Insurance 5/01/04 to 5/31/04
Mutzabaugh' s
Groceries
Stonebridge Health and Rehab
Activity Fund
Stonebridge Health and Rehab
Room and Board
Omnicare Pharmacies
Meds ~ Stonebridge
5.64
7.40
4.74
15.00
17.05
16.30
25.00
5.75
6.71
97.00
11.93
25.00
3,584.24
156.72
ember j~ncL
IN THE C01JRT OF COMMON PLEAS OF. -:OlJNTY, PE1\TNSYL VANIA
ORPHA.'JS' COURT DlY1SION
IN RE: :r3/~/)J?~), an incapacitated person FILE NO. //J~-dOO'
GUARDIA.N OF PERSON ANNUAL REPORT
[20 Pa. C.S.A. 5521 (c)]
FRO1\.1 m~~200s..T01/P:L.30, 200~
1. I an the _ Limited ~ Plenary Guardian of the Person of my ward, named above.
2. I was appointed Guardian by Order ofille Court dated d /tJL/#Ia~, which was
~s noynodified by Court Order(s) dated
3. Is the incapacitated person still living? ~
If no, answer the following:
(a) Date of Death?
(b) Place of DeaL~?
(c) Name of Ad.rnirjstrator or Executor?
(d) Date Guardian of the Person filed the last A..nuual Report?
4. If the incapacitated person is still living, 3....T1SWer the folloWL'1g questions:
(a) Date Guardian of the Person filed the last Annual Repon? ~....gt)1 c2tJO,!i"'
(b) Current address of the incapacitated person
~,~..~~>t!da..t-~
/();l. ~.rA.h~, -OJj~ Pa... /7(J~ 0
(c) Current age 97 Date of birth of incapacitated person /~ jtJ8 /09'
(d) The incapacitated person's residence is:
Ward's own residence
~ Nursing Home
_ Hospital or Medical Facility
_ My bome/aparunem
Relative's Home
BoardL.'1g Home
i
I
\
I
I
I
I
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I
I
I
I
i
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e.,
'-
- (e) The incapacitated person has been living there since &~ c:l /. c2 00 /
. If moved witl-ill1 the past year, state from where and L.~e reason for the change
co",
C.A. . 27
I
~
~
'.
Hl
'-
(f) I rate his/her living arrangement as:
Excellent / Average
Explain:
_ Below Average
(g) I believe he/she is:
L content with the living situation- h4A/ .~..2'hL ~
unhappy with the living situation ~ ~ ~ ~
-unaware of the ,living situation ~ ~~
5. Physical health
(a) Current physical condition of the incapacitated person is:
Excellent ' Good Fair Poor
(b) His/her major physical health problems are as follows:
~/~a.1r, ~~cJ~'
(c) Dw.-rng the past year, his/her physical condition has:
v remained about the same.
_ improved. Expla~ ~/l:.C- ~~ /~CJ;t.<l€.~~~
_ worsened. Explarn ~ ~-'/v~ '7"'~)'i~/u~.
(d'D' th ~~h/h . ~th~~~l 'C' 'd
\.) 1.:rlr..g e past year, e, s. e recelVed.' e l011m;"'l21g meruca treannem .1llClU e
check-ups and dental work):
Date
Ailment
Type oftreatrnent
Doctor1s name
~ Z~~-:;;~;C~~~.DnU'~r~n.4.w
( '. .' ~~~.i~~"'> .
~~~~~~~~~~~~u~
6. Mental Health
(a) The incapacitated person's condition is. ..t.bY~~~~
, ~~
excelle:J.t _ good _ poor
("0) nis/her major mental health problems are as follows: .' .~~
;;~J::Z ~~h~':j/=:-;;;'4' ~;~;;::
,
~L
r
::u
.ti
(c) During the past year, his/her mental condition has:
L- remained about the same.
~ Improved. Explain
_ Worsened. Explain
(d) During th~ past year, treatinent or evaluation by a psychiatrist, psychologist or social
worker ~ was _ was not provided. Such mental health services are briefly
described as:
Z-=':;;=:;;;:3~~ffu~J LZ. ~
7. Social Activities / Services
(a) His/her current social condition is: /
excellent ~ good
fair
_ poor
(b) During the past year, his/her social condition has:
v remained about the same.
_ improved. Explain.
_ worsened. Explain.
(c) During the past year he/she has panicipated in the foUowing activities:
v recreationau~
~ educational 7: V
vSOcial~~ ~ ~~<>' ~~
= occup~t~o.nal. ~~ n '. ~;~
_ no actlvltles avaIlable. ~ ~ ~ ~
_ he/she refuses to participate in any activities.
_ he/she is unable to participate in any activities.
:.0
8. Visitation
(al During the east year. I visited him/her as follows: ~.AL~ ~P.-V
~ ..a:...-~~~~/?'...cJ.J/pt/pd",~.
(/
(b) The average amount of ti..lI1e I spent on each visit was / - / ~;:J~
(c) The last time I visited was on 111~ /~ ).()O/P
d te
~~~~~eJ;~f{jjiE~~.
