HomeMy WebLinkAbout11-19-12 (8)rr 17
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ANNUAL REPORT OF ,fl
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GUARDIAN OF THE ESTATE r
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COURT OF COMMON PLEAS OF ~' ca
_ COUNTY, PENNSYLVANIA
Cumberland County
ORPHANS COURT DIVISION
_, an Incapacitated Person
Estate of Inez H. Davis
„r„ 21-07-0200
was appointed
I, INTRODUCTION _~
Qloria J. Banks Oler ' ~"
Limited Guardian of the Estate by Decree of
mPlenary
dated April 4, 2007
2011
Jul 12 -~
p. This is the Annual Report for the period from Y -~-'
201 (the "Report Penod"); or
to Jul 11
ort for the period from ~-
g. This is the Final Rep p and is filed
(the "Re ort Period"),
to
for the following reason:
l , 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
Farm G-172 rev. 10.13.06
Estate of Inez H. Davis , Ari Incapacitated Person
II. SUMMARY
A. State the value of the estate reported on the Inventory $ 75.00
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.) $ 690.77
C. What is the total amount of income earned during the
Report Period? $ 17,143.72
D. What is the total amount of income and principal
spent for all purposes during the Report Period? $ 17,532.77
E. What are the balances remaining at the end of the Report
Period?
1. Principal $ 301.72
2. Income $ 0.00
3. Total of Principal and Income $ 301.72
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.):
Principal is maintained in an interest-bearing Resident Trust Account at
Golden Living Center, the nursing home in which the Incapacitated Person
receives care.
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 c-oz rev. 10.13.06 Page 2 of 5
Estate of Inez H. Davis
b. List purpose and amount of expenditures:
misc personal care items
An Incapacitated Person
389.05
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
State sources and amounts of income received
during the Report Period (e.g., Social Security,
pension, rents, etc.):
Social Security
Pension
Total income received during Report Period:
$ 3,932.00
$ 13,2]1.42
$ 17,143.42
Form c-oz ren. 10.13.06 Page 3 of 5
Estate of Inez H. Davis , An Incapacitated Person
How is income currently invested? (Please
specify, e.g., restricted bank accounts, client
care account, etc.):
Income is maintained in an interest-bearing Resident Trust Account at
Golden Living Center, the nursing home in which the Incapacitated Person
receives care.
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.):
The Incapacitated Person is a Medical Assistance recipient at a long-term care
facility. Her income, with the exception of $45 per month personal needs
allowance, is applied to the cost of her nursing facility care. The personal needs
allowance is applied to the cost of personal care needs such as clothing and hair
care.
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
Courl
Approval Obtained
none
Yes ~No
Yes ^No
Fo.m c-oz .ev. in ~a.oe Page 4 of 5
Estate of Inez H. Davis
An Incapacitated Person
F. Counsel Fee
List amounts paid as counsel fee, and indicate whether Court approval was obtained.
Amount
Court
Approval Obtained
None ~~ Yes 0 No
Yes ~ No
I verify that the foregoing information is correct to the best of my Irnowledge,
information and belief; and that this Verification is subject to the penaltie~o of 18 Pa.C.S. § 4904
relative to unsworn falsification to authorities.
Signature ojGvardia he Esrore
Date
Gloria J. Banks
Name ofGvardion ojthe Estate (type or prior)
576 Catherine Street
Harrisburg, PA 17112
Ciry, Emre, Zip
717 545-481
TelepMne
Page 5 of 5
Form G-01 rev. 10./3.06