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03 _o 6
ANNUAL REPORT OF n ro— 1v „ m°
GUARDIAN OF THE PERSON z (n ° o
� C-� o -t; -„ -n
M
COURT OF COMMON PLEAS OF cn o j
COUNTY,PENNSYLVANIA
ORPHANS' COURT DIVISION
Estate of `I / -C • an Incapacitated Person
No. a/ 0 17UI
I. INTRODUCTION / , )
/ 11 /� l A • N(/�11� � � �' was appointed
0 Plenary eLimited Guardian of the Person by Decree of Ea.,q
dated
® A. This is the Annual Report for the period from AIPWI _ L°Z
to J 6 3 L— dell-? (the"Report Period');or
0 B. This is the Final Report for the period from
to (the"Report Period"), and is filed
for the following reason:
I. The death of the Incapacitated Person. Date of death:
2. The Guardianship was terminated by the Court by Decree of
7.,dated
For a Final Report,omit Sections II through TY.
Form 6-03 rev.10,13.06 Page I of
IC
Estate of __ �?i1 i ll( /f r' an Incapacitated Person
H. PERSONAL DATA
Age of the Incapacitated Person: Date of Birth:
III. LIVING ARRANGEMENTS
A. Current address of the Incapacitated Person:
B. The Incapacitated Person's residence is:
D_own home/apartment
0 nursing home
Q boarding home/personal care home
M Guardian's home/apartment
hospital or medical facility
relative's home(name,relationship and address)
O other:
C. The Incapacitated Person has been in the present residence since
If the Incapacitated Person has moved within the
past year, state prior residence and reason(s)for move:
Form G-03 rm 10.13.06 Page 2 of 4
Estate of /10 `i ��G"" an Incapacitated Person
D. Name and address of the Incapacitated Person's primary caregiver:
1<1�m A
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:
�OPINION
V. GIIA RD IAN'S
A. It is the opinion of the Guardian of the Person that the guardianship should:
continue
0 be modified
0 be terminated
Form G-03 rev. 10.13.06 Page 3 of 4
Estate of U .an Incapacitated Person
The reasons for the foregoing opinion are:
t h-eA.r�
f
B. During the past year,the Guardian of
IV Person has visited the Incapacitated Person
�t� times with the Zv e visit lasting hours, minutes. j
coo�e report of social service organization employed by the Guardian to oversee and
e 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. § 4404
relative to unsworn A,fallsification to authorities. lob
Date s—'YSmra,Y ofGuccdron aftse Person
L= t` JJ , 1/4z L'..r'0✓-
Name of Guardian of the Person(type or print)/
// Q"lV+
Addnas I
City,$ade,Zip
Telephone
Form G43 m.10.13.06 . Page 4 of 4