10. I believe he/she has the following unmet needs:
11. The guardianship /should _ should not be continued without modification
~e~~u~:;:'~:;::~-::::::::;~~~~AH-d' 4k
~~~~. go
Z~=~~~.A_~" '- ,v.
~~~.
13. I V. am _ am not 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 true
and correct to the best of my knowledge, information and belief.
Date:~~~ /rf; ~CJO ~
~///;"kP~~.
Signature of the Guardian ofille Person
Name: /J!, /J;..ecJ '7Je / /
Address:~~;~ ~. f//7h ~-C.
!Janc.a. c... /"'b~C
Telephone # (Home)7/7.-<f 3Y- .:33d.g
(Work)
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.
5/03/05
5/03/05
5/25/05
6/03/05
6/03/05
6/25/05
7/03/05
7/03/05
7/25/05
8/03/05
8/03/05
8/25/05
9/03/05
9/03/05
9/25/05
10/03/05
10/03/05
10/25/05
11/03/05
11/03/05
11/25/05
12/03/05
12/03/05
12/25/05
1/03/06
1/03/06
1/25/06
2/03/06
2/03/06
2/25/06
3/03/06
3/03/06
3/25/06
4/03/06
4/03/06
4/03/06
INCOME MA Y 1,2005 TO APRIL 30, 2006
RR RETIREMENT
SS
INTEREST
RR RETIREMENT
SS
INTEREST
RR RETIREMENT
SS
INTEREST
RR RETIREMENT
SS
INTEREST
RR RETIREMENT
SS
INTEREST
RR RETIREMENT
SS
INTEREST
RR RETIREMENT
SS
INTEREST
RR RETIREMENT
SS
INTEREST
RR
SS
INTEREST
RR RETIREMENT
SS
INTEREST
RR RETIREMENT
SS
INTEREST
RR RETIREMENT
SS
INTEREST
856.83
390.00
2.57
856.83
390.00
2.78
856.83
390.00
1.84
856.83
390.00
1.73
856.83
390.00
1.91
856.83
390.00
1.65
856.83
390.00
1.65
856.83
390.00
1.64
880.05
405.00
1.63
880.05
405.00
1.71
880.05
405.00
1.45
880.05
405.00
1.85
PAY MENTS MAUE .FUR W ARU MA Y I, 2UU5 TU APRlL 3U, 2UU6
05/04/05 Mutzabaughs 18.19
Groceries
05/09/05 Senior Blue 106.00
Health Insurance
05/17/05 Mutzabaughs 6.01
Groceries
0520/05 Orphans Court 10.00
File 2005 estate Report
OS/20/05 Orphans Court 10.00
File 2005 Guardianship Report
OS/20/05 Postmaster 8.95
Stamps for Postage
OS/23/05 Orphans Court 10.00
Each report required an extra 5.00
OS/24/05 Mutzabaughs 11.55
Groceries
OS/25/05 Wal-Mart 13.92
2 packs of briefs
06/04/05 Mutzabaughs 10.19
Groceries
06/1 0/05 Senior Blue 106.00
Health Insurance
06/14/05 Stonebridge Health and Rehab Center 2268.46
Room and Board
06/14/05 Mutzabaughs 19.00
Groceries
06/21/05 Mutzabaughs 4.23
Groceries
06/25/05 Newport Bank 6.00
Service Charge
07/05/05 Rite Aid 7.49
Hearing aid batteries
07/08/05 Senior Blue 106.00
Health Insurance
07/12/05 Mutzabaughs 5.11
Groceries
07/12/05 Stonebridge Health and Rehab 1100.83
Room and Board
07/25/05 Mutzabaughs 10.96
Groceries
08/04/05 Rite Aid 3.16
Frame and Kleenex
08/04/05 Mutzabaughs 11.91
Groceries
08/08/05 Senior Blue 106.00
Health Insurance
08/11/05 Stonebridge Health and Rehab 1003.83
Room and Board
08/11/05 K -Mart 21.97
Sneakers
08/14/05 Mutzabaughs 9.80
Groceries
08/18/05 Mutzabaughs 5.07
Groceries
08/18/05 Postmaster 7.40
Book of stamps
08/23/05 Mutzabaughs 4.86
Groceries
08125/05 Duncannon E.M.S. 50.00
Ambulance membership
08127/05 Mutzabaughs 9.07
Groceries
08/31/05 Mutzabaughs 16.27
Groceries
09/1 0/05 Mutzabaughs 9.07
Groceries
09/12/05 Senior Blue 106.00
Health Insurance
09/12/05 Stone bridge Health and Rehab Center 1100.83
Room and Board
10/02/05 Mutzabaughs 6.46
Groceries
10/07/05 Stone bridge Health and Rehab 1100.83
Room and Board
10/08/05 Mutzabaughs 12.55
Groceries
10/08/05 Senior Blue 106.00
Health Insurance
10/26/05 Mutzabaughs 10.24
Groceries
