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ANNUAL REPORT �� ; � � �
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OF GUARDIAN OF THE ESTATE ' � � - � ='
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COURT OF COMMON PLEAS OF ' ` ' . _ ��? f -`�
CUMBERLAND COUNTY,PENNSYLVANIA ` �� -�-'
ORPHANS' COURT DIVISION `�, `'" ��i
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Estate of Sven O.Jensen ,an Incapacitated Person
No. 21-09-0807
I. INTRODUCTION
Ke,ystone 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 , 2013
to September 29 , 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 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 $258,850.80
Income $25,691.49
C. What is the total amount of income earned during the
Report Period? $36,312.11
D. What is the total amount of income and principal
spent for all purposes during the Report Period? $(80,253.75)
E. Federal Tax Withheld $(23,556.00)
F. What are the balances remaining at the end of the Report
Period?
1. Principal $213,691.11
2. Income $ 3,353.54
3. Total of Principal and Income $217,044.65
IIL ADDITIONAL INFORMATION
(If more space is needed,please attach additional pages)
A. Principal
l. 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 $15,476.11
Mid Penn MM#18055350 $165,000.00
Halifax Bank CD#300114354 $15,000.00
Mid Penn CD #301084438 $10,000.00
Burial Reserve: Hollinger Funeral Home $8,215.00
Total Principal Balance: $213,691.11
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
1. State sources and amounts of income received during
the Report Period (e.g., Social Security, pension, rents,
etc.):
Interest Income $1,221.37
Annuity Income $8,376.14
US Treasury— Social Security $24,255.60
US Treasury—2013 Federal Tax Refund $2,459.00
Total income received during Report Period: $36,312.11
2. How is income currently invested? (Please
specify, e.g., restricted bank accounts, client
care account, etc.):
HNB Checking#100110983 $2,029.00
Mid Penn Bank MM#18055350 $454.85
Mid Penn Bank CD #301084438 $479.27
Halifax Bank CD #300114354 $390.42
Total Income Balance: $3,353.54
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 $70,265.04
Commonwealth of PA Mobile Dentistry $65.00
Family Practice Center $5.00
Heartland Healthcare Services $2,684.44
On Sight Healthcare $620.75
Pinnacle Health Hospitals $171.16
See Right Pharmacy $1,992.85
Total Expenses for Care and Maintenance: $75,804.24
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 $909.45
Cumberland County Register of Wills $15.00
Keystone Guardianship—costs $181.82
Keystone Guardianship—reimbursed $96.99
Leona Shaffer—tax preparation $95.00
Patriot News $195.00
Total for Other Expenditures: $1,493.26
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
$2,956.25 Fees �$75.00�er hour) �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.
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Date Signatur of Guardian of the Estate
Melanie Peters
Name of Guardian of the Estate(type or printJ
PO Box 804
Address
Elizabethville.Pa 17023
City,State,Zip
717-674-5757
Telephone
Page 5 of 5
Income Statement- SQL-L,edger Uersion 2.8.27- Sven Jensen-kg-sjensen http:Ukeyguard.anteil.com/rp.pl
Sven )ensen
INCOME STATEMENT
for Period
September 30 2013 To September 29 2014
INCOME Sep 30 2013
- �, Sep 29 2014
Interest Income 1,221.37
Annuity Income 8,376.14
US Treasury - Social Security 24,255.60
refund of payment 2,459.00
TOTAL INCOME 36,312.11
EXPENSES
� „.. s �...
Purchases 96.99
Nursing Home Expenses 70,265.04
Federal Tax Witheld 23,556.00
Medical 5,539.20
Keystone Services Cost 181.82
Keystone Services Fees 2,956.25
Household Expenses 1,214.45
TOTAL EXPENSES 103,809.75
INCOME / (LOSS) (67,497.64)
1 of 1 10/30/2014 1:45 PM
Account 4010- Interest Income/Sven Jensen- SQL-L.edger Uersion 2.... http://keyguard.anteil.com/ca.pl?action=list transactions&department...
