HomeMy WebLinkAbout04-23-15 (4) f
ANNUAL REPORT OF
W � GUARDIAN OF THE PERSON
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1-1 U.- a_
ca cn -J COURT OF COMMON PLEAS OF
UJhAbCd� COUNTY, PENNSYLVANIA
a o ORPHANS' COURT DIVISION
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Estate of i-
r-101- 1i1 �' , an Incapacitated Person
No.,V-o2ag-
I. INTRODUCTION
was appointed
Plenary OLimited Guardian of the Person by Decree of �Y►Od'bL4S. A, � , J.,
// dated 7,�0l a-
A. This is th Annual Re ort for the period fr m �l6t K<( ,
to c,,-JILA-44-e-- 1 ,�(the "Report Period"); or
j 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:
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 I of 4
y
Estate of , an Incapacitated Person-
11. PERSONAL DATA
Age of the Incapacitated Person:_ Date of Birth: 1
III. LIVING ARRANGEMENTS
A. Current address of the Incapacitated Person:
/zlg 4- LOuH P�--
C'a,rh's (e-, -PA 1761-3
B. The Incapacitated Person's residence is:
0 own home/apartment
0 nursing home
0 boarding home/personal care home
XGuardian's home/apartment
hospital or medical facility
relative's home (name, relationship and address)
Mother:
C. The Incapacitated Person has been in the present residence since
If the Incapacitated Person has moved within the
past year, state prior residence and reason(s) for move:
Form G-03 rev.10.13.06 Page 2 of 4
Estate of , an Incapacitated Person
D. Name and address of the Incapacitated Person's primary caregiver:
140 �.�� L-OtzA, ,-,
IV. MEDICAL INFORMATION
A. The major medical or mental problems of the Incapacitated Person are as follows:
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at , o
B. Specify what, if any, social, medical, psychological and support services the
Incapacitated Person is receiving: i r �
V. GUA96AN'S 1_`;ION
• f ^
A. It is the opinion of the Guardian of the Person that the guardianship should:
ontinue
Elbe modified
0 be terminated
Form G-03 rev. 10.13.06 Page 3 of 4
Estate of -�W I e- kae-1 G�4/K�l1ni an Incapacitated Person
The reasons for the foregoing opinion are:
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)11r4E� Axe4el-a—,
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14'4JF4Dr&u-riinYg the past year,the Guardian of the Person has zvisit-AZthe 4Incapacitated M-Pe-tr--s-oroi-,,/,",,
4.6
times with the average visit lasting hours, minutes 5f
6b7*L—
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.
Dale rl—gllahtre of Guardian oft&Person
Name of Guardian of the Person(type or print)�J
1_t14
Address
cc:�Iiste—
City,State,Zip
Telephone
Form G-03 rev.!0.!3.06 Page 4 of 4