11/03/05 Rite Aid 7.49
Hearing Aid Batteries
11/03/05 Mutzabaughs 7.53
Groceries
11/03/05 Stonebridge 1100.83
Room and Board
11/07/05 Senior Blue 106.00
Health Insurance
11/14/05
11/21/05
11/27/05
11/30/05
12/06/05
12/06/05
12/11/05
12/20/05
12/20/05
12/22/05
12/23/05
12/20/05
01/04/06
01/09/06
01110/06
01/10/06
01/10/06
01/17/06
01/22/06
02/05/06
02/07/06
02/09/06
02/09/06
Mutzabaughs 19.49
Groceries
Mutzabaughs 13.09
Groceries
Mutzabaughs 14.13
Groceries
Karns 13 .60
Groceries
Karns 20.87
Groceries
Stonebridge Health and Rehab Center 1100.83
Room and Board
Mutzabaughs 27.09
Groceries
G.J.Manning 25.00
Christmas Gift for Son
Mutzabaughs 9.40
Groceries
Blue Cross 157.00
Health Insurance (Senior Blue now being billed through Blue Cross)
Mildred Bell 9.37
Groceries
Mutzabaughs 8.56
Groceries
Mutzabaughs 10.03
Groceries
Postmaster 7.84
Stamps
Mutzabaughs 4.80
Groceries
Stonebridge Health and Rehab 1090.53
Room and Board
Blue Cross 157.00
Health Insurance
Mutzabaughs 7.82
Groceries
Mutzabaughs 5.95
Groceries
Mutzabaughs 4.69
Groceries
Blue Cross 75.97
Adjustment on Health Insurance
A.T.&T. 17.66
Hearing phone lease
Stonebridge Health and Rehab Center 1085.57
Room and Board
02/09/06 Mutzabaughs 4.33
Groceries
02/13/06 Rite Aid 6.31
Nail Clippers
02/13/06 Mutzabaughs 14.38
Groceries
02/1 7/06 Mutzabaughs 3.47
Groceries
02/20/06 Mutzabaughs 9.43
Groceries
02/24/06 Giant 14.06
Groceries
02/28/06 Rite Aid 6.74
Hearing Aid Batteries
02/28/06 Mutzabaughs 7.47
Groceries
03/01/06 West Shore EMS-BLS 58.71
Stretcher transport 12/28/05
03/06/06 Stonebridge Health and Rehab Center 1169.06
Room and Board
03/06/06 Rite Aid 2.87
Hearing Aid Batteries with Coupons
03/06/06 Mutzabaughs 13.34
Groceries
03/13/06 Mutzabaughs 12.94
Groceries
03/15/06 Blue Cross 129.99
Health Insurance-final adjustment
03/19/06 Mutzabaughs 5.56
Groceries
03/21/06 Weis 8.80
Groceries
03/21/06 Mutzabaughs 11.38
Groceries
03/29/06 Mutzabaughs 7.09
Groceries
04/04/06 Mutzabaughs 20.24
Groceries
04/05/06 Blue Cross 129.99
Health Insurance
04/09/06 Mutzabaughs 11.24
Groceries
04/09/06 G.J.Manning 25.00
Birthday gift for son
04/12/06 Postmaster 7.80
Stamps
04/15/06 Mutzabaughs 10.)4
Groceries
04/20/06 Mutzabaughs 11.55
Groceries
04/20/06 Stonebridge Health and Rehab Center 1115.10
Room and Board
04/24/06 Mutzabaughs 8.27
Groceries
04/25/06 Cash 20.00
Trip with Stonebridge to Ranch House for dinner
04/27/06 Pennsylvania Neurological Assoc 10.00
Doctor visit co-pay
04/29/06 Mutzabaughs 13.07
Groceries
ANNUAL REPORT OF
GUARDIAN OF THE PERSON
t.....)
c::>
COURT OF COMMON PLEAS OF
~./....,..... //_*~ COUNTY, PENNSYL VANIA
ORPHANS' COURT DIVISION
( )
c='
Estate of
~~. ~~D--
,
No. //111).. ..JOOI
f"",)
CJ
, an Incapacitated Person
I. INTRODUCTION
~-'duod.. je ~ o/~ . was appointed
tgp'lenaryDLimited Guardian of the Person by Decree of'~M~~ ~ #~~/, 1.,
dated ~Jn"/ JO,J,.. u
~ A. This is the Annual Report for the period from ~~ I , c.21J (J &,
to ~~L..30 . ~tJ{)? (the "Rep Period"); or
o B. This is the Final Report for the period from
to
(the "Report Period"), and is filed
for the following reason:
1. The death of the Incapacitated Person. Date of death:
2. The Guardianship was terminated by the Court by Decree of
J., dated
For a Final Report, omit Sections II through W.
