HomeMy WebLinkAbout01-0075
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IN THE COURT OF COMMON PLEAS OF _...J1I.. 1 COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
IN RE: ~ I.J." (J - S~ r1 , an in~acitated person FILE NO, J i -(i I - "1 3-
~ f\A. L
GUARDIAN OF THE ESTATE-JitJpq~AL REPORT
[20 Pa.C.S.A. 5521 (c)]
FROM3!.J../(j3 ,200_TO 5/;0/03 ,200_
~ I I ,
1) I am the _Limited ~lenary Guardian of the Estate of my ward, named above.
I was appointed Guardian by Order of the Court dated '6 J ().. J 0 I , which
was/ was not modified by Court Order(s) dated' I
2) Is the incapacitated person still living? ti D
If no, answer the following: /
~~ ~:~o:;;:th_il~~~~6i((t~..:'J~~~"~W~~t~~il~ ("I\'tef
(c) Name of Administrator/trix o~ecutori%
(d) Date Guardian of the Person filed the last Annual Report '~/.2. to z, - () ..!J
PLEASE ANSWER THE FOLLOWING QUESTIONS WHETHER THE
INCAPACITATED PERSON IS LIVING OR DECEASED.
3) My initial Inventory was filed on
$ ~
'-\ /~ 0/ 0 ( and listed a total estate value of
I '
The Inventory }Jsted a total. monthly income of $ ~ ~ ~~ cf) comprised of the
following: ~(~) '~o..-' ~~~'~~1 '
4) At the beginning date of this reporting period, my initial balance on hand was
$ S1.cc~' lQ ~' .
C.A. . 28
;:t,
rF,
~
G-vG4
5) During this reporting period, the following reflects all sources of income (other than
social security) received by me for my ward: (Add additional pages if needed)
Date Received
Source of Income
1.
2.
3.
4.
5.
6.
TOTAL
Amount
6) During this reporting period, the following reflects all payments I have made for my
ward: (Add additional pages if needed)
. Date
To Whom Paid
Reason for Payment Amount
1.
2.
3.
4.
5.
6.
TOTAL
7) The present principal assets of my ward are:
Description of Asset
1.
2.
Present Value
L~
't U
3.
4.
5.
6.
TOTAL
8) The present amount and sources of income for my ward are:
Source of Income
Amount of Income
(Indicate whether monthly,
quarterly, annually)
1.
2.
3.
4.
5.
6.
9) The regular monthly expenses of my ward which I pay are:
To Whom Paid
Amount
1.
2.
3.
4.
5.
6.
rR,
rF ,
'---J
:::P
11: ~
10) I hav~ (circle one) petitioned the Court for permission to invade principal to
meet th . needs of my ward.
(If applicable) The following expenses of my ward have been paid from principal:
To Whom Paid
Purpose
Amount
1.
2.
3.
4.
5.
6.
11) I havelhave not ( circle one) paid myself compensation for services I rendered as
guardian.
The amount I Paid myself totaled $ and was
calculated at the following rate: $ / tJt) per wee~irCle one).
12) Check the correct response and complete, if appropriate.
There will be no need for extraordinary expenditures on behalf of my ward in
the next (12) months.
There well be a need for extraordinary expenditures on behalf of my ward in
the next (12) months because:
13) Check the correct response and complete, if appropriate.
_A. My ward receives monthly social security benefits directly.
B. I am the designated payee to receive my ward's social security benefits.
R,
M=
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14) Please note any concerns about the incapacitated person's physical or mental well
being or the finances that the Court should know.
//
15) I am am not guardian of the incapacitated person's person. If yes,
report is attached.
I certify under the penalties of perjury that the information contained in this report is
true and correct to the best of my knowledge, information and belief.
~~~~~~
Telephone No. (Home)::2 qCt - ~slo 8
(Work) '~4c1 - 1fu('f'
PA GUARDIANSHIP ASSOC.
