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Home My WebLink About06-10-14 ANNUAL REPORT OF GUARDIAN OF THE ESTATE � � COURT OF COMMON PLEAS OF �.= � � �'' CUMBERLAND COUNTY,PENNSYLVANIA i=<; � C �� ORPHANS' COURT DIVISION r�; ��- �? z ��> =� . .� __ ... r-- �, - .; ,::�T �� < � � ., c� 4..� �. ��' ;r {;7 c":°; "L� ;s —r� Estate of Ravmond Clark ,an Incapacita'ted�rsan- W';� . � ►--+ _- c� `i N 6.._ � '�� No. 21-12-0040 =-� c-z in c, � � I. INTRODUCTION Kevstone Guardianship Service , was appointed �Plenary Limited Guardian of the Estate by Decree of Thomas A. Placey , C.P.J., dated Februar�16, 2012 � A. This is the Annual Report for the period from February 17 , 2013 to Februarv 16 , 2014 (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 1 of 4 Estate of Ravmond Clark ,an Incapacitated Person II. SUMMARY A. State the value of the estate reported on the Inventory $0.00 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 $0.00 Income $2,452.83 C. What is the total amount of income earned during the Report Period? $26,848.53 D. What is the total amount of income and principal spent for all purposes during the Report Period? $(27,273.69) E. What are the balances remaining at the end of the Report Period? 1. Principal $0.00 2. Income $ 2,027.67 3. Total of Principal and Income $2,027.67 III.ADDITIONAL INFORMATION (If 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.): Total Principal Balance: $0.00 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: c. Was Court approval received prior to expending the principal? ...................................................... ❑ Yes ❑ No Page 2 of 4 Estate of Ravmond Clark ,an Incapacitated Person 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 1. State sources and amounts of income received during the Report Period (e.g., Social Security, pension, rents, etc.): Interest Income $10.21 PBGC—Bethlehem Steel pension $9,838.32 US Treasury—Social Security $17,000.00 Total income received during Report Period: $26,848.53 2. How is income currently invested? (Please specify, e.g., restricted bank accounts, client care account, etc.): Halifax Bank Checking#036297210 $2,027.67 Total Income Balance: $2,027.67 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.): Edward E. Lamarque,MD $608.64 Golden Living West Shore $25,086.42 Total Expenses for Care and Maintenance: $25,695.06 Page 3 of 4 Estate of Ravmond Clark ,an Incapacitated Person 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.) Keystone Guardianship—costs $234.88 Keystone Guardianship—reimburse $128.75 Register of Wills $15.00 Total for Other Expenditures: $378.63 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 $1,200.00 Fees ($100.00 per month) �Yes ❑ No 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. < SI�.�/�y Date ign ure af Guardian of the Estate Melande Peters Name of Guardian of the Estate(type or print) PO Box 804 Address Elizabethville.Pa 17023 Ciry,State,Zip 717-674-5757 Telephone Page 4 of 4 Income Statement- SQL-Ledger Uersion 2.8.27-Raymond Clark-kg... http:Ukeyguard.anteil.com/rp.pl Raymond Clark INCOME STATEMENT for Period February 17 2013 To February 16 2014 INCOME Feb 17 2013 ... . .... ., ��. Feb 16 2014 Interest Income 10.21 PBGC - Bethlehem Steel pension 9,838.32 US Treasury - Social Security 17,000.00 TOTAL INCOME 26,848.53 EXPENSES �;�,,; ..