Form G-03 rev. 10.13.06
Page 1 of 4
~
Estate of
~JZ.___,.A" ~. ~~,,/ , an Incapacitated Person
II. PERSONALDATA
Age of the Incapacitated Person:
92
Date of Birth: /(J /()9' ;"8
m. LIVING ARRANGEMENTS
A. Current address of the Incapacitated person:~~hA ~Z2c, qI ~
/~~ e-/I~~
I"a.. /7tJ.;J.O
~
B. The Incapacitated Person's residence is:
D own home / apartment
JSriiursing home
D boarding home / personal care home
D Guardian's home / apartment
D hospital or medical facility
D relative's home (name, relationship and address)
Dother:
C. The Incapacitated Person has been in the present residence since ~./'~~ of. /
02. 00 J
. If the Incapacitated Person has moved within the
past year, state prior residence and reason(s) for move:
Form 0-03 rev. 10.13.06
Page 2 of 4
Estate of
~~-A~-L >no ~
, an Incapacitated Person
D. Name and address of the Incapacitated Person's primary caregiver:
IV. MEDICAL INFORMATION
A. The major medical or mental problems of the Incapacitated Person are as follows:
CN~" ~~..d-...J ~~~I S/P~
~J~" ~,~4/r~'/~
B. Specify what, if any, social, medical, psychological and support services the
Incapacitated Person is receiving:
(]) ~~-~~>u.-rl~~
a;Y8' 'J~~ '.
@ ~~~~&-.tI~..~~~~
(j) ~. ~/1U.I!.~
@ >e~~7e~ lJ&I~~~'~..:L-~~,~
(?i)~~~~~~#~
V. GUARDIAN'S OPINION
A. It is the opinion of the Guardian ofthe Person that the guardianship should:
~continue
o be modified
o be terminated
Form G-()3 rev. lO.13,()6
Page 3 of4
Estate of
J.:f.e..-..,b k. k~/,
, an Incapacitated Person
The reasons for the foregoing opinion are:
P~~Zi>~y~~. 4<<~~
~ q' C"~~-47:' ./l:d~ ..z;.,...~ ~/ ~ ~
~.
B. During the past year, the Guardian of the Person has visited the Incapacitated Person
~"JI ~ :iima.with the average visit lasting I ~ - ~ hours, minutes.
The report of a social service organization employed by the Guardian to oversee and
coordinate the care of the Incapacitated Personfor the period covered by this Report may be
attached to supplement this Report.
I verify that the foregoing information is correct to the best of my knowledge,
information and belief; and that this Verification is subject to the penalties of 18 Pa. C.S.A. ~ 4904
relative to unsworn falsification to authorities.
Date~~ J~J ..2.00 '?
~~/d-A-1~ >? ko~./
Signature o/Guardian o/the Person
~ /d !\pJ .k'. ,dE'. / /
Name o/Guardian o/the Person (type or prim)
/-7..201 )" ~~d7:'
Address
/J3/A?-'A-~~ 11... /11);(t)
City, State, Zip
1/1- R 3~- 33t:2?
Telephone
Form G-03 rev. 10.13.06
Page 4 of 4
ANNUAL REPORT OF
GUARDIAN OF THE ESTATE
()
\)
>
-",~,J
'--J
COURT OF COMMON PLEAS OF
rJ.UJ1"",hh;_~ COUNTY, PENNSYL VANIA
ORPHANS' COURT DIVISION
r ';
t_,
- ~;
t',"")
\L;
Estate of
~~~;m.k~~
No. /180-~1
, an Incapacitated Person
I. INTRODUCTION
~;.ldfl-~d",>fJ.. ~J P.I../
JB"Plenary DLimite~ Guardian of the Estate by Decree ouda...4ca.e. E':
,
dated A/04f/o:J.
.
, was appointed
~~ " ,1.,
ff A. This is the Annual Report for the period from
to ~~.J1, L,g 0 , ,J,()tJ '? (the "Re
o B. This is the Final Report for the period from
, ~Ol)~
Period"); or
to
(the "Report Period"), and is filed
for the following reason:
1. The death of the Incapacitated Person. Date of death:
Name of Personal Representative:
2. The Guardianship was terminated by the Court by Decree of
J., dated
Form G-02 rev. 10.13.06
Page 1 of5
~
Estate of
~R.-..-~ >no ~~
. An Incapacitated Person
II. SUMMARY
A. State the value of the estate reported on the Inventory $
B. State the value{s) of principal assets at the beginning of
the Report Period. (Same as Inventory if fIrst Report,
otherwise, ending balance from last Report.)
$ ~ ~ l,d. 3.3
C. What is the total amount of income earned during the
Report Period?
$ /:~ PJl9. 7 cJ...
D. What is the total amount of income and principal
spent for all purposes during the Report Period?
$ / 6:' ~ 3 If. , ,
E. What are the balances remaining at the end of the Report
Period?
1. Principal $
2. Income $
3. Total of Principal and Income
$~. SFJ. /39:00
III. ADDITIONAL INFORMATION
(If more space is needed, please attach additional pages.)
A. Principal
1. How is the principal balance listed above currently
invested? (Please specify, e.g., real estate,
certifIcates of deposit, restricted bank accounts, etc.):
~~~4lUnt? ~tI~.
~~~~-u-~~.~
~~~. ~.u~'::1~ ~
~ e.,.l.~~.~~'~, ~~~ ~d-~~iI
?U<""'-fO~' AZC-. .4.~.t~'''f+t.# c-- ~4.4.~e...uI ~ ~~ ~.