P.O.BOX 7295
Lanca~;t-!,. 0\ 17604-7295
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ITEMIZED CATEGORY REPORT
1/ I' 0 Through 5/31' 3
PAGA_CUS-PAGA Custodial page 2
5/13' 3
Date Num Description Memo Category Clr Amount
-------- ------ ------------------ ------------- ----------------- - ---------
9/16' 2 2694 SWAIM HEALTH CENTE VIDA SAMPSON SAMPSON, VIDA/COST -554.00
10/14' 2 2730 SWAIM HEALTH CENTE VIDA SAMPSON SAMPSON,VIDA/COST -535.00
10/14' 2 R5487 DEPOSIT SSDI SAMPSON,VIDA/SSDI 654.00
10/14' 2 R5488 DEPOSIT SSDI SAMPSON,VIDA/SSDI 654.00
10/15' 2 2762S PAGA GENERAL ACCOU GUARDIAN FEE SAMPSON,VIDA/GUAR -200.00
II/II' 2 R5554 DEPOSIT SSDI SAMPSON,VIDA/SSDI 654.00
11/12' 2 2792S PAGA GENERAL ACCOU GUARDIAN FEE SAMPSON,VIDA/GUAR -100.00
11/14' 2 2820 SWAIM HEALTH CENTE VIDA SAMPSON SAMPSON, VIDA/COST -546.00
12/10' 2 2884 SWAIM HEALTH CENTE VIDA SAMPSON SAMPSON,VIDA/COST -535.00
12/11' 2 2893S PAGA GENERAL ACCOU GUARDIAN FEE SAMPSON,VIDA/GUAR -100.00
12/12' 2 R5613 DEPOSIT SSDI SAMPSON,VIDA/SSDI 654.,00
1/17' 3 2976 SWAIM HEALTH CENTE VIDA SAMPSON SAMPSON, VIDA/COST -551.00
1/30' 3 R5665 DEPOSIT SSDI SAMPSON,VIDA/SSDI 663.00
2/ 6' 3 3003S PAGA GENERAL ACCOU GUARDIAN FEE SAMPSON,VIDA/GUAR -200.00
.2/ 6' 3 R5709 DEPOSIT SSDI SAMPSON,VIDA/SSDI 663.00
2/18' 3 3058 SWAIM HEALTH CENTE VIDA SAMPSON SAMPSON, VIDA/COST -533.04
3/ 4' 3 R5757 DEPOSIT SSDI SAMPSON,VIDA/SSDI 663.00
3/11' 3 3132 SWAIM HEALTH CENTE VIDA SAMPSON SAMPSON, VIDA/COST -560.04
3/31' 3 3157 S PAGA GENERAL ACCOU SAMPSON,VIDA/GUAR -200.00
4/ 3' 3 R8209 DEPOSIT SSDI SAMPSON,VIDA/SSDI 663.00
4/ 7' 3 3172 SWAIM HEALTH CENTE VIDA SAMPSON SAMPSON, VIDA/COST -551.04
---------
TOTAL SAMPSON,VIDA 566.68
---------
TOTAL INCOME 566.68
---------
TOTAL INCOME/EXPENSE 566.68
---------
---------
')
ITEMIZED CATEGORY REPORT
1/ I' 0 Through 5/31' 3
PAGA_CUS-PAGA Custodial Page 1
5/13' 3
Date Num Description Memo Category Clr Amount
-------- ------ ------------------ ------------- ----------------- - ---------
INCOME/EXPENSE
INCOME
SAMPSON, VIDA
-----------,-
2/21' 1 R9161 DEPOSIT SSDI SAMPSON,VIDA/SSDI X 637.00
5/ 8' 1 1658 S PAGA GENERAL ACCOU MAY FEE SAMPSON,VIDA/GUAR X -200.00
5/ 9' 1 R7422 DEPOSIT SSDI SAMPSON,VIDA/SSDI X 636.00
6/ 7' 1 1701 S PAGA GENERAL ACCOU INITIAL/MARCH SAMPSON,VIDA/GUAR X -1,100.00
6/ 7' 1 R7453 DEPOSIT SSDI SAMPSON,VIDA/SSDI X 636.00
6/21' 1 1751 VIDA SAMPSON VIDA SMPSON P SAMPSON,VIDA/PNA X -60.00
6/21' 1 1752 PENN CREDIT CORP. VIDA SMPSON SAMPSON,VIDA/UTIL X -58.13
6/27' 1 R7491 DEPOSIT BANK TRANSFER SAMPSON,VIDA/CLOS X 1,616.81
6/27' 1 1754 SWAIM HEALTH CENTE VIDA SAMPSON SAMPSON, VIDA/COST X -691.40
6/27' 1 1755 VIDA SAMPSON C/O S PERSONAL NEED SAMPSON,VIDA/PNA X -100.00
7/ 2' 1 1761 AGWAY PEARL SAMPSON SAMPSON,VIDA/UTIL X -121.18
7/10' 1 R7514 DEPOSIT SSDI SAMPSON,