>.�_ . ,.�.. ,... Nursing Home Expenses 25,086.42 Medical 608.64 Keystone Services Cost 234.88 Keystone Services Fees 1,200.00 Keystone Services Purchases 128.75 Household Expenses 15.00 TOTAL EXPENSES 27,273.69 INCOME / (LOSS) (425.16) 1 of 1 5/23/2014 2:28 PM Account 4010- Interest Income/Raymond Clark- SQL-Ledger Uersi... http://keyguard.anteil.com/ca.pl?action=list transactions&departmen... Account 4010 - Interest Income / Raymond Clark February 17 2013 - February 16 2014 Description Date Reference Debit Credit Balance 1.61 Interest - HB Checking 05-31-2013 Auto Deposit 1.12 2.73 Interest - HB Checking 06-30-2013 Auto Deposit 1.04 3.77 Interest - HB Checking 07-31-2013 Auto Deposit 1.25 5.02 Interest - HB Checking 08-31-2013 Auto Deposit 1.11 6.13 Interest - HB Checking 09-30-2013 Auto Deposit 1.22 7.35 Interest - HB Checking 10-31-2013 Auto Deposit 1.23 8.58 Interest - HB Checking 1i-30-2013 Auto Deposit 0.96 9.54 Interest - HB Checking 12-31-2013 Auto Deposit 1.09 10.63 Interest - HB Checking 01-31-2014 Auto Deposit 1.19 11.82 10.21 10.21 11.82 1 of 1 6/5/2014 8:20 AM Account 4016-PBGC-Bethlehem Steel pension/Raymond Clark-... http://keyguard.anteil.com/ca.pl?action=list transactions&departmen... Account 4016 - PBGC - Bethlehem Steel pension / Raymond Clark February 17 2013 - February 16 2014 Description Date Reference Debit Credit Balance 9,018.46 PBGC Pension 03-01-2013 Auto Deposit 819.86 9,838.32 PBGC Pension 04-01-2013 Auto Deposit 819.86 10,658.18 PBGC Pension 05-01-2013 Auto Deposit 819.86 11,478.04 PBGC Pension 05-31-2013 Auto Deposit 819.86 12,297.90 PBGC Pension 07-01-2013 Auto Deposit 819.86 13,117.76 PBGC Pension 08-01-2013 Auto Deposit 819.86 13,937.62 PBGC Pension 08-30-2013 Auto Deposit 819.86 14,757.48 PBGC Pension 10-01-2013 Auto Deposit 819.86 15,577.34 PBGC Pension 11-01-2013 Auto Deposit 819.86 16,397.20 PBGC Pension 11-29-2013 Auto Deposit 819.86 17,217.06 PBGC Pension 01-02-2014 Auto Deposit 819.86 18,036.92 PBGC Pension 01-31-2014 Auto Deposit 819.86 18,856.78 9,838.32 9,838.32 18,856.78 1 of 1 6/5/2014 8:21 AM Account 4017-US Treasury- Social Security/Raymond Clark- SQ... http://keyguard.anteil.com/ca.pl?action=list transactions&deparhnen... Account 4017 - US Treasury - Social Security / Raymond Clark February 17 2013 - February 16 2014 Description Date Reference Debit Credit Balance 16,746.00 Social Security 03-13-2013 Auto Deposit 1,413.00 18,159.00 Social Security 04-10-2013 Auto Deposit 1,413.00 19,572.00 Social Security 05-08-2013 Auto Deposit 1,413.00 20,985.00 Social Security 06-12-2013 Auto Deposit 1,413.00 22,398.00 Social Security 07-10-2013 Auto Deposit 1,413.00 23,811.00 Social Security 08-14-2013 Auto Deposit 1,413.00 25,224.00 Social Security 09-11-2013 Auto Deposit 1,413.00 26,637.00 Social Security 10-09-2013 Auto Deposit 1,413.00 28,050.00 Social Security 11-13-2013 Auto Deposit 1,413.00 29,463.00 Social Security 12-1i-2013 Auto