HomeMy WebLinkAbout12-02-13 ANNUAL REPORT RECORDED OFFICE Of
OF GUARDIAN OF THE ESfFOJJTER OF WILLS
1013 DEC 2 PR 1 05
COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY,PENNSYLVANIACLERK OF
ORPHANS' COURT DIVISION ORPHANS' COURT
CUMBERLAND CO., PA
Estate of Sven O. Jensen an Incapacitated Person
No. 21-09-0807
I. INTRODUCTION
Keystone Guardianship Service was appointed
®Plenary ❑ Limited Guardian of the Estate by Decree of M.L. Ebert J.,
dated September 29 2009
® A. This is the Annual Report for the period from September 30 2012
to September 29 , 2013 (the 'Report Period"); or
❑ B. This is the Final Report 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 I of 5
Estate of Sven O. Jensen an Incapacitated Person
II. SUMMARY
A. State the value of the estate reported on the Inventory $504,534.10
B. State the value(s) of income and principal assets at the
beginning of the Report Period. (Same as Inventory if first
otherwise, ending balance from last Report.)
Principal $307,638.06
Income $20,710.53
C. What is the total amount of income earned during the
Report Period? $38,198.86
D. What is the total amount of income and principal
spent for al I purposes during the Report Period? $(82,005.16)
F. What are the balances remaining at the end of the Report
Period?
I. Principal $258,850.80
2. Income $ 25,691.49
3. Total of Principal and Income $284,542.29
III. ADDITIONAL, INFORMATION
(!f 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.):
HNB Checking #100110983 $2,198.37
Jackson National IRA #1005683323 $208,437.43
Halifax Bank CD #300114354 $15,000.00
Mid Penn CD 4301084438 $10,000.00
Mid Penn CD 4301084437 $15,000.00
Burial Reserve: Hollinger Funeral Home $8,215.00
Total Principal Balance: $258,850.80
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
b. List purpose and amount of expenditures:
All principal used is transferred to Income.
Page 2 of 5
Estate of Sven O. Jensen an Incapacitated Person
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
I. State sources and amounts of income received during
the Report Period (e.g., Social Security, pension, rents,
etc.):
Interest Income $304.17
Annuity Income $12,872.69
US Treasury—Social Security $23,883.00
US Treasury—2012 Federal Tax Refund $1,139.00
Total income received during Report Period: $38,198.86
2. How is income currently invested? (Please
specify, e.g., restricted bank accounts, client
care account, etc.):
HNB Checking 9100110983 $6,305.75
Mid Penn Bank CD #301084437 $265.74
Mid Penn Bank CD #301084438 $373.62
Jackson National IRA 41005683323 $18,746.38
Total Income Balance: $25,691.49
Page 3 of 5
Estate of Sven O. Jensen an Incapacitated Person
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.):
Arden Courts $62,178.50
Commonwealth of PA Mobile Dentistry $130.00
Family Practice Center $30.00
Freedom Blue PPO $15.00
Manor Care Health Services LLC $5,625.00
On Sight Healthcare $324.43
Pinnacle Health Hospitals $129.48
See Right Pharmacy $3,105.81
Total Expenses for Care and Maintenance: $71,538.22
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.)
Comcast $867.29
Halifax National Bank—checks $16.67
Keystone Guardianship—costs $273.30
Keystone Guardianship— reimbursed $272.83
Leona Shaffer—tax preparation 595.00
Patriot News $65.00
Register of Wills $15.00
Total for Other Expenditures: $1,605.09
E. Guardian's Commissions
List amounts of compensation paid as Guardian's commission
and state how amount was determined:
Court
Amount Method of Determination Approval Obtained
$3,575.00 Fees ($75.00 per hour) [1 Yes ❑ No
Page 4 of 5
Estate of Sven O. Jensen an Incapacitated Person
F. Counsel Fee
List amounts paid as counsel fee, and indicate whether Court approval was obtained.
Court
Amount Approval Obtained
N/A ❑ Yes ❑ 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.
ft�dS�l3 e�A-11JAIL,
Dale Signa ire of Guardian of the Estate
Melanie Peters
Name of Guardian of the Estate(type or print)
PO Box 804
Address
Elizabethvillc Pa 17023
City,State,ZIp
717-674-5757
Telephone
Page 5 of 5
Income Statement- SQL-Ledger Version 2.8.27- Sven Jensen-kg-sj... http://keyguard.anteii.conifrp.pi
Sven Jensen
INCOME STATEMENT
for Period
September 30 2012 To September 29 2013
INCOME Sep 30 2012
Sep 29 2013
Interest Income 304.17
Annuity Income 12,872.69
US Treasury - Social Security 23,883.00
refund of payment 1,139.00
TOTAL INCOME 38,198.86 -
EXPENSES
Purchases 272.83
Nursing Home Expenses 67,803.50
Federal Tax Witheld 5,286.85
Medical 3,734.72
Check Charge 16.67
Keystone Services Cost 273.30
Keystone Services Fees 3,575.00
Household Expenses 1,042.29
TOTAL EXPENSES 82,005.16
INCOME / (LOSS) (43,806.30)
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Account 4018-refund of payment/Sven Jensen- SQL Ledger Versio... h ttp://keyguard.anteil.com/ea.pl?path=bin/mozilla&action=list_transa...
