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ANNUAL REPORT OF
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GUARDIAN OF THE PERSON ~=' z rn ~ .,
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COURT OF COMMON PLEAS OF ~ ~
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COUNTY, PENNSYLVANIA ~~ ''
ORPHANS' COURT DIVISION
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Estate of (=-~~ f1zu,~~%:~ ~% ~'~an!~.~ Vic' . J~/~ i7~?~.~ , an Incapacitated Person
No. 2 ~ - l~~ - 4=?~~
I. INTRODUCTION
__~. %~r~;li/~ ~ ~ , ~~~~~~,'~ ,was appointed
1vJ Plenary Limited Guardian of the Person by Decree of ~-1L,,5.~'a. ~~~~rf~ ~~,,~ e , J.,
dated
A. This is the Annual Report for the period from ~ ~ ,~ ~ ' Gi t-~'
to ~~~s.~ ,~ G~'l (the " eport Period"); or
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
For a Final Report, omit Sections II through IV.
Form G-03 rev. 10.13.06
J., dated
Page 1 of 4
Estate of ~~'-~~ ~~'~~'~ S' ~~-~-~~~~-~ ~~''~ > >~~~ , an Incapacitated Person
II. PERSONAL DATA
Age of the Incapacitated Person: ~~
III. LIVING ARRANGEMENTS
A. Current address of the Incapacitated Person:
Date of Birth: ,~ %~J~~k ~`~ La. ~~
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
relative's home (name, relationship and address)
other:
C. The Incapacitated Person has been in the present residence since ~u-~ ~' %,y~'
~ 1~,~- If the 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 ~~;,y~l~:~ ~ ~~c1ty~~- ~~~~ ~~~C /-~,~~,,~-l;,v ,S~ ~ , an Incapacitated Person
~%~~./,~s /,~ ~ ~,~- ~ 7G~.3
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:
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B. Specify what, if any, social, medical, psychological and support services the
Incapacitated Person is receiving:
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V. GUARDIAN'S OPINION
A. It is the opinion of the Guardian of the Person that the guardianship should:
ontinue
be modified
be terminated
Form C-03 rev. 10.13.06 Page 3 of 4
Estate of ~ ~~, F,~~~,~,/„~~ S~" ("~rs~e , d~ )7~ l~ , an Incapacitated Person
The reasons for the foregoing opinion are: 'r ~ ~ ~ i~ ~~~~ i ~;~{ 5~~-,~ ~~~ h~ ~.~
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B. During the past year, the Guardian of the Person has visited the Incapacitated Person
times with the average visit lasting 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.
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Date nature of Guardian oft e Person
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Name of Guardian of the Person (type or pr t)
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Address
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City, State, Zip
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Telepho
Form G-03 rev. 10.13.06 Page 4 of 4