HomeMy WebLinkAbout01-12-15 c
ANNUAL REPORT OF
GUARDIAN OF THE ESTATE C=D Mrn '
—
r�r � � =� cn x►
COURT OF COMMON PLEAS OF
Ott en p✓' I&,,J COUNTY,PENNSYLVANJA-
ORPHANS' COURT DIVISION
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Estate of A 4 4 u an Incapacitated Person
No. a -/L1 63 33-
1.
.rI. INTRODUCTION
LTi I I 8.. e r r e ,was appointed
0161enary El Limited Guardian of the Estate by Decree of or e y C P, J.,
dated 2n a � 5((D `f
A. This is the Annual Report for the period from J-v ( L�
to 8 P r,f✓A h e /L. , G2.0/`f (the "ReportPeriod"); or
El 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
Form G-02 rev.10.13.06 Page 1 of 5
Estate of A4 A a 114 A o W e /Z. ,An Incapacitated Person
II. SUMMARY
A. State the value of the estate reported on the Inventory $
B. State the value(s) of principal assets at the beginning of
the Report Period. (Same as Inventory if first Report,
otherwise, ending balance from last Report.) $
C. What is the total amount of income earned during the
Report Period? $
D. What is the total amount of income and principal
spent for all purposes during the Report Period? $ --��
E. What are the balances remaining at the end of the Report
Period?
1. Principal $
2. Income $
3. Total of Principal and Income $ 0.00
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.):
2. Have there been any expenditures from the principal
during the Report Period? . . . . . . . . . . . . . . . . . . . . . . . . . . . . El Yes 03/No
If yes:
a. Have all expenditures from the principal been for
the sole benefit of the Incapacitated Person? . . . . . . . . ❑ Yes ❑No
Form G-01 rev.10.13.06 Page 2 of 5
Estate of 4 n✓l G ►"1 60 Ui An Incapacitated Person
b. List purpose and amount of expenditures:
$
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? . . . . . . . . . . . 0 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.): N�l�
$
Total income received during Report Period: $ .0'0.00
Form G-02 rev.10.13.06 Page 3 of 5
Estate of AA 4 a !"( AQ CLJ(VU ,An Incapacitated Person
2. How is income currently invested? (Please
specify, e.g., restricted bank accounts, client
care account, etc.):
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.):
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.)
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
Yes E]No
Yes E]No
Form G-02 rev.10.13.06 Page 4 of 5
l f
Estate of 1 4 r1 u Al '6 0 W e Jz" ,An Incapacitated Person
F. Counsel Fee n /
List amounts paid as counsel fee, and indicate whether Court approval was obtained. ®v ftA
Court
Amount Approval Obtained
Q 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.
Date Signature Guardian of the Estate
pcecce-
Name of Guardian of the Esta/tee(type or print) `
Address
Ca,aI /'A 1 7v ll
City,State,Zip
( 7/J� 77
Telephone
Form G-02 rev.10.13.06 Page 5 of 5