2. Have there been any expenditlhes from thl' prinCipal
during the Report Period? ............................ if Yes D No
If yes:
a. Have all expenditures from the principal been for
the sole benefIt of the Incapacitated Person? . . . . . . . . )J!J.,Yes 0 No
Form G-Q2 rev. 10.13.06
Page 2 of5
Estate of
..>-?~~ ~< ~
b. List purpose and amount of expenditures:
~<-... ~7fij-,-k~ -<?A II z:a, $
$
$
$
. An Incapacitated Person
c. Was Court approval received prior to
expending the principal? ....................... 0 Yes 0 No
3. Were additional principal assets received during the
Report Period which were not included in the
Inventory or a prior Report filed for the Estate? ........... DYes a-No
If yes:
a. Was Court approval requested prior to
receiving the additional principal? . . . . . . . . . . . . . . .. 0 Yes 0 No
b. State the sources and amounts of the
additional principal received:
B. Income
1. State sources and amounts of income received
during the Report Period (e.g., Social Security,
pension, rents, etc.)~,. .
)ii;:::~: ~
.......JJ.... "'"T:/' ~ ~ ~ 7'":
Total income received during Report Period:
Form G-02 rev. 10.13.06
$
$
$
$
$
$ ~ 9/1,. ao
$ '" (,119. cJl.J.
$ - '..4 9"1. J./.~
$
$
$
$ /S;9J1? 7 J....~
Page 3 of5
Estat.eof .lJ.P_.__k~. ~~.....
2. How is income currently invested? (please
specify, e.g., restricted bank accounts, client
care account, etc.):
. An Incapacitated Person
~ ~~" c~7 a.c.u-~..z.
C. Expenses foFCare and Maintenance
Specify what expenditures were made from the principal and
income for the care and maintenance of the Incapacitated
Person (e.g., clothing, nursing home, medicine, support, etc.):
~ ~t:L~
D. Other Expend.jtures
Speci.,. What other expenditures were made during the Report
Period. (Do not include any items stated in response to
question C above.)
E. Guardian's Commissions
List amounts of compensation paid as Guardian's commission
and state how amount was determined:
Amount
Method of Determination
O.DO
Form G-02 rev. 10.13.06
Court
Approval Obtained
DYes DNo
DYes DNo
Page 4 of5
Estate of
..!1L----h ~.~
, An Incapacitated Person
F. Counsel Fee
List amounts paid as counsel fee, and indicate whether Court approval was obtained.
Amount
Court
Approval Obtained
00. DD
DYes DNo
DYes DNo
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. ~ 4904
relative to unsworn falsification to authorities.
~~ .-/1" 02/)() '1
~~/'A-I-'-' ~ ~-'L~
SignaJure of Guardian of the EstoJe
-A?//,//,C'/ )(1. 'J!e.I/
Name of Guardian of the Estate (type or print)
/...2",2 .:l AI. ~.A..I.. .Ar..........~
Address
~~..hIII-'H~. ~# /~~.2tJ
City, State, Zip
7/7 - ? -$/;- 33.2R
Telephone
Form Go02 rev. 10.13.06
Page 5 of5
INCOME MAY 1, 2006 TO APRIL 30, 2007
MAY 1,2006 RR RETIREMENT 880.05
MAY 1,2006 S.S. 405.00
MAY 25,2006 INTEREST 1.62
MA Y 12, 2006 OMNICARE REFUND 263,18
JUNE 1, 2006 RR RETIREMENT 880.05
JUNE 1, 2006 S.S. 405.00
JUNE 25, 2006 INTEREST 1.82
JULY 1,2006 RRRETIREMENT 880.05
JULY 1,2006 S.S. 405.00
JUL Y 25, 2006 INTEREST 1.53
AUGUST 1, 2006 RR RETIREMENT 880.05
AUGUST 1,2006 S.S. 405,00
AUGUST 25, 2006 INTEREST 1.93
SEPT 1,2006 RR RETIREMENT 880.05
SEPT 1, 2006 S.S. 405.00
SEPT 25, 2006 INTEREST 1.82
OCT 1, 2006 RR RETIREMENT 880.05
OCT 1, 2006 S.S. 405.00
