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Home My WebLink About11-04-11ANNUAL REPORT OF GUARDIAN ~~ -,-~ OF THE ESTATE ~ ~ ~ ~~ ~ -r C7 _ ii- COURT OF COMMON PLEAS OF -- - ;'T1 ~;; ~ ~ _ CUMBERLAND COUNTY, PENNSYLVANIA ~ , `c _~ ORPHANS' COURT DIVISION ~-;:- C. Estate of Sven O. Jensen , an Incapacitated Person No. 21-09-0807 I. INTRODUCTION Keystone Guardianship Service ,was appointed ~X Plenary Limited Guardian of the Estate by Decree of M.L. Ebert __ _ ____________, J., dated _ 9/29/109___. A. This is the Annual Report for the period from September 30 2010__ to September 29 201 1 (the "Report Period"); or B. This is the Final Report for the period from to (the "Report Period"), and is tiled for the following reason: 1. 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 Page l of 5 Estate of Sven O. Jensen , an Incapacitated Person II. SUMMARY A. State the value of the estate reported on the Inventory $504,534.10 B. State the value(s) of income and principal assets at the beginning of the Report Period. (Same as Inventory if first otherwise, ending balance from last Report.) Principal $399,812.72 Inco-ne $15,018.62 L. What is the total amount of income earned during the Report Period? $32,981.51 D. What is the total amount of income and principal spent for all purposes during the Report Period? $(77,219.92) E. Federal taxes withheld $(1,031.73) H. What are the balances remaining at the end of the Report Period? 1. Principal $351,407.07 2. Income $ 18,154.13 3. Total of Principal and Income $369,561.20 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.): HNB Checking #100110983 $6,495.12 HNB Savings #200112953 $46,785.00 Jackson National IRA #1005683323 $249,911.95 HNB CD#300114354 $15,000.00 Mid Penn CD #301084438 $10,000.00 Mid Penn CD #301084437 $15,000.00 Burial Reserve: Hollinger Funeral Home $8,215.00 Total Principal Balance: $351,40'7.07 Page 2 of S Estate of Sven O. Jensen an Incapacitated Person 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 b. List purpose and amount of expenditures: All principal used is transferred to Income. c. Was Court approval received prior to expending the principal? ............................ 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? ...... If yes: a. Was Court approval requested prior to receiving the additional principal? ....................... 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.): Interest income Annuity income -Jackson National IRA US Treasury -Social Security Refund -Federal tax refund Total income received during Report Period: ® Yes ' No ................ .Yes ~Y No Yes No $475.35 $8,680.16 $22,794.0(1 $1,032.00 $32,981.51 Page 3 of 5 Estate of Sven O. Jensen , an Incapacitated Person 2. How is income currently invested? (Please specify, e.g., restricted bank accounts, client care account, etc.): HNB Checking #100110983 $886.40 Jackson National IRA #1005683323 $17,267.73 Total Income Balance: $18,154.13 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.): Advanced Podiatry Services $115.79 Arden Courts $62,505.95 Comm. Of PA Mobile Dentistry $65.00 Family Practice Center $105.00 Freedom Blue PPO $12.00 Heartland Healthcare Services $4,061.70 Mobile Dentistry $65.00 On Sight Healthcare $173.17 Pinnacle Health Hospitals $310.38 See Right Pharmacy $73.75 Total Expenses for Care and Maintenance: $67,487.74 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.) Comcast 822.15 Cumberland County -filing fees $15.00 Custer, Faust & Associates $165.00 Halifax National Bank $13.57 Hazen Elder Law $1,349.00 Keystone Guardianship -costs $950.46 PA Department of Revenue $27.00 Register of Wills $15.00 Total for Other Expenditures: $ 3,357.18 Page 4 of 5 Estate of Sven O. Jensen , an Incapacitated Person E. Guardian's Commissions List amounts of compensation paid as Guardian's commission and state how amount was determined: Court Amount Method of Determination Approval Obtained $6,375.00 ($75.00 per hour) Yes No F. Counsel Fee List amounts paid as counsel fee, and indicate whether Court approval was obtained. Court Amount Approval Obtained N/A ..