Account 4010 - Interest Income / Sven 7ensen
September 30 2013 - September 29 2014
Description Date Reference Debit Credit Balance
1,885.11
Interest - Halifax CD #300114354 (matures 3/14/15) 09-30-2013 Auto Deposit 390.42 2,275.53
390.42
interest - HNB checking 09-30-2013 Auto Deposit 3.99 2,279.52
interest - HNB checking 10-31-2013 Auto Deposit 1.95 2,281.47
interest - HNB checking 1i-30-2013 Auto Deposit 1.69 2,283.16
interest - HNB checking 12-31-2013 Auto Deposit 3.97 2,287.13
interest - HNB checking 01-31-2014 Auto Deposit 18.21 2,305.34
interest - HNB checking 02-28-2014 Auto Deposit 81.85 2,387.19
interest - HNB checking 03-31-2014 Auto Deposit 59.44 2,446.63
interest - HNB checking 04-30-2014 Auto Deposit 9.48 2,456.11
interest - HNB checking 05-31-2014 Auto Deposit 7.70 2,463.81
interest - HNB checking 06-30-2014 Auto Deposit 5.64 2,469.45
interest - HNB checking 07-31-2014 Auto Deposit 4.35 2,473.80
interest - HNB checking 08-31-2014 Auto Deposit 2.01 2,475.81
200.28
Interest - Mid Penn CD #301084437 12-18-2013 Auto Deposit 70.17 2,545.98
70.17
Interest - Mid Penn CD #301084438 08-14-2014 Auto Deposit 105.65 2,651.63
105.65
Interest - Mid Penn MM #18055350 03-31-2014 Auto Deposit 33.45 2,685.08
Interest - Mid Penn MM #18055350 04-30-2014 Auto Deposit 83.65 2,768.73
Interest - Mid Penn MM #18055350 05-30-2014 Auto Deposit 83.68 2,852.41
Interest - Mid Penn MM #18055350 06-30-2014 Auto Deposit 86.51 2,938.92
Interest - Mid Penn MM #18055350 07-31-2014 Auto Deposit 86.55 3,025.47
Interest - Mid Penn MM #18055350 08-29-2014 Auto Deposit 81.01 3,106.48
454.85
1,221.37 3,106.48
1 of 1 10/30/2014 1:46 PM
Account 4015-Annuity Income/Sven Jensen- SQLrl,edger Uersion 2.... http://keyguard.anteil.com/ca.pl?path=bin/mozilla&action=list transact...
Account 4015 - Annuity Income / Sven Jensen
September 30 2013 - September 29 2014
Date Reference Description Debit Credit Balance
30,140.42
01-09-2014 Auto Deposit Jackson National annuity income 8,376.14 38,516.56
8,376.14
8,376.14 38,516.56
1 of 1 10/30/2014 1:46 PM
Account 4017- US Treasury- Social Security/Sven Jensen- SQL-Le... http://keyguard.anteil.com/ca.pl?action=list transactions&department...
Account 4017 - US Treasury - Social Security / Sven 7ensen
September 30 2013 - September 29 2014
Description Date Reference Debit Credit Balance
92,770.00
Social Security 10-16-2013 Auto deposit 1,997.00 94,767.00
Social Security 11-20-2013 Auto deposit 1,997.00 96,764.00
Social Security 12-18-2013 Auto deposit 1,997.00 98,761.00
Social Security 01-15-2014 Auto deposit 2,030.00 100,791.00
Social Security 02-19-2014 Auto deposit 2,030.00 102,821.00
Social Security 03-19-2014 Auto deposit 2,030.00 104,851.00
Social Security 04-16-2014 Auto deposit 2,030.00 106,881.00
Social Security 05-21-2014 Auto deposit 2,030.00 108,911.00
Social Security 06-18-2014 Auto deposit 2,027.60 110,938.60
Social Security 07-16-2014 Auto deposit 2,029.00 112,967.60
Social Security 08-20-2014 Auto deposit 2,029.00 114,996.60
Social Security 09-17-2014 Auto deposit 2,029.00 117,025.60
24,255.60
24,255.60 117,025.60
1 of 1 10/30/2014 1:46 PM
Account 4018-refund of payment/Sven Jensen- SQL-Ledger Uersion... http://keyguard.anteil.com/ca.pl?path=bin/mozilla&action=list transact...