Deposit 1,413.00 30,876.00 Social Security 01-08-2014 Auto Deposit 1,435.00 32,311.00 Social Security 02-12-2014 Auto Deposit 1,435.00 33,746.00 17,000.00 17,000.00 33,746.00 1 of 1 6/5/2014 8:21 AM AP Transactions/Raymond Clark- SQIrLedger Uersion 2.8.27-R... http://keyguard.anteiLcom/ap.pl?actionrtransactions&direction=AS... AP Transactions / Raymond Clark From February 17 2013 To February 16 2014 Open Closed Vendor Date Invoice Description Total Paid Edward E. Lamarque MD 05-06-2013 Check #136 279.04 279.04 Edward E. Lamarque MD 06-11-2013 Check #140 89.78 89.78 Edward E. Lamarque MD 07-16-2013 Check #145 25.90 25.90 Edward E. Lamarque MD 09-17-2013 Check #151 110.32 110.32 Edward E. Lamarque MD 10-16-2013 Check #154 25.90 25.90 Edward E. Lamarque MD 11-18-2013 Check #159 25.90 25.90 Edward E. Lamarque MD 02-14-2014 Check #169 51.80 51.80 608.64 608.64 Golden Living West Shore 03-06-2013 Check #130 2,066.86 2,066.86 Golden Living West Shore 03-15-2013 Check #132 2,108.86 2,108.86 Golden Living West Shore 05-06-2013 Check #137 1,808.82 1,808.82 Golden Living West Shore 06-11-2013 Check #141 2,298.12 2,298.12 Golden Living West Shore 07-16-2013 Check #146 2,151.74 2,151.74 Golden Living West Shore 08-14-2013 Check #147 2,113.76 2,113.76 Golden Living West Shore 09-17-2013 Check #152 1,977.54 1,977.54 Golden Living West Shore 10-16-2013 Check #155 2,061.96 2,061.96 Golden Living West Shore 11-11-2013 Check #157 2,231.85 2,231.85 Golden Living West Shore 12-16-2013 Check #162 2,063.07 2,063.07 Golden Living West Shore 01-15-2014 Check #165 2,114.87 2,114.87 Golden Living West Shore 02-11-2014 Check #167 2,088.97 2,088.97 25,086.42 25,086.42 Keystone Guardianship - Costs 03-08-2013 Check #131 17.30 17.30 Keystone Guardianship - Costs 04-08-2013 Check #135 15.96 15.96 Keystone Guardianship - Costs 05-10-2013 Check #138 18.65 18.65 Keystone Guardianship - Costs 06-06-2013 Check #139 27.56 27.56 Keystone Guardianship - Costs 07-15-2013 Check #143 20.69 20.69 Keystone Guardianship - Costs 08-15-2013 Check #148 19.50 19.50 Keystone Guardianship - Costs 09-11-2013 Check #150 7.02 7.02 Keystone Guardianship - Costs 10-11-2013 Check #153 21.76 21.76 Keystone Guardianship - Costs 11-11-2013 Check #158 28.15 28.15 Keystone Guardianship - Costs 12-10-2013 Check #161 20.43 20.43 Keystone Guardianship - Costs 01-07-2014 Check #163 19.40 19.40 Keystone Guardianship - Costs 02-10-2014 Check #166 18.46 18.46 234.88 234.88 Keystone Guardianship - Fees 03-08-2013 Check #131 100.00 100.00 Keystone Guardianship - Fees 04-08-2013 Check #135 100.00 100.00 Keystone Guardianship - Fees 05-10-2013 Check #138 100.00 100.00 Keystone Guardianship - Fees 06-06-2013 Check #139 100.00 100.00 Keystone Guardianship - Fees 07-12-2013 Check #143 100.00 100.00 Keystone Guardianship - Fees 08-15-2013 Check #148 100.00 100.00 Keystone Guardianship - Fees 09-11-2013 Cjecl #150 100.00 100.00 Keystone Guardianship - Fees 10-11-2013 Check #153 100.00 100.00 Keystone Guardianship - Fees 11-11-2013 Check #158 100.00 100.00 Keystone Guardianship - Fees 12-10-2013 Check #161 100.00 100.00 Keystone Guardianship - Fees 01-07-2014 Check #163 100.00 100.00 Keystone Guardianship - Fees 02-10-2014 Check #166 100.00 100.00 1 of 2 6/5/2014 8:22 AM AP Transacrions/Raymond Clark- SQL-L,edger Uersion 2.8.27-R... http://keyguard.anteil.com/ap.pl?actionrtransactions&direction=AS... 1,200.00 1,200.00 Keystone Guardianship - Purchases 06-06-2013 Check #139 7.98 7.98 Keystone Guardianship - Purchases 07-15-2013 Check #144 2.98 2.98 Keystone Guardianship - Purchases 08-19-2013 Check #149 13.90 13.90 Keystone Guardianship - Purchases 10-21-2013 Check #156 68.93 68.93 Keystone Guardianship - Purchases 11-22-2013 Check #160 32.22 32.22 Keystone Guardianship - Purchases 02-14-2014 Check #168 2.74 2.74 128.75 128.75 Register of Wiiis 07-05-2013 Check #142 15.00 15.00 15.00 15.00 27,273.69 27,273.69 AP Transaction Vendor Invoice. ' 2 of 2 6/5/2014 8:22 AM Balance Sheet- SQLrL.edger Uersion 2.8.27-Raymond Clark-kg-rclark http://keyguard.anteil.com/rp.pl Raymond Clark BALANCE SHEET as at Feb 16 2014 ASSETS Feb 16 2014 . _�., .�,w�. . �. ,.� �.. .. �� Income- HB Checking #036297210 2,027.67 TOTAL ASSETS 2,027.67 LIABILITIES ,.:;�,: .. , ..::�. y. ,... TOTAL LIABILITIES - SHAREHOLDER'S EQUITY ��s�; .,��:,_ .....��_ . Current Earnings 2,027.67 TOTAL EQUITY 2,027.67 TOTAL LIABILITIES & EQUITY 2,027.67 1 of 1 5/23/2014 2:27 PM ANNUAL REPORT OF GUARDIAN OF THE PERSON COURT OF COMMON PLEAS OF CUMBERLAND COUNTY,PENNSYLVANIA ORPHANS' COURT DIVISION N � ° � c- --.- :� � p ^ r'� tC`�j1 �'� � C �� C'a `1l Estate of Ravmond Clark ,an IncapacitatedrP',e�o�' � `:�' �, ��' r � r�� - � �� .,r c:;J' No. 21-12-0040 " ` ' � . � r--•i � C> `'-� C:�S —fl ..�'y `!1 C'? v _i 1 � ,�,.. `�1 e:� <__ —__ ►—+ �-�: t°� � ._�'.{ rV ��,`" rn I. INTRODUCTION � �'�' �" ° cn � Keystone Guardianship Services was appointed � Plenary Limited Guardian of the Person by Decree of Thomas A. Placey , J., dated February 16, 2012 � This is the Annual Report for the period from February 17 , 2013 to February 16 2014 (the "Report Period"); or B. This is the Final Report for the period from , to , (the "Report Period"), and is filed for the 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. Form G-03 rev. 10.13.06 Page 1 of 4 � Estate of Ravmond Clark ,an Incapacitated Person II. PERSONAL DATA Age of the Incapacitated Person: 72 Date of Birth: 3/1/1942 III. LIVING ARRANGEMENTS A. Current address of the Incapacitated Person: Golden Living West Shore Secured Unit 770 Poplar Church Road Camp Hill, PA 17011 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 5/3/2011 If the Incapacitated Person has moved within the past year, state prior residence and reason(s) for move: Furm G-03 rev. 10.13.06 Page 2 0£4 Estate of Ravmond Clark .an Incapacitated Person D. Name and address of the Incapacitated Person's primary caregiver: Skilled Care staff of the Golden Living West Shore 770 Poplar Church Road Camp Hill,PA 17011 IV. MEDICAL INFORMATION A. The major medical or mental problems of the Incapacitated Person areas follows: Cunent Diagnosis(s): dementia, hypertension, C/V Disease,general pain (he does not complain of pain to them,convulsions (seizures)cognitive difficulties, CDA(Stroke)he is