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. ~o/2~f~ij Date Si afore of Gz~ardian of the Estate Constance E. Stoneroad Narne of Guardian of the Fstate (q=pe or print) .Address Elizabelhville. Pa 17023 Ciry, State. Gip 7/ 7-265-4056 telephone Page 5 of 5 Sven7ensen INCOME STATEMENT for Period September 30 2010 To September 29 2011 INCOME Interest Income Annuity Income US Treasury -Social Security refund of payment TOTAL INCOME EXPENSES Nursing Home Expenses Federal Tax Witheld Medical Check Charge Keystone Services Cost Keystone Services Fees Household Expenses TOTAL EXPENSES INCOME / (LOSS) Sep 30 2010 Sep 29 2011 475.35 8,680.16 22,794.00 1,032.00 32,981.51 62,505.95 1,031.73 4,981.79 13.57 950.46 6,375.00 2,393.15 78,251.65 (45,270.14) Sven7ensen BALANCE SHEET as at Sep 29 2011 ASSETS Sep 29 2011 Income- HNB Savings #200112953 886.40 Income- Jackson National Insurance- IRA #1005683323 17,267.73 Principal- HNB Checking #100110983 6,495.12 Principal- HNB Savings #200112953 46,785.00 Jackson National Insurance- IRA #1005683323 249,911.95 HNB CD #300114354 (matures 12/14/2011) 15,000.00 Mid Penn CD #301084438 (matures 7/14/2012) 10,000.00 Mid Penn CD #301084437 (matures 8/14/2011) 15,000.00 Burial Reserve: Hollinger Funeral Home & Crossroads Cemetary Asso. 8,215.00 TOTAL ASSETS 369,561.20 LIABILITIES TOTAL LIABILITIES - SHAREHOLDER'S EQUITY Assets at time of Appointment 504,534.10 Assets discovered after Appointment 2,693.67 Current Earnings (137,666.57) TOTAL EQUITY 369,561.20 TOTAL LIABILITIES & EQUITY 369,561.20 From September 30 2010 To September 29 2011 Open Closed Vendor Advanced Podiatry Services Advanced Podiatry Services Arden Courts Arden Courts Arden Courts Arden Courts Arden Courts Arden Courts Arden Courts Arden Courts Arden Courts Arden Courts Arden Courts Arden Courts Comcast Comcast Comcast Comcast Comcast Comcast Comcast Comcast Comcast Comcast Comcast Comcast Comcast AP Transactions / Sven Jensen Date Invoice Description 02-25-2011 Check #276 06-27-2011 Check #307 10-06-2010 11-04-2010 11-29-2010 12-29-2010 01-26-2011 02-28-2011 04-06-2011 04-27-2011 06-07-2011 06-27-2011 07-29-2011 08-29-2011 10-06-2010 10-28-2010 11-29-2010 12-29-2010 01-26-2011 02-25-2011 04-06-2011 04-27-2011 06-07-2011 06-27-2011 07-20-2011 08-23-2011 09-27-2011 Check #240 Check #250 Check #252 Check #259 Check #271 Check #278 Check #283 Check #295 Check 3303 Check #308 Check #315 Check #325 Check #243 Check #248 Check #253 Check #261 Check #270 Check #277 Check #284 Check #292 Check #301 Check #309 Check #311 Check #323 Check #330 Comm. of PA Mobile Dentistry 01-05-2011 Check 3264 Cumerland County General 12-27-2010 Check #258 Fund Total Paid 79.86 79.86 35.93 35.93 115.79 115.79 ~ 5,025.99 5,025.99 5,035.46 5,035.46 5,000.00 5,000.00 5,046.00 5,046.00 5,514.00 5,514.00 5,282.50 5,282.50 5,264.00 5,264.00 5,278.00 5,278.00 5,273.00 5,273.00 5,264.00 5,264.00 5,259.00 5,259.00 5,264.00 5,264.00 62,505.95 62,505.95 62.72 62.72 62.71 62.71 62.71 62.71 62.71 62.71 62.71 62.71 62.71. 62.71 62.71. 62.71 62.71 62.71 62.72 62.72 62.72 62.72 62.72 62.72 66.15 66.15 66.15 66.15 822.15 822.15 65.00 65.00 65.00 65.00 ~ 1:1.00 15.00 15.00 15.00 Custer, Faust & Associates Family Practice Center Family Practice Center Family Practice Center Family Practice Center Family Practice Center Family Practice Center Family Practice Center Freedome Blue PPO Freedome Blue PPO 04-18-2011 Check #288 10-06-2010 Check #242 10-28-2010 Check #247 12-15-2010 Check #255 01-21-2011 Check #269 04-27-2011 Check #293 06-07-2011 Check #302 07-20-2011 Check #312 01-12-2011 Check #267 01-26-2011 Check #272 165.00 165.00 165.00 165.00 .