Account 4018 - refund of payment / Sven Jensen
September 30 2013 - September 29 2014
Date Reference Description Debit Credit Balance
21,969.35
03-04-2014 Deposit US Treasury - 2013 Federal tax refund 2,459.00 24,428.35
2,459.00
2,459.00 24,428.35
1 of 1 10/30/2014 1:47 PM
AP Transactions/Sven Jensen- SQLrLedger Uersion 2.8.27- Sven Je... http:Ukeyguard.anteil.com/ap.pl?action=h-ansactions&direction=ASC...
AP Transactions / Sven Jensen
From September 30 2013
To September 29 2014
Open
Closed
Vendor Date Invoice Description Total Paid
Arden Courts 10-04-2013 Check #473 5,783.50 5,783.50
Arden Courts 12-18-2013 Check #486 11,449.00 11,449.00
Arden Courts 01-17-2014 Check #491 5,908.00 5,908.00
Arden Courts 02-05-2014 Check #493 5,881.00 5,881.00
Arden Courts 03-05-2014 Check #501 5,905.00 5,905.00
Arden Courts 04-08-2014 Check #509 5,899.00 5,899.00
Arden Courts 05-07-2014 Check #516 5,902.50 5,902.50
Arden Courts 06-05-2014 Check #520 5,891.44 5,891.44
Arden Courts 07-10-2014 Check #525 5,880.00 5,880.00
Arden Courts 08-07-2014 Check #530 5,879.50 5,879.50
Arden Courts 09-12-2014 Check #537 5,886.10 5,886.10
,/70,265.04 70,265.04
Comcast 10-04-2013 Check #474 74.07 74.07
Comcast 11-05-2013 Check #477 74.07 74.07
Comcast 12-05-2013 Check #483 74.07 74.07
Comcast 01-17-2014 Check #492 74.07 74.07
Comcast 02-05-2014 Check #494 74.07 74.07
Comcast 03-05-2014 Check #503 85.15 85.15
Comcast 04-08-2014 Check #508 75.65 75.65
Comcast 05-07-2014 Check #517 75.66 75.66
Comcast 05-21-2014 Check #519 75.66 75.66
Comcast 06-23-2014 Check #522 75.66 75.66
Comcast 07-29-2014 Check #528 75.66 75.66
Comcast 09-10-2014 Check #536 75.66 75.66
✓909.45 909.45
Comm. of PA Mobile Dentistry 02-27-2014 Check #500 65.00 65.00
�/65.00 65.00
Cumberland Co. Register of Wills 11-27-2013 Check #482 15.00 15.00
�5.00 15.00
Family Practice Center 01-17-2014 Check #490 5.00 5.00
�5.00 5.00
Heartland Healthcare Services 07-10-2014 Check #524 872.76 872.76
Heartland Healthcare Services 08-20-2014 Check #532 864.47 864.47
Heartland Healthcare Services 09-10-2014 Check #534 947.21 947.21
✓2,684.44 2,684.44
Keystone Guardianship- costs 10-11-2013 Check #476 14.57 14.57
Keystone Guardianship- costs 11-1i-2013 Check #479 21.62 21.62
Keystone Guardianship- costs 12-10-2013 Check #484 22.55 22.55
Keystone Guardianship- costs 01-07-2014 Check #487 10.68 10.68
Keystone Guardianship- costs 02-10-2014 Check #497 30.63 30.63
Keystone Guardianship- costs 03-17-2014 Check #504 12.24 12.24
Keystone Guardianship- costs 04-09-2014 Check #511 11.70 11.70
Keystone Guardianship- costs 05-14-2014 Check #518 12.59 12.59
Keystone Guardianship- costs 06-11-2014 Check #521 2.45 2.45
Keystone Guardianship- costs 07-10-2014 Check #527 27.60 27.60
Keystone Guardianship- costs 08-12-2014 Check #531 1.96 1.96
1 of 2 10/30/2014 1:47 PM
AP Transactions/Sven Jensen- SQIrL.edger Uersion 2.8.27- Sven Je... http://keyguard.anteil.com/ap.pl?action�i-ansactions&directiorrASC...
