Loading...
HomeMy WebLinkAbout02-06-13 (2) rn n C © ~.' rn ~ ~ ~ ~ cr ~ cn =~ ANNUAL REPORT OF ~~ ~ ~' -~ ~~' ~ ~ ~ ~, ~:,r~, ~~~ GUARDIAN OF THE PER SON ` ~ ~ -~~ C~ ...~„ '"`„~ ~:,~ ~ ~ ~ F._~ x.,,6"'1 ~' COURT OF COMMON PLEAS OF ' ~ ~~~ ~ z~ ~Ull~ ~ z~ ~ COUNTY PENNSYLVA NIA , ORPHANS' COURT DIVISION Estate of ~6~~~~ C~ ~ ~ , an Inca acitated Person P / ~- I. INTRODUCTION ~..._ appointed ~ - ~ Plenary ©Limited Guardian of the Person by Decree of , J., dated A. Thi is the Annu 1 Report for the period from 1 ~jd ~Q~ to ~'C,~.~~~Q~' ~jt ~- the " e ort Period" • oy° r ), ©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 Section s II through IV. J., dated Form c-o3 ,~e,~. io.l3.oh Page 1 of 4 „i~ Estate of T~~~~JS ~ c'1 . II. PERSONAL DATA Age of the Incapacitated Person: ~ III. LIVING ARRANGEMENTS an Incapacitated Person Date of Birth: ~ ' 22 A. Current address of the Incapacitated Person: ~1M~~~'US ~ -~'e~V~b~ l(11\ec~~v~c.~~r' , ~ , ~ 7~~~~ ~ 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 I~ ~ ~ li ~~~' ~`' ~~ If the Incapacitated Person has moved within the past year, state prior residence and reason(s) for move: Fo~~m c-o3 ,~e,~. gyn. ~ 3.0~ Page 2 of 4 Estate of , 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: ~.-~.,sr~~ ~~~~,~~~----~ C~~~ ~ ~ ~~~~' ~~~ ~ ~s ~~ ~'" C~~~~~~ Cpl ~'Gv ~~~ ~ l~~ G'~~' V. GUARDIAN'S OPINION A. It is the opinion of the Guardian of the Person that the guardianship should: 'continue be modified ©be terminated r~,~,~ c-n3 ,-~,~. gyn. r3.nh Page 3 of 4 Estate of , , an Incapacitated Person The reasons for the foregoing opinion are: ~~~~~ ~ ~ ~~ ~ss~~5 ~~~~~w ~ B. During the 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. 20 l Date Signahn•e of ~Guarnian o/'!he Person ~ ~G Name o/~Guarnian o ~lhe Person (tipe or prin!) ~h ~ U~!~yu ~y'. Andress O Cih~. State, "Lip 2tU ~ (~~~ ~ a2~ ~ Telephone ~F'~~c>~2 ~ ~ , /Zt~/ll ~ ~o G/2ca`~'p s' 7Zc~ (x,42. Form G-0.3 ren. 10.13.06 z1~ ~~ ~~.-~~~s~