HomeMy WebLinkAbout01-09-15 ^ �Rese-'t Form!
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A�NNUAL REPORT OF �� � � � `� �
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GUARDIAN OF THE PERSON - �.� �-� `D :; �'
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COURT OF COMMON PLEAS OF , ��' _r_ � �,
Cumberland COUNTY,PENNSYLVANIA r �'
ORPHANS' COURT DIVISION
Estate of TIEN KHAI TRAN , an Incapacitated Person
No. 21-12-1251
I. INTRODUCTION
Ut Michael K. Tran and KimQui T. Tran , was appointed
�J Plenary�Limited Guardian of the Person by Decree of M. L. Ebert, Jr. � J_�
dated 31 January 2013
� A. This is the Annual Report for the period from 31 March � 2014
to 31 December a 2014 (the"Report Period"); or
� B. This is the Final Report far the period frorn ,
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.
FoYm c-o3 r�v.�0.�3.06 Page 1 of 4
TIEN K_HAI TRAN
Estate of , an Incapacitated Person
II. PERSONAL DATA
Age of the Incapacitated Person: l.9 Date of Birth: 10/07/1995
IIL LIVING ARRANGEMENTS
A. Current address of the Incapacitated Person:
508 Ellen Road
Camp Hill, PA l 7011
B. The Incapacitated Person's residence is:
�own home/apartment
�nursing home
❑boarding home�'personal care horne
�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 resic�ence sinee 1 May 2005
. If the Incapacitated Person has moved within the
past year, state prior residence and reason(s) for move:
Form G-03 reu 10.13.Ob Page 2 of 4
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TIEN KHAI TRAN
Estate of , an Incapacitated Person
D. Name and address of the Incapacitated Person's primary caregiver:
Ut Michael K. Tran and K.imQui T. Tran
50$ Ellen Road
Camp Hill, PA 17011
IV. MEDICAL INFORMATION
A. The major medical or mental problems of the Incapacitated Person are as follows:
Autism and Mental Retardation
B. Specify what, if any, social, medical,psychologicai and support services the
Incapacitated Person is receiving:
Behavioral Health Rehabilitation Services - Behavior Supports Consultant
Cumberland County MH IDD Supports Coordinator
PennState Hershey Medical Group - Psychiatry - Autism Life Care Model
Rehab Options at Carlisle Regional Medical Center - Speech Language Therapy
Living Unlimited - Music Therapy
V. GUARDIAN'S OPINION
A. It is the opinion of the Guardian of the Person that the guardianship should:
�continue
❑be modified
�be terminated
Form G-03 rev.1213.06 Page 3 of 4
1
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TIEN KHAI TRAN
Estate of , an Incapacitated Person
The reasons for the foregoing opinion are:
B. During the past year,the Guardian of the Person has visited the Incapacitated Person
times with the average visit Iasting hours, minutes.
Tien lives with both of his guardians all year long.
The report of a social service organization employed by the Guardian to oversee and
coordinate the care af the hzcapacitated 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 unswarn falsification to authorities. ,! �,. ��.� (��� �"��
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5 January 2015 t�� �l`� /��/
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Date Signature of Gu¢rdian of the Pexson
Ut Michael K. Tran and KimQui T. Tran
Name of Guardia»of the Per,son(ryl�e or print)
508 Ellen Road
Address
Camp Hill, PA 17011
City,State."lip
717-73I-1677
Telephone
Form G-03 rev. 10.13.06 Page 4 of 4