~ 15.00 15.00 15.00 15.00 15.00 15.00 1`1.00 15.00 15.00 15.00 1`.1.00 15.00 15.00 15.00 105.00 105.00 3.00 3.00 :3.00 3.00 Freedome Blue PPO 06-27-2011 Check #306 3.00 3.00 Freedome Blue PPO 09-27-2011 Check #329 :3.00 3.00 12.00 12.00 / Halifax National Bank 07-12-2011 Auto 13.57 13.57 deduction 13.57 13.57 '~ Hazen Elder Law 10-06-2010 Check #244 295.00 295.00 Hazen Elder Law 12-29-2010 Check #260 295.00 295.00 Hazen Elder Law 04-06-2011 Check #286 35:L.00 351.00 Hazen Elder Law 04-27-2011 Check #291 152.00 152.00 Hazen Elder Law 05-19-2011 Check #299 256.00 256.00 1,349.00 1,349.00 ~ Heartland Healthcare Services 10-19-2010 Check #245 669.27 669.27 Heartland Healthcare Services 11-15-2010 Check #251 707.20 707.20 Heartland Healthcare Services 12-15-2010 Check #257 82:3.90 823.90 Heartland Healthcare Services 01-12-2011 Check #268 75.31 75.31 Heartland Healthcare Services 02-17-2011 Check #275 129.70 129.70 Heartland Healthcare Services 03-07-2011 Check #281 15:3.97 153.97 Heartland Healthcare Services 04-18-2011 Check #290 191.58 191.58 Heartland Healthcare Services 05-19-2011 Check #298 165.20 165.20 Heartland Healthcare Services 06-27-2011 Check #305 172.80 172.80 Heartland Healthcare Services 07-20-2011 Check #313 300.13 300.13 Heartland Healthcare Services 08-10-2011 Check #319 340.47 340.47 Heartland Healthcare Services 09-13-2011 Check #327 332.17 332.17 4,061.70 4,061.70 / Keystone Guardianship- costs 10-04-2010 Check #238 19.82 19.82 Keystone Guardianship- costs 11-01-2010 Check #249 2:x.53 25.53 Keystone Guardianship- costs 12-02-2010 Check #254 2:3.30 23.30 Keystone Guardianship- costs 01-03-2011 Check #262 30.02 30.02 Keystone Guardianship- costs 02-01-2011 Check #273 62.70 62.70 Keystone Guardianship- costs 02-02-2011 Check #279 58;2.86 582.86 Keystone Guardianship- costs 04-01-2011 Check #282 1:3.12 13.12 Keystone Guardianship- costs 05-03-2011 Check #296 3:1.00 31.00 Keystone Guardianship- costs 06-02-2011 Check #300 94.29 94.29 Keystone Guardianship- costs 07-05-2011 Check #310 15.48 15.48 Keystone Guardianship- costs 08-03-2011 Check #317 40.38 40.38 Keystone Guardianship- costs 09-12-2011 Check #326 1:L.96 11.96 950.46 950.46 / Keystone Guardianship -fees 10-04-2010 Check #238 43:L.25 431.25 Keystone Guardianship -fees 11-01-2010 Check #249 712.50 712.50 Keystone Guardianship -fees 12-02-2010 Check #254 450.00 450.00 Keystone Guardianship -fees 01-03-2011 Check #262 600.00 600.00 Keystone Guardianship -fees 02-01-2011 Check #273 1,0613.75 1,068.75 Keystone Guardianship -fees 02-02-2011 Check #279 37 5.00 375.00 Keystone Guardianship -fees 04-01-2011 Check #282 24:3.75 243.75 Keystone Guardianship -fees 05-03-2011 Check #296 56 2.50 562.50 Keystone Guardianship -fees 06-02-2011 Check #300 71 2.50 712.50 Keystone Guardianship -fees 07-05-2011 Check #310 450.00 450.00 Keystone Guardianship -fees 08-03-2011 Check #317 431.25 431.25 Keystone Guardianship -fees 09-12-2011 Check #326 337.50 337.50 6,375.00 6,375.00 ~ Mobile Dentistry 07-29-2011 Check #316 6`i.00 65.00 65.00 65.00 ~ On Sight Healthcare PA Department of Revenue Pinnacle Health Hospitals Pinnacle Health Hospitals Pinnacle Health Hospitals Pinnacle Health Hospitals Pinnacle Health Hospitals Pinnacle Health Hospitals Register of Willsl See Right Pharmacy See Right Pharmacy See Right Pharmacy See Right Pharmacy See Right Pharmacy See Right Pharmacy See Right Pharmacy See Right Pharmacy See Right Pharmacy See Right Pharmacy 09-13-2011 Check #328 04-18-2011 Check #287 2010 state taxes 10-06-2010 Check #241 04-18-2011 Check #289 04-27-2011 Check #294 08-10-2011 Check #320 08-10-2011 Check #321 08-10-2011 Check #322 0-22-2010 Check #246 filing fee for annual report 10-06-2010 Check #239 12-15-2010 Check #256 01-05-2011 Check #263 02-03-2011 Check #274 03-07-2011 Check #280 04-06-2011 Check #285 05-19-2011 Check #297 06-07-2011 Check #304 07-20-2011 Check #314 08-29-2011 Check #324 AP Transaction Vendor Invoice. 17;3.17 173.17 173.17 173.17 ~ z7.oo z7.oo 27.00 27.00 ,/ 5;1.01 53.01 76.10 76.10 53.82. 53.82 5:3.82 53.82 59.76 59.76 1:3.87 13.87 310.38 310.38 15.00 15.00 15.00 15.00 ~ 5.99 5.99 .'i.39 5.39 5.39 5.39 1E~.17 16.17 3.59 3.59 10.78 10.78 10.27 10.27 5.39 5.39 5.39 5.39 5.39 5.39 73.75 73.75 77,219.92 77,219.92 Account 4018 -refund of payment / Sven Jensen September 30 2010 -September 29 2011 Date Reference Description Debit Credit Balance 5,837,45 05-10-2011 Deposit US Treasury - 2010 Federal tax refund 1,032.00 6,869.45 1,032,00 6,869.45