HomeMy WebLinkAbout11-28-11 (3)ANNUAL REPORT OF
GUARDIAN OF THE ESTATE ~
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COURT OF COMMON PLEAS OF
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COUNTY, PENNSYLVANIA ,-~",' ~.z7 GO
ORPHANS' COURT DIVISION , ~ _ ~- ~ -,-r
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Estate of D~J ~ , an Incapacitated Person
L INTRODUCTION
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L~ ~ '\ i ~~ ~ ~' l 0 ~ ~ ~ `, ~~ ~ ' ,was appo' ted
^ Plenary limited Guardian of the Estate by Decree of ~ ~ ~ f~ ~k ~ J.,
dated ~ ~ C . lam, ~ ~'~~ ~ '
^ A. This is the Annual Report for the period from 0 ~ ~ ~d I~ ~~~~
to ~ ~ 7- ~ 1 , ~-`' l~ (thc "Rcport eriod"); or
^ B. This is the Final Report for the period from ,
to ,
for the following reason:
(the "Report Period"), and is filed
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
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Form G-02 rev. 10.13.06 Page I of 5
Estate of ~~' ~ ~ ~ ~' ~ ~'U H- f ~ D ~ ~ ~ , 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
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$ ~ 1, r~ ~ ~
$ Lc ~1 ~~~
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1. How is the principal balance listed above currently
invested? (Please specify, e.g., real estate,
certificates of deposit, restricted bank accounts, etc.):
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
b. List purpose and amount of expenditures:
An Incapacitated Person
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$ ~
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
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
a~
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:
Form G-02 rev. 10.13.06
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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.):
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
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Form G-02 rev. 10.13.06
Court
Approval Obtained
^ Yes ^ No
^ Yes ^ No
Page 4 of 5
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.):
Estate of ~, ~ ~ ~ ~. ~~~'t' //d '"v ~ ~ , An Inca acitated Person
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F. Counsel Fee
List amounts paid as counsel fee, and indicate whether Court approval was obtained.
Amount
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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 Signature of Guardian of the Estate
Name of Guardian of the Estate (type or print)
Address
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Telephone
Form G-02 rev. 10.13.06 Page 5 of 5