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ANNUAL REPORT OF °~, c~ `~~' --~
GUARDIAN OF THE PERSON ~~' ~~= `-~'~ `~" "~ ,_~-;~
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COURT OF COMMON PLEAS OF
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C~Lf tl i ~~~. ~ ~- W N_ ~ COUNTY, PENNSYLVAI`~~A t:.~~
ORPHANS' COURT DIVISION
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Estate of _ ~.,if~ f/~- /~( y~'- L.... ~ (tc /~5 ~ , an Incapacitated Person
I. INTRODUCTION
_.., , ~ _ j
-~~/ ~- ~ ~' "~-~- ,was appointed
,® Plenary ®Limited Guardian of the Person by Decree of~ ~~ /~i ~_ ~:}L. ~. , J.,
dated G% -~ /~ ~' ~~ ~'~ / ~
^ A. This is the Annual Report for the period from ~~ ;•G~..-~~-- /~~ _ D ~'
to ~~~-yl.L~~-r~ ~i `~/ ~~c~ /~:~d (t e "Report Period"); 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:
2. The Guardianship was terminated by the Court by Decree of
For a Final Report, omit Sections II through IV.
J., dated
Form G-03 rev. 10.13.06 Page 1 of 4
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Estate of ~ ~ , an Incapacitated Person
II. PERSONAL DATA
Age of the Incapacitated Person: _ ` ~ Date of Birth: ~~" ~`f' " ~ ~ 1r~
III. LIVING ARRANGEMENTS
A. Current address of the Incapacitated Person:
B. The Incapacitated Person's residence is:
^ own home /apartment
® nursing home
~ boarding home /personal care home
® Guardian's home /apartment
^ hospital or medical facility
®relative's home (name, relationship and address)
^ other:
C. The Incapacitated Person has been in the present residence since ~ - ~, !~' l~1 ~ f
`~"~ ~ - ~~ ~ If the Incapacitated Person has moved within the
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past year, state prior residence and reason(s) for move:
Form G-03 rev. 10.13.06 Page 2 of 4
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Estate of ~ ~~ I~ f~ I~ ~--- ~7 k i ~5 ~ , an Incapacitated Person
D. Name and address of the Incapacitated Person's primary caregiver:
IV. MEDICAL INFORMATION
A. The major medical or mental problems of the Incapacitated Person are as follows:
B. Specify what, if any, social, medical, psychological and support services the
Incapacitated Person is receiving:
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V. GUARDIAN'S OPINION
A. It is the opinion of the Guardian of the Person that the guardianship should:
,~ continue
0 be modified
®be terminated
Form G-03 rev. 10.13.06 Page 3 of 4
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Estate of ~~~ ~ ~ ,/~ ,~'" ~ - ~ .~
f~~r.~ 'F ~ ~ `"1 ~ l •~5~~` , an Incapacitated Person
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The reasons for the foregoing opinion are: /
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B. During e past year, the Guardian of the Person has visited the Incapacitated Person
times with the average visit lasting ,:~~: hours, minutes.
The report of a social service organization employed by the Guardian to oversee and
coordinate the care of the Incapacitated Person for the period covered by this Report may be
attached to supplement this Report.
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.A. § 4904
relative to unsworn falsification to authorities.
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Date
Signature of Guardian he Person
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Name ojGuardian of the Person (type or print)
Address
City, State, Zip
Telephone
Form G-03 rev. 10.13.06 Page 4 of 4