HomeMy WebLinkAbout03-12-14 N ,
ANNUAL REPORT OF
GUARDIAN OF THE PERSON
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COURT OF COMMON PLEAS OF mz
CtiVnb-�,Ox�� COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
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Estate of an Incapacitated Person
No. Al-14
I. INTRODUCTION
, was appointed
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14Plenary[Limited Guardian of the Person by Decree of 7�- u 1 eowzy- J.,
dated SLR rto_ U , 9,0 t
10 A. This is the Annual Report for the period from 9-6-
to 12-3.1-1', (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:
1. The death of the Incapacitated Person. Date of death:
2. The Guardianship was terminated by the Court by Decree of
J., dated
For a Final Report, omit Sections II through IV.
Fo„„c-03 rev. 10.13,06 Page 1 of 4
Estate of an Incapacitated Person
II. PERSONAL DATA Q
Age of the Incapacitated Person: Date of Birth:
III. LIVING ARRANGEMENTS
A. Current address of the Incapacitated Person:
C",\isle PA Ilbl3
B. The Incapacitated Person's residence is:
®own home/apartment
®nursing home
boarding home/personal care home
193uardian'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 20( f
If the Incapacitated Person has moved within the
past year, state prior residence and reason(s) for move:
Form G-03 rev. 10.13.06 Page 2 of 4
4
y%
Estate of 'Owu t V- W eiA.0 ex- an Incapacitated Person
D. Name and address of the Incapacitated Person's primary caregiver:
3hrnE-
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:
AL
V. GUARDIAN'S OPINION
A. It is the opinion of the Guardian of the Person that the guardianship should:
ontinue
®be modified
®be terminated
Form G-03 rev. 10.13.06 Page 3 of 4
1 .
Estate of C—�U l Q . UJ 2QUJ 2.1' an Incapacitated Person
The reasons for the foregoing opinion are:1r�o�C
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.
Date Signature of Guardian of the Person
N-Li\'�we E . ,is
Name of Guardian of the Person(type or t)
Address
( ats�e Pa ►70 3
Ci9.State.Zip
Telephone
Form G-03 rev.10.13.06 Page 4 of 4