HomeMy WebLinkAbout01-07-10Clerk of Orphans' Court of Cumberland County
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~ ~: ~ Lo~~~.j ~ ~ /~~{'t Docket No. ~ ~ ~~
An Incapacitated Person
ANNUAL REPORT OF GUARDIAN OF THE PERSON
I, L Q R~~ ~~. ~1`t1'i~~ CD ~ ~~ Y ,was /were appointed
plenary guardian(s) of the person of C~ ~~~~N~p ~ ~~ ~-- by Decree of the
Honorable Judger (rA' ~~~~dated ~ l ~. This is my annual report for
the period from /~` to , ("The Report Period").
1. Present age of the incapacitated person:
2. Current address of the incapacitated person
C/~~n~7` /Yu~~s~~
~_Yrs.
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The incapacitated person's residence is:
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~ own home/apartment C^,
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nursing home ~ ~ v -~,
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~ boarding home/personal care home ,~ ~:~
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0 guardian's home/apartment
0 hospital or medical facility
0 relative's home
ame and relationship)
~ other: ~ue5°°°G,
4• The incapacitated person has been in the present residence since ®. ~/ 04 . If
the incapacitated person has moved within the past year, state change and reason(s) for
change:
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5. Name and address of the incapacitated person's primary care giver:
6.
The major medical or mental problems of the incapacitated person are as follows:
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Specify what, if any, social, medical, psychological and support services the incapacitated
7.
person is receiving:
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It is our opinion as guardian of the person that the guardianship should: (check one)
8.
~ontinue, D be modified, D be terminated. (sriefly explain your response)
9. During the past year, I have visited the incapacitated person ~_times with the
average visit lasting
~; ~ ~ !l' oyrr
(State number of hours/minutes, etc.)
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 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.
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Dat Signature of Guardian
* FILING FEE $15 MUST ACCOMPANY THIS FILING.