HomeMy WebLinkAbout10-09-09ANNUAL REPORT OF
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GUARDIAN OF THE PERSON ~ ~ ~=
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COU T OF COMMON PLEAS OF ~ ~ r -~' _`
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~-~+ Ow~~ COUNTY, PENNSYLVANIA ~ ~ ~ -~ _~
ORPHANS' COURT DIVISION`.'
Estate of C~~ ~.\ , an Incapacitated Person
No. ~~~ -'
I. INTRODUCTION
(tibat~~ ~~,o
was appointed
J
Plenary Limited Guardian of the Person by Decree of , J•,
ated
A. is the Annual Report for the period from U--'--~- ~ ~= ~ ~
to v~ ~., ~-~ (th Report Period"); or
B. T 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 IV.
Forn~ G-03 ~~. ~o.~s.o6 Page 1 of 4 Q
ll(
Estate of _ ~+~ i ' -~ ~
II. PERSONAL DATA
Age of the Incapacitated Person: ~~
III. LIVING ARRANGEMENTS
A. Current address of the Inc~apacnitated Person:
~ ~~ ~a~~ ~
B. The Incapacitated Person's residence is:
own home /apartment
_ nursing home
boarding home /personal care home
Guardian's home /apartment
® hospital or medical facility
an Incapacitated Person
Date of Birth: ~ ~ ~~ ~"~
relative's home (name, relationship and address)
other:
C. The Incapacitated Person has been in the present residence since ~ ~ ~ ~ 5~
. If the Incapacitated Person has moved within the
past year, state prior residence and reason(s) for move:
Fornr G-03 rev. 10.13.06 Page 2 of 4
Estate of
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:
S
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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 of the Person that the guardianship should:
continue
be modified
be terminated
Form G-03 rev. 10.13.06 Page 3 of 4
Estate of ~~ , an Incapacitated Person
The reasons for the foregoing opinion are:
B. During the past year, the Guardian of the Person has visited the Incapacitated Person
__12 times with the average visit lasting hours, l~ r 2 ~ 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 subj the penalties 18 Pa. C.S.A. § 4904
relative to sworn falsification to authorities.~v
Date Sio~na e of G dian of the Person
Name of Guar of the Person (type or print)
~-.~d~ . ~~C j ~~ ~ ~
Ad ss
'r~~ ~~ ~ ~la~g
City, State, Zip ~
~t~ ^ 3~Zr ~-` ~~ ~~~
Telephone
Form G-03 rev. 10.13.06 Page 4 of 4
<~
ANNUAL REPORT OF ~~,
-,
GUARDIAN OF THE ESTATE ~~ ~' ~-~ ~~'
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l
. cs~
OU T OF COMMON PLEAS OF _~?
~L~ CL° COUNTY, PENNSYLVANIA. ___, -, r--- ~''
_., ;~ _
ORPHANS' COURT DIVISION ~~ Ga `-
•-.,
Estate of ~ J , an Incapacitated Person
No. ~ (JCS ~ ~ `'~
I. INTRODUCTION
//~~ was appointed
-. Plenary ~ Limited Guardian of the Estate by Decree of C..11a-tom U , J,,
dated 1~ v ~ Z'
-,.1~7 A. This is e Annu 1 Report for the period from ~Z U
to L '~ (the "Re ort Period"); or
B. This is the Final Report for the period from
to (the "Report Period"), and is filed
for the following reason:
l . 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 of 5
r-
Estate of ~~ , 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.)
C. What is the total amount of income earned during the
Report Period? $
D. What is the total amount of income and principal
spent for all purposes during the Report Period? $
E. What are the balances remaining at the end of the Report
Period?
1. Principal $
2. Income $
3. Total of Principal and Income $ 0.00
III. ADDITIONAL INFORMATION
(If mo~~e 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 acco , s, etc.)~~~/~~~_.~,~,,,
~ ~1 ~.:
~~ ,
~~-~,~,~. ~ ~1 ~L ~~-'
2. Have there been any expenditures from the principal
during the Report Period? ............................ ~ es ®No
If yes:
a. Have all expenditures from the principal been for /
the sole benefit of the Incapacitated Person? ........ ,~) Yes ^ No
Fa•n+G-Ol rev. ]0,]3.06 page 2 Of 5
Estate of An Incapacitated Person
F. Counsel Fee
List amounts paid as counsel fee, and indicate whether Court approval was obtained.
Amount
Court
Approval Obtained
Yes ~ No
Yes ~ No
I verify that the foregoing information is correct to the best of my knowledge,
information and belief; and that this Verification is subjec the penalties of 18 a.C.~ 4904
relative to unsworn falsification to authorities. ~~ ~,
Date Signahrre of Cnr rdran of the Eslale
~~~~
Name of Gluardi of thQe Estate (r)ipe or prinlJ
Address ; ,~" _ ~ -
cry; Stare, zp
Telephone
Form G-02 rer. 10.13.06 Page 5 of 5
Estate of ~ ' ~~ , An Incapacitated Person
b. purpospaand amount o~e~penditures:
c. Was Court approval received prior to
expending the principal? ....................... ^ Yes ~o
Were additional principal assets received during the
Report Period which were not included in the
Inventory or a prior Report filed for the Estate? ........... ~ Yes
If yes:
a. Was Court approval requested prior to
receiving the additional principal? ................ 0 Yes ^ 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,
p ion,~re~ , e ,
Total income received during Report Period: $ o.oo
Fann G-02 rev. 10.73.Ob Page 3 of 5
Estate of , An Incapacitated Person
2. How is income currently invested? (Please
specify, e.g., restricted bank accounts, client
care account, etc.):
~c~~~~,cZ. C~~ ~~-~ ~ ~'~P .
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.}:
n,,t~ ..~~ P.~~-.~ ~ ~
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:
A~~zount Method of Dete~~tnination
Cozn~t
Approval Obtained
®Yes ~ No
®Yes ~ No
Fa•n~ G-02 rev. 10.13.06 Page 4 of 5