Keystone Guardianship- costs 09-08-2014 Check #533 13.23 13.23
�181.82 181.82
Keystone Guardianship - fees 10-11-2013 Check #476 200.00 200.00
Keystone Guardianship - fees 11-1i-2013 Check #479 243.75 243.75
Keystone Guardianship - fees 12-10-2013 Check #484 431.25 431.25
Keystone Guardianship - fees 01-07-2014 Check #487 200.00 200.00
Keystone Guardianship - fees 02-10-2014 Check #497 412.50 412.50
Keystone Guardianship - fees 03-17-2014 check #504 200.00 200.00
Keystone Guardianship - fees 04-09-2014 Check #511 206.25 206.25
Keystone Guardianship - fees 05-14-2014 Check #518 200.00 200.00
Keystone Guardianship - fees 06-11-2014 Check #521 200.00 200.00
Keystone Guardianship - fees 07-10-2014 Check #527 262.50 262.50
Keystone Guardianship - fees 08-12-2014 Check #531 200.00 200.00
Keystone Guardianship - fees 09-08-2014 Check #533 200.00 200.00
2,956.25 2,956.25
Keystone Guardianship - Purchase 11-22-2013 Check #481 51.19 51.19
Keystone Guardianship - Purchase 01-13-2014 1
Keystone Guardianship - Purchase 01-13-2014 Check #489 29.99 29.99
Keystone Guardianship - Purchase 02-11-2014 Check #498 5.82 5.82
Keystone Guardianship - Purchase 04-29-2014 Check #513 9.99 9.99
�96.99 96.99
Leona Shaffer 03-18-2014 Check #505 95.00 95.00
1/95.00 95.00
Onhealth Care LLC 11-05-2013 Check #478 491.04 491.04
Onhealth Care LLC 02-05-2014 Check #495 129.71 129.71
�/620.75 620.75
Patriot News 10-04-2013 Check #475 65.00 65.00
Patriot News 04-17-2014 Check #512 65.00 65.00
Patriot News 09-10-2014 Check #535 65.00 65.00
{�195.00 195.00
Pinnacle Health Hospitals 02-05-2014 Check #496 41.01 41.01
Pinnacle Health Hospitals 04-08-2014 Check #510 37.29 37.29
Pinnacle Health Hospitals 05-07-2014 Check #515 92.86 92.86
�/171.16 171.16
See Right Pharmacy 10-04-2013 check #472 387.17 387.17
See Right Pharmacy 11-19-2013 Check #480 384.71 384.71
See Right Pharmacy 12-16-2013 Check #485 396.01 396.01
See Right Pharmacy 01-08-2014 Check #488 379.01 379.01
See Right Pharmacy 02-14-2014 Check #499 90.17 90.17
See Right Pharmacy 03-05-2014 Check #502 75.47 75.47
See Right Pharmacy 04-08-2014 Check #507 97.33 97.33
See Right Pharmacy 05-07-2014 Check #514 77.71 77.71
See Right Pharmacy 07-10-2014 Check #526 102.73 102.73
See Right Pharmacy 08-07-2014 Check #529 2.54 2.54
�1,992.85 1,992.85
80,253.75 80,253.75
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AP Transaction �( Vendor Invoice. ;
2 of 2 10/30/2014 1:47 PM
Balance Sheet- SQLrLedger Uersion 2.8.27- Sven Jensen-kg-sjensen http://keyguard.anteil.com/rp.pl
Sven ]ensen
BALANCE SHEET
as at Sep 29 2014
ASSETS Sep 29 2014
Income- HNB Checking #100110983 2,029.00
Income- Mid Penn MM #18055350 454.85
Income- Mid Penn CD #301084438 (matures 8/14/2014) 479.27
Income- Halifax Bank CD #300114354 (matures 3/14/2015) 390.42
Principal- HNB Checking #100110983 15,476.11
Principal- Mid Penn MM #18055350 165,000.00
Halifax Bank CD #300114354 (matures 3/14/2015) 15,000.00
Mid Penn CD #301084438 (matures 9/14/2016) 10,000.00
Burial Reserve: Hollinger Funeral Home &Crossroads Cemetary Asso. 8,215.00
TOTAL ASSETS 217,044.65
LIABILITIES
TOTAL LIABILITIES -
SHAREHOLDER'S EQUITY
� �� ��-
Assets at time of Appointment 504,534.10
Assets discovered after Appointment 2,693.67
Current Earnings (290,183.12)
TOTAL EQUITY 217,044.65
TOTAL LIABILITIES & EQUITY 217,044.65
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