OCT 25, 2006 INTEREST 1.80
NOV 1, 2006 RR RETIREMENT 880.05
NOV 1, 2006 S.S. 405.00
NOV 25, 2006 INTEREST 1.82
DEC 12006 RR RETIREMENT 880.05
DEC 1,2006 S.S. 405.00
DEC 25, 2006 INTEREST 1.70
JAN 1,2007 RRRETIREMENT 902.21
JAN 1,2007 S.S. 419.00
JAN 25, 2006 INTEREST 1.73
FEB 1 , 2006 RR RETIREMENT 902.21
.FEB 1, 2007 S.S. 419.00
; :' .FEB 25, 2007 INTEREST 1.96
MAR, 1,2007 RR RETIREMENT 902.21
MAR 25, 2007 S.S. 419.00
MAR 25, 2007 INTEREST 1.72
APR 1, 2007 RR RETIREMENT 902.21
APR 1, 2007 S.S. 419.00
APR 25, 2007 INTEREST 1.85
EXPENSES FOR MAY 1,2006 TO APRlL3l\2007
JUL 26, 2006 CASH
ACTIVITY FUND AT STONEBRIDGE 20.00
JUL 30, 2006 MUTZABAVGH'S MARKET
GROCERIES 12.11 1.3/~.l{.1
AVG 09, 2006 CAPITAL BLUE CROSS
HEALTH INSURANCE 129.99
AVG 09, 2006 POSTMASTER
BOOK OF STAMPS 7.80
AVG 10, 2006 STONEBRIDGE HEALTH AND REHAB
ROOM AND BOARD 1115.06
AVG 11,2006 MUTZABAVGH'S MARKET
GROCERIES 18.35
AVG 20, 2006 CASH
ACTIVITY FUND AT STONEBRIDGE 20.00
1~9/. t1.0
SEPT 05,2006 CASH
ACTIVITY FUND AT STONEBRIDGE 20.00
SEPT 07, 2006 CAPITAL BLUE CROSS
HEALTH INSURANCE 129.99
SEPT 07, 2006 STONEBRIDGE HEALTH AND REHAB
ROOM AND BOARD 1115.06
SEPT 08, 2006 RITE AID
HEARING AID BATTERIES 5.49
SEPT 08, 2006 MUTZABAVGH'S MARKET
GROCERIES 13.63
SEPT 15,2006 DOLLAR TREE
ROOM DECORATIONS 5.30
SEPT 15,2006 MUTZABAVGH'S MARKET
GROCERIES 9.98 /~ 9?1/!>-
OCT 07, 2006 CAPITAL BLUE CROSS
HEALTH INSURANCE 129.99
OCT 09, 2005 GLENN MANNING
SON'S BIRTHDA Y 25.00
OCT 12, 2006 STONEBRIDGE HEALTH AND REHAB
ROOM AND BOARD 1115.06
OCT 12, 2006 MUTZABAVGH'S MARKET
GROCERIES 9.45
OCT 23, 2006 MUTZABAVGH'S MARKET
GROCERIES 9.56
OCT 23, 2006 CASH
ACTIVITY FUND AT STONEBRIDGE 20.00
NOV 04, 2005 MUTZABAVGH'S MARKET /3(}'I.O~
GROCERIES 10.79
NOV 04, 2006 STONEBRIDGE HEALTH AND REHAB
ROOM AND BOARD 1115.06
NOV 08. 2006 CAPITAL BLUE CROSS
HEALTH INSURANCE 129.99
NOV 18, 2006 MUTZABAUGH'S MAARKET
GROCERIES 11.16
NOV 28, 2006 MUTZABAUGH'S MARKET
GROCERIES 8.82
/,J75. a~
DEC 02, 2006 MUTZABAUGH'S MARKET
GROCERIES 14.46
DEC 02, 2006 RITE AID
HEARING AID BATTERIES, GARLAND 14.17
DEC 07, 2006 PHILHA YEN
CO-PAY 10.00
DEC 07, 2006 STONEBRIDGE HEALTH AND REHAB
ROOM AND BOARD 1115.06
DEC 09, 2006 CAPITAL BLUE CROSS
HEALTH INSURANCE 85.30
DEC 11,2006 MUTZABAUGH'S MARKET
GROCERIES 26.77
DEC 20, 2006 GLENN MANNING
CHRISTMAS GIFT FOR SON 25.00
DEC 22, 2006 MUTZABAUGH'S MARKET
GROCERIES 15.30
DEC 29, 2006 POSTMASTER
BOOK OF STAMPS 7.80
DEC 30, 2006 MUTZABAUGH'S MARKET
GROCERIES 6.55
/.3~O. "1-/
IAN 05,2007 CAPITAL BLUE CROSS
HEALTH INSURANCE 85.30
IAN 05, 2007 STONEBRIDGE HEALTH AND REHAB
ROOM AND BOARD 1199.44
IAN 05, 2007 MUTZABAUGH'S MARKET
GROCERIES 4.51
IAN 14, 2007 RITE AID
HEARING AID BATTERIES 5.99
IAN 14,2007 MUTZABAUGH'S MARKET
GROCERIES 5.02
IAN 22, 2007 MUTZABAUGH'S MARKET
GROCERIES 6.28
IAN 26, 2007 MUTZABAUGH'S MARKET
GROCERIES 15.87
Ja~d. . J./ I
FEB 05, 2007 MUTZABAUGH'S MARKET
GROCERIES 12.74
FEB 11,2007 MUTZABAUGH'S MARKET
GROCERIES 6.17
FEB 11,2007 CAPITAL BLUE CROSS
HEALTH INSURANCE 85.30
FEB 15,2007 STONEBRlDGE HEALTH AND REHAB
ROOM AND BOARD 1154.75
FEB 20, 2007 MUTZABAUGH'S MARKET
GROCERIES 8.17
FEB 22, 2007 MUTZABAUGH'S MARKET
GROCERIES 3.72
FEB 27, 2007 MUTZABAUGH'S MARKET
GROCERIES 3.72
/:J, ?.y. c5?
