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ANNUAL REPORT OF
GUARDIAN OF THE ESTATE
COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
Estate of Mimi Blazer
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an Incapacitated Person
No. 21-09-1029
I. INTRODUCTION
STEPHANIE E. CHERTOK ,was appointed
Plenary ~ Limited Guardian of the Estate by Decree of J. WESLEY OLER,JR. J
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dated 12/28/09
A. This is the Annual Report for the period from ,
to (the "Report: Period"); or
B. This is the Final Report for the period from DECEMBER 28 2009
to JANUARY 23 ~ 2010 (the "Report Period"), and is filed
for the following reason:
1. The death of the Incapacitated Person. Date of death: 1/23/10.
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
Estate of Mimi Blazer , .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
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.):
$ 0.00
$ 0.00
$ 0.00
$ 0.00
2. Have there been any expenditures from the principal
during the Report Period? ............................ ~ Yes ~ No
If yes:
a. Have all expenditures from the principal been for
the sole benefit of the Incapacitated Person? ........ ^ Yes ^ No
Form G-02 rev. 10.13.06 Page 2 of 5
Estate of Mimi Blazer
b. List purpose and amount of expenditures:
,An Incapacitated Person
c. Was Court approval received prior to
expending the principal? ....................... ^ Yes ^ 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? ........... ~ Yes ~ No
If yes:
a. Was Court approval requested prior to
receiving the additional principal? ................ ^ 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,
pension, rents, etc.):
Total income received during Report Period:
~ o.oo
Form G-02 rev. 10.13.06 Page 3 of 5
Estate of Mimi Blazer
2. How is income currently invested? (Please
specify, e.g., restricted bank accounts, client
care account, etc.):
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.):
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
~~n Incapacitated Person
Court
Approval Obtained
~ Yes Q No
Yes ~ No
Form G-02 rev. 10.13.06 Page 4 of 5
Estate of Mimi Blazer
~~n 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 subject to the penalties of 18 Pa.C.S. § 4904
relative to unsworn falsification to authorities.
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Date ignatur of Guardian of the Estate
Name of Guardian of the Estate (type or print)
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Address
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City, State, Zip
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Telephone
Form G-02 rev. 10.13.06 Page 5 of 5