at risk of falls; he fell at the facility and broke his hip on March 25, 2013 . Medicine list attached. B. Specify what, if any, social, medical, psychological and support services the Incapacitated Person is receiving: Edward Lamarque,MD,Primary Care Doctor Chris Vargo,Nurse Practitioner for Dr. Lamarque evaluated Raymond for enrollment in Optim program,he scored moderately in dementia range, no med changes,going to have podiatrist take care of toenails,has cataracts,will see the eye doctor,no aggressive prostate or colonoscopy and has no living will. Participates in the facility activities, likes to watch TV all sports V. GUARDIAN'S OPINION A. It is the opinion of the Guardian of the Person that the guardianship should: �continue be modified be terminated E�o�c-o3 r�.�.io.i3.o� Page 3 of 4 Estate of Ravmond Clark ,an Incapacitated Person The reasons for the foregoing opinion are: It is my opinion Mr. Clark lacks the ability to mental and physical to care for himself. He seems adjusted and content with his environment, life style and care provided by the staff of Golden Living. B. During the past year,the Guardian of the Person has visited the Incapacitated Person 24- 30 times with the average visit lasting 15—30 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. !�/.3/i� � x� r Date 'gnarure of Cuardian of the Person Constance E.Stoneroad Name of Cuardian of the Person(type or print) PO Box 804 Address Eliznbethvil[e.Pa 17023 City,State,Zip 717-265-4056 Telephone Form G-03 rev. 10.13.06 Page 4 of 4 i i i id3 ia5u VULUEN LIVING CENTER 02:01:29 p.m. 02-11-2014 12/2g � � � O � O m m m w � m O O � m r � � �� a � � � F•� � � � . � � O � �. � � � � �- °o � � N � � m � a y E � � � $ � � o � � � a � � � W � � J � z O � � O y Z . � � H S Z O � � � � � � W � � � 0 V � v C Z Q O � W � � � � � � r 1� Y � p� Q W � N N �j C � N � N V � � � N � eo � LL � � � m V- � m � � a Z .�. .o� �o�� aVLUtIVLIVIIVC�CtIVltfi 02:00:14p.m. 02-11-201d 7/2g LL m ry U � •t � N � y � � � i o N m a W w p� � C � ,. �, n u �p O w p z N O q ' � � � a a � „ m v� o: a `� N � � � Q � , � � � `� Z � � � o � � � W oc � N M v � } � e�i e� q .� � � eQ $ QO m ¢ � _ � � g � y r � � m t� c5 U v c Q 3 m � � ' � .. � � � � G m � o� z a77 � � � � � a � � � � � LL � � � � � " � ° � � � � ° � N � O � � � � � W 0 � F r �� 7� 7 2 � � � � �F 7�. 7� , '� C = z � f9 �Q � � '~ 'Q '� � � �- Q � � �N � � _!� �Q �� 7 y Z l� !9 �.1 � 0 a t�y LL � �� 7� 7� 7� 9 p e O' � (�Z�� o '�2 '� � ''� '� � . � 7 g� � � �` 7� 7 2 I � ia � � �� 6 � � � �� W 6 � >� �o � � �� o',� � m �� `" '� '� �'� ?� � �Z � ' �� '� �� 9 m � '3 �� o �� s� � �y � �� Z � � ��s��$ .. g �� b $ � � � � �� W, � � � �� W> � �� ° � � W � � °� $ � � � � a � N '�� € Wa � � "� � R � � � S' g 3N � a a3� � �O ' � � C7 z° � � e �yWj � �m ��v �o � � �e � o g � $ � m a � � � � N � � � � �— �� t s , � � � � � o c� m °� � � � � c�a�� o�, � � � � �0 � �v � " � m �Er °��1 ,° .� � � � � S� � N 'f, °oG � �� oR 1i. � � � F�� 17� �� m $ � � o�:., � � ^ � � > ` ` o�'i e. is t�2 � 8 €'�b c �� C�� v � �a 0 m � � O � �"�` � � � �� i �� _� �� m _ ! 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