MAR 09, 2007 CAPITAL BLUE CROSS
HEALTH INSURANCE 85.30
MAR 09, 2007 MUTZABAUGH'S MARKET
GROCERIES 15.42
MAR 12,2007 STONEBRlDGE HEALTH AND REHAB
ROOM AND BOARD 1160.15
MAR 13, 2007 MUTZABAUGH'S MARKET
GROCERIES 4.77
MAR 18, 2007 MUTZABAUGH'S MARKET
GROCERIES 4.91
MAR 25, 2007 MUTZABAUGH'S MARKET
GROCERIES 15.95
/~altJ .SO
APR 03, 2007 MUTZABAUGH'S MARKET
GROCERIES 6.77
APR 09, 2007 CAPITAL BLUE CROSS
HEALTH INSURANCE 85.30
APR 16, 2007 STONEBRlDGE HEALTH AND REHAB
ROOM AND BOARD 1197.61
APR 13,2007 MUTZABAUGH'S MARKET
GROCERIES 7.53
APR 13, 2007 RITE AID
HEARING AID BATTERIES 13.77
APR 23, 2007 MUTZABAUGH'S MARKET
GROCERIES 5.54
/,3/1o.5;t.
ANNUAL REPORT OF
GUARDIAN OF THE ESTATE
COURT OF COMMON PLEAS OF
~~~ COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
Estate of Zit<J,/1~-A.P ':;n.
~CVJ~'J9-
~
No. / /t?tJ -,.200 I
, an Incapacitated Person
I. INTRODUCTION
~"f'd.A-J?~ J11. ~---H~ , was appointed
~Ienary 0 Limited Guardian of the Estate by Decree of,"//' /,:/," C ~r ' J.,
dated ;J.. / () 0/ 0';; .
D A. This is the Annual Report for the period from
to (the "Report Period"); or
13: B. This is the Final Report for the period from ~ ~ /
, 02tJO 7
to ~~ 6lt?
, JIJO fJ (the "Report Period"), and is filed
for the following reason:
rGJThe death of the Incapacitated Person. Date of death~ It,. 02 1M 7
Name of Personal Representative:
a....
2. The Guardianship was terminated by the Court by Decree of
m
(".l
0..1
u...J
Ll....
C:J
(-:=:
:=..)
J., dated
c5
: ~.. ~
Form G-02 rev. 10./3.06
Page I of5
1
Estate of
~---4~, ~~uu~~
, An Incapacitated Person
II. SUMMARY
A. State the value of the estate reported on the Inventory
$
B. State the value(s) of principal assets at the beginning of
the Report Period. (Same as Inventory if first Report,
otherwise, ending balance from last Report.)
$ ~) 6""6'3. /3
c. What is the total amount of income earned during the
Report Period?
$ ~ 74t.. t5:l
D. What is the total amount of income and principal
spent for all purposes during the Report Period?
$ ~.3 It, D. / J..
E. What are the balances remaining at the end of the Report
Period?
I. Principal $
2. Income $
3. Total of Principal and Income
$ /91/1..35" ~
.
III. ADDITIONAL INFORMATION
(If more space is needed, please attach additional pages.)
A. Principal
] . How is the principal balance listed above currently
invested? (please specify, e.g., real estate,
certificates of deposit, restricted bank accounts, etc.):
~~ ~~aZ/z.,~.~.uv arv
----e:/~~ h~C7 ~tf ~
2. Have there been any expenditures from the principal
during the Report Period? ............................ 5 Ves D No
If yes:
a. Have all expenditures from the principal been for
the sole benefit of the Incapacitated Person? . . . . . . .. &Ves 0 No
Form G-02 rev. 10.13.06
Page 2 of5
-
Estate of
~~AU"..A~ >n, ~~A-1r!
-
, An Incapacitated Person
b. List purpose and amount of expenditures:
~bJ~~ $
~A?ff ~ $
~JC1~~e-4- $ ~ 3~~ ./1
~AA:" ~.AJ,--r_P'y'm~A. $
~~ ~d4
c. Was Court approval received prior to
expending the principal? ....................... 0 Yes )f3fNo
3. Were additional principal assets received during the
Report Period which were not included in the
Inventory or a prior Report filed for the Estate? ........... 0 Yes "'J No
If yes:
a. Was Court approval requested prior to
receiving the additional principal? . . . . . . . . . . . . . . .. 0 Yes 0 No
b. State the sources and amounts ofthe
additional principal received:
B. Income
1. State sources and amounts of income received
during the Report Period (e.g., Social Security,
pension, rents, etc.):
>f~'''~'~,,~~
~-di.h 6.....J.Z:
':#y~~ ~~q/./Jrl
?,I). gO ~ , 'I
Total income received during Report Period:
Form G-02 rev. 10.13.06
$
$
$
$
$
$ i32. ()()
$ / fj'O 1./ .'1 J--
$' 9. /g S-
$ 9.? 9'1
$
$
$ d. 7'1k.!J I ~
Page 3 of5
Estate of
~d4K"k }..n, ,)m""-#~../1r
2. How is income currently invested? (Please
specify, e.g., restricted bank accounts, client
care account, etc.):
~d~
C. Expenses for Care and Maintenance
Specify what expenditures were made from the principal and
income for the care and maintenance of the Incapacitated
Person (e.g., clothing, nursing home, medicine, support, etc.):
~~~~ .......~
~~t7-1~~ 7IC
D. Other Expenditures
Specify what other expenditures were made during the Report
Period. (Do not include any items stated in response to
question C above.)
