HomeMy WebLinkAbout01-13-15 (2) �
ANNUAL REPORT OF � `� � rn
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GUARDIAN OF THE PERSON � ° �, � � �
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� f COURT�`�OF CONIMON PLEAS OF ,
Estate of �m�' �/�'1'C% ���j�r , an Incapacitated Person
II. PERSONAL DATA
Age of tlie Incapacitated Person:� Date of Birth:
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It�. LIVING ARRANGEMENT5
A. Current address of the Incapacitated Person:
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Bo The Incapacitated Person's residence is:
�own home/apartment
❑nursing home
❑boarding home/personal care home -
, ��A 0 Guardian's home/aparttnent
' �hospital or medical facility
❑relative's home(name,relationship and address)
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�other: ---------------
C. The Incapacitated Person has been in the present residence since S�PT. �1 �
�O 1 4 . If the Incapacitated Person has moved within the
past year, state prior residence and reason(s)for move:
_ __--� _ _ - --------------____
2 ss ►V �a���-R s�r, i ELIZ�13t.T�1- 1'OWN � (�/� l 7� ZZ
�L�-cE� IN A-�3��rE F�c ��i�rY DVE To DE�r���rrN� !
� �d� B I T�0 i�I •A-N 17 R L C O M M E►J D I}�'i d N O� I�i�F y S I G�}N S, '.
Fornr G03 rev.10.13.06 Page 2 of 4
Estate of ��M /L � �/�/E l�I !L L6 r� , an Incapacitated Person
D. Name and address of the Incapacitated Person's primary caregiver:
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IV. MEDICAL INFORMATION
A. The major medtcal or mental problems of the Incapacitated Person are as follows:
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B. Specify what,if any, social,medical,psychological and support services the
Incapacitated Person is receiving:
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V. GUARDIAN'S OPINION
A. It is the opinion of the Guardian of the Person that the guardianship should:
�continue
�be modified
0 be terminated
Form G-03 rev.10.13.06 Page 3 of 4
Estate of �/�'1 I I,�_/ ��� 1 '�r , an Incapacitated Person
The reasons for the fore oin o inion are: - - - - - - -
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L.��fl/�y /� /Nc�}-�R-L�T►3T'CD !}N,D vNfh3L�E To ��incr��N aN 1l�iQ oWN,
� �. During the past year,the Guazdian of the Person has visited the Incapacitated Person
j�� times with the average visit lasting / hours, -- minutes.
The report of a social service organization employed by the Guardian to oversee and -
coordinate t�ie care of the�.Ittcapacitated 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�4�4_______._
' relative to unsworn falsification to authorities.
_ _ -- _ -- _. __
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� Signature ofGuardian ofthe Person
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Name of Guardian of the Person(type ar print) �
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Address
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Form G-03 rev.10.13.06 Page 4 of 4