Account 4018 - refund of payment / Sven Jensen
September 30 2012 - September 29 2013
Date Reference Description Debit Credit Balance
20,830.35
04-05-2013 Deposit US Treasury - 2012 Federal tax refund 1,139.00 21,969.35
1,139.00
1,139.00 21,969.35
1 oft 11/13/2013 9:15 AM
AP Transactions/Sven Jensen- SQL-Ledger Version 2.8.27- Sven J... http://keyguard.anteil.com/ap.pl?action--transactions&direction=AS...
AP Transactions / Sven Jensen
From September 30 2012
To September 29 2013
Open
Closed
Vendor Date Invoice Description Total Paid
Arden Courts 10-05-2012 Check #409 5,485.00 5,485.00
Arden Courts 11-21-2012 Check #416 5,464.00 5,464.00
Arden Courts 01-02-2013 Check #424 5,000.00 5,000.00
Arden Courts 01-08-2013 Check #426 6,178.50 6,178.50
Arden Courts 03-06-2013 Check #435 5,660.00 5,660.00
Arden Courts 04-05-2013 Check #440 11,454.00 11,454.00
Arden Courts 05-08-2013 Check #448 5,730.00 5,730.00
Arden Courts 08-05-2013 Check #462 17,207.00 17,207.00
✓62,178.50 62,178.50
Comcast 10-05-2012 Check #407 70.48 70.48
Comcast 11-06-2012 Check #413 70.47 70.47
Comcast 11-20-2012 Check #415 70.48 70.48
Comcast 12-31-2012 Check #422 70.48 70.48
Comcast 02-07-2013 Check #431 70.48 70.48
Comcast 03-06-2013 Check #437 70.48 70.48
Comcast 04-05-2013 Check #442 74.07 74.07
Comcast 04-29-2013 Check #447 74.07 74.07
Comcast 06-04-2013 Check #451 74.07 74.07
Comcast 07-08-2013 Check #456 74.07 74.07
Comcast 08-05-2013 Check #464 74.07 74.07
Comcast 09-09-2013 Check #469 74.07 74.07
867.29 867.29
Comm. of PA Mobile Dentistry 11-06-2012 Check #411 65.00 65.00
Comm. of PA Mobile Dentistry 09-09-2013 Check #470 65.00 65.00
✓130.00 130.00
Family Practice Center 12-31-2012 Check #421 5.00 5.00
Family Practice Center 01-17-2013 Check #428 5.00 5.00
Family Practice Center 03-06-2013 Check #438 5.00 5.00
Family Practice Center 04-05-2013 Check #444 5.00 5.00
Family Practice Center 07-08-2013 Check #458 5.00 5.00
Family Practice Center 08-05-2013 Check #463 5.00 5.00
V30.00 30.00
Freedome Blue PPO 10-05-2012 Check #408 6.90 6.90
Freedome Blue PPO 07-19-2013 Phone Payment 8.10 8.10
✓15.00 15.00
Halifax National Bank 02-20-2013 Auto Deduction - 16.67 16.67
16.67 16.67
Keystone Guardianship- costs 10-08-2012 Check #410 17.00 17.00
Keystone Guardianship- costs 11-06-2012 Check #414 9.23 9.23
Keystone Guardianship- costs 12-07-2012 Cheeck #417 10.73 10.73
Keystone Guardianship- costs 01-08-2013 Check #425 24.27 24.27
Keystone Guardianship- costs 02-08-2013 Check #433 16.88 16.88
Keystone Guardianship- costs 03-08-2013 Check #439 38.67 38.67
Keystone Guardianship- costs 04-08-2013 Check #446 24.11 24.11
Keystone Guardianship- costs 05-10-2013 Check #450 30.91 30.91
Keystone Guardianship- costs 06-06-2013 Check #452 30.87 30.87
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AP Transactions/Sven Jensen- SQL-Ledger version 2.8.27- Sven J... http://keyguai d.anteit.com/ap.pl?action=transactions&direction=AS...
Keystone Guardianship- costs 07-12-2013 Check #459 28.60 28.60
Keystone Guardianship- costs 08-15-2013 Check #466 31.15 31.15
Keystone Guardianship- costs 09-11-2013 Check #471 10.88 10.88
273.30 273.30
Keystone Guardianship - fees 10-08-2012 Check #410 200.00 200.00
Keystone Guardianship - fees 11-06-2012 Check #414 200.00 200.00
Keystone Guardianship - fees 12-07-2012 Check #417 200.00 200.00
Keystone Guardianship - fees 01-08-2013 Check #425 543.75 543.75
Keystone Guardianship - fees 02-08-2013 Check #433 243.75 243.75
Keystone Guardianship - fees 03-08-2013 Check #439 543.75 543.75
Keystone Guardianship - fees 04-08-2013 Check #446 412.50 412.50
Keystone Guardianship - fees 05-10-2013 Check #450 225.00 225.00
Keystone Guardianship - fees 06-06-2013 Check #452 225.00 225.00
Keystone Guardianship - fees 07-12-2013 Check #459 262.50 262.50
Keystone Guardianship - fees 08-15-2013 Check #466 318.75 318.75
Keystone Guardianship - fees 09-11-2013 Check #471 200.00 200.00
3,575.00 3,575.00
Keystone Guardianship - Purchase 03-08-2013 Check #439 234.95 234.95
Keystone Guardianship - Purchase 05-10-2013 Check #450 18.94 18.94
Keystone Guardianship - Purchase 07-15-2013 Check #460 18.94 18.94
272.83 272.83
Leona Shaffer 04-05-2013 Check #441 95.00 95.00
95.00 95.00
Manor Care Health Services LLC 09-09-2013 Check #468 5,625.00 5,625.00
1/5,625.00 5,625.00
On Sight Healthcare 10-05-2012 Check #406 108.31 108.31
On Sight Healthcare 12-31-2012 Check #419 216.12 216.12
V324.43 324.43
Patriot News 07-08-2013 Check #457 65.00 65.00
65.00 65.00
Pinnacle Health Hospitals 01-17-2013 Check #429 10.37 10.37
Pinnacle Health Hospitals 02-07-2013 Check #432 13.07 13.07
Pinnacle Health Hospitals 04-05-2013 Check #445 53.02 53.02
Pinnacle Health Hospitals 07-08-2013 Check #454 53.02 53.02
U129.48 129.48
Register of Wills 12-21-2012 Check #418 15.00 15.00
15.00 15.00
See Right Pharmacy 10-05-2012 Check #405 308.33 308.33
See Right Pharmacy 11-06-2012 Check #412 300.60 300.60
See Right Pharmacy 12-31-2012 Check #423 451.61 451.61
See Right Pharmacy 01-08-2013 Check #427 443.97 443.97
See Right Pharmacy 02-07-2013 Check #430 188.14 188.14
See Right Pharmacy 03-06-2013 Check #149.46 149.46 149.46
See Right Pharmacy 04-05-2013 Check #443 146.17 146.17
See Right Pharmacy 05-08-2013 Check #449 162.60 162.60
See Right Pharmacy 06-11-2013 Check #453 165.74 165.74
See Right Pharmacy 07-08-2013 Check #455 218.20 218.20
See Right Pharmacy 08-14-2013 Check #465 233.68 233.68
See Right Pharmacy 09-09-2013 Check #467 337.31 337.31
{/3,105.81 3,105.81
76,718.31 76,718.31
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AP Transactions/Sven Jensen- SQL-Ledger Version 2.8.27- Sven J... http://keyguard.anteif.com/ap.pl?action=transactions&direction=AS...
AP Transaction Vendor Invoice.
3 of 11/12/2013 4:31 PM
Balance Sheet- SQl`.Ledger Version 2.8.27 - Sven Jensen- kg-sjensen http://keyguard.anteil.comirp.pi
Sven Jensen
BALANCE SHEET
as at Sep 29 2013
ASSETS
Sep 29 2013
Income- HNB Checking #100110983 6,305.75
Income- Mid Penn CD #301084437 (matures 12/14/2013) 265.74
Income- Mid Penn CD #301084438 (matures 8/14/2014) 373.62
Income- Jackson National Insurance- IRA #1005683323 18,746.38
Principal- HNB Checking #100110983 2,198.37
Jackson National Insurance- IRA #1005683323 208,437.43
Halifax Bank CD #300114354 (matures 9/14/2013) 15,000.00
Mid Penn CD #301084438 (matures 8/14/2014) 10,000.00
Mid Penn CD #301084437 (matures 12/14/2013) 15,000.00
Burial Reserve: Hollinger Funeral Home &Crossroads Cemetary Asso. 8,215.00
TOTAL ASSETS 284,542.29
LIABILITIES
........................__..__.....
TOTAL LIABILITIES -
SHAREHOLDER'S EQUITY
Assets at time of Appointment 504,534.10
Assets discovered after Appointment 2,693.67
Current Earnings (222,685.48)
TOTAL EQUITY 284,542.29
TOTAL LIABILITIES & EQUITY 284,542.29
I of] 11/12/2013 4:22 PM