E. Guardian's Commissions
List amounts of compensation paid as Guardian's commission
and state how amount was determined:
Amount
Method of Determination
()
Form G-02 rev. 10.13.06
, An Incapacitated Person
Court
Approval Obtained
DYes DNo
DYes DNo
Page 4 of5
-
Estate of
d~~)w. ~~
. An Incapacitated Person
F. Counsel Fee
List amounts paid as counsel fee, and indicate whether Court approval was obtained.
Amount
Court
Approval Obtained
()
DYes DNo
DYes DNo
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. ~ 4904
relative to unsworn falsification to authorities.
Date
r-J/c2 c?' 10 8'
~p7dA-~d ~.l1P>#"
Signatur: Guardian of the Estate
~/clAed ~_ 'Rel/
Name of Guardian of the Estate (type or print)
bdc1.~, Xbcf'fi~~~
Address
~A""--fl~)g. /7tJol{)
City, State, Zip
//7 -cf ~~-33;2J>
Telephone
Form G-02 rev. 10.13.06
Page 5 of5
-
ANNUAL REPORT OF
GUARDIAN OF THE PERSON
COURT OF COMMON PLEAS OF
~J~~ COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
Estate of ~~ 0/. ~aA1AU1~
No. //J!~ dtJO(
, an Incapacitated Person
I. INTRODUCTION
%/~)f Wt?JL , was appointed
~Ienary DLimited Guardian of the Person by Decree of &LHf' 1.'. Jt,-f'P.J , J.,
dated dl /0 LJ /Od.- .
, ,
o A. This is the Annual Report for the period from
to (the "Report Period"); or
38.
This is the Final Report for the period from
~~ /.J
, a200 l
to
:ir-d-. c:< J
, c:2t;o fI. (the "Report Period"), and is filed
.:T
1--
for the following reason:
CD The death of the Incapacitated Person. Date of death:ruz /b J 2tJO '7
W-
CT\
('-\
CD
l.L..l
Ll.....
~
C,:::::'
C:':;';l
2. The Guardianship was terminated by the Court by Decree of
J., dated
1..--.'
For a Final Report, omit Sections II through We
Form G-03 rev. 10./3.06
Page 1 of 4
s
Estate of
~'lVk ~ ,'m~!,
, an Incapacitated Person
II. PERSONAL DATA
Age of the Incapacitated Person:
Date of Birth:
III. LIVING ARRANGEMENTS
A. Current address of the Incapacitated Person:
B. The Incapacitated Person's residence is:
o own home / apartment
o nursing home
o boarding home / personal care home
o Guardian's home / apartment
o hospital or medical facility
o relative's home (name, relationship and address)
o other:
C. The Incapacitated Person has been in the present residence since
. Ifthe Incapacitated Person has moved within the
past year, state prior residence and reason(s) for move:
Form G-03 rev. 10.13.06
Page 2 of 4
Estate of
Zr/~k ~. >n~ ' an Incapacitated Person
D. Name and address ofthe Incapacitated Person's primary caregiver:
IV. MEDICAL INFORMATION
A. The major medical or mental problems of the Incapacitated Person are as follows:
B. Specify what, if any, social, medical, psychological and support services the
Incapacitated Person is receiving:
V. GUARDIAN'S OPINION
A. It is the opinion of the Guardian ofthe Person that the guardianship should:
D continue
D be modified
,Ef be terminated
Form G-03 rev. 10.13.06
Page 3 of 4
Estate of
;(~~p 7JI- YJ1C('/H~I/
, an Incapacitated Person
The reasons for the foregoing opinion are:
Z1knd~ ~ ~06
B. During the past year, the Guardian of the Person has visited the Incapacitated Person
If)
times with the average visit lasting / - .2. hours,
minutes.
The report of a social service organization employed by the Guardian to oversee and
coordinate the care of the Incapacitated Person for the period covered by this Report may be
attached to supplement this Report.
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.
~~ ~J>. 02t)c8
Date '
~f~dJ1;. ~p;~,
Signature of Guardian of the Person
/It/d;.ed )r. /fell
Name of Guardian of the Person (type or print)
/J,J:( >>. 0rr/Jiiar
Address
~~. /7t101{)
City, State, Zip
7/7- tf.3Lf. 33;2J>
Telephone
Form G-03 rev. /0./3.06
Page 4 of 4