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HomeMy WebLinkAbout01-10-12`-~ -- '~ . -- ANNUAL REP~~T Off: -? _ ~1[TA~DIAN ®F T~-IE ESTATE _ . _, , - -.. ~_- .~, -.- COURT OF COMMON PLEAS OF -~' C i.1 ~1 ~3F~Zi.-P5 1V D COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION . ~'~ . ~' t the I~, an Incapacitated Person Estate of A ~ No.:i, I _ ~ G... p ~ C I. INTRODUCTION ~ ~~~ ~ 0~~~ ~ ~ appointed _ ~ 1J J., Plenary ~ Limited Guardian of the Estate by Decree. of dated A. This is the Annual Report for the period from to (~ ' ~ ~ r ?,U ,~ ~ _ (the "Report Period"); or B. This is the ~a~al Repot 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: Name of Personal Representative: 2. The Guardianship was terminated by the Court by Decree of J., dated Page 1 of 5 Form G-02 rev. 10.13. D6 ~' _._. -- .. .. c. ~ p _ _ _ ~ " ~ An Inca acitated Person Estate of gI, SYJIvIlV1~iR~' A. State the value of the estate reported on the Inventory B, State the value(s) of p~e pasallass n ~ if firs~Reportof the Report Period. (S 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 CS $ ~_ 2. Income 3;. Total of Principal and Income III. ADDITIONAL IlITPORMA~TeO ~ ch additional pages.) (If more space is needed, p 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.): $ ~ $ -- ~ $ .~~ $ ---{~- $ ~~ X00.00 ~~ ~ n , ~~ 2. Have there been any expenditures from the principal 0 Yes ~ No during the Report Period? ......................... . If yes: a. Have all expenditures from the principal been for the sale benefit of the Incapacitated Person? ........ ^ Yes ^ No Page 2 of 5 Form x,_02 rev. 10.13.06 .. .. ~-~~ ~ -~~ " " " "- Ari Incapacitated Person " .- Estate of ~ ~~ e" (~` V b. List pur ose and amount of expenditures: $ r, ~G,L~ , ~ G CC~.`~~~ ----- g_ ~~ ~-- Q '~ $ c, Was Court approval received prior to yes ®No expending the principal? ....... . ............ . 3, Were additional prin were not included inthe g the Report Period which ~ ~ yeS ~No Inventory or a prior Report filed for the Estate. If yes: a, "Was Court approval requested prior to ®yeS ©No .receiving the additional principal? ............ b. State the sources and amounts of the additional principal received: ~, l:ncome 1. State sources and amounts of income received during the Report Period (e.g., Social Security, pension, ren~etc.)~ ~~~ i 1 S OCR- C ~ S ~ ~ ~5 Total income received during Report Period: ~ E~ a .~ ~ ~ ~ ~.~ $ ~ ~~° ~ $ ~ }~ ~ ~~. Rio Page 3 of 5 Form G-01 rev. 10.13.06 ~....... _ .. g ~t"~ ~~ An Incapacitated Person .... _ _ ._ ~,~ 1C,c,t .. l Y l Estate of 2. How is income currently invested? (Please specify, e.g., restricted bank accounts, client care account, etc.): C, 1Expenses for Care and 1~Iaiaitenance Specify what expendituresaw~enance ofthe Incapac tatedand income for the care and m Person (e.g., clothing, nursing home, medicine, support, etc.): ~6 ~' ~~ . X1'1 e~c~~ ~, Q~ther Ezpendafures ~ the Re ort Specify what other expenditurem scat d in rsponse to p Period. (Do not include any question C above.) N o tint e. E. Guardian's Commissions List amounts of compensation paid as Guardian's commission and state how amount was determined: Court 1Qppt°oval Obtained .Amount Method ofDetermination (.~ h~l ,~ ~ Yes ~ No _['~__iYes [~No Page 4 of 5 Form G-02 rev. 10.13.06 __ .. _. _ ... ~.G.. _~ An Incapacitated Person _ ._ Estate of ..... ~ C ~, Counsel fee List amounts paid as counsel fee, and indicate whether Court approval was obtained. Co 1lYt Approval Obtained Amount ~ ~ ~ Yes 0 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.. C~ ~~ ~,~cp ~ 3, Z ~l ~ v Date KARTIC C. CUSS X23-2231180 CERTIFIED PURLEN LAOPA 11025 125 N. ENOIA DR. ~. ~___ ~ _ ._ -~ Signature of Guardian of the Estate ~oy~c~~ l~ ~ ~ ~uc~ hr~e afGuardian of the Estate (type or print) ii ', ; ,4ddress City, State, Zip 73 ~.-.~ o ~- 3 G Telephone Page 5 of 5 ~~,~~~~~ c~7 ~ ~~ ,Form G-02 rev. 10.13.06