HomeMy WebLinkAbout07-22-09i
~, Clerk of Orphans' Court of Cumberland County
IN RE: ~ ~ f } ~1 Y~ N }/~, I l I Docket No. Z OCR 6 (} G y ~ G
An Incapacitated Person
ANNUAL REPORT OF GUARDIAN OF THE PERSON
,was /were appointed
plenary guardian(s) of the person of ~ G hn IvyE ~ ~ ~ by Decree of the
Honorable Judge (~' e r ,dated -~ Ln vte. ~p ZGG (O This is my annual report for
the period from ~h ~ 1, o?Od8' to ~ / ~2C>D , ("The Report Period").
1. Present age of the incapacitated person: ~_yrs.
2. Current address of the incapacitated person
1~~ i ~`//c~-~sf ~- A~~ ads
3. The incapacitated person's residence is:
p own home/apartment n
C p ~'~`',,
~
.°
.3 ~ 1
o -
c,. ~ -
^ nursing home
;;~~
r
~
--i G ~ ~ `1
~ _ ~
^ boarding home/personal care home -.~ ~~ o ~~ ~ -
-' ~ ~ - _~
~' guardian's home/apartment ~ ~ ~' -
- .~- _ -.
rn ,
p hospital or medical facility
p relative's home (Name and relationship)
p other:
(describe)
4. The incapacitated person has been in the present residence since ~/~, ~ p~ D Dom, , If
the incapacitated person has moved within the past year, state change and reason(s) for
change:
Name and address of the incapacitated person's primary caze giver:
5
~~- Q,S' ~G r ~.
The major medical or mental problems of the incapacitated person aze as follows:
6
S~ V ~ H
Yo[i
Specify what, if any, social, medical, psychological and support services the incapacitated
7.
person is receiving:
iii ~lii~-~b 7~~ ~~ ,~~'. 176//
It is our opinion as guardian of the person that the guardianship should: (check one)
~ontinue, ^ be modified, O be terminated. (sriefly expta~n your ~esponse>
8
9. During the past year, I have visited the incapacitated person ~ times with the
average visit lasting
~c~•',~ ,'s w,'~ lnL 7x14 ~~ ~r up~'~'~x•'s"'~~~~,~
(State number of hours/tnmutes, etc.)
i
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 maybe attached to
supplement this report.
I verify that the foregoing information is con ect 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.
d~~ ~
Date
Signature o rd'
* FILING FEE $15 MUST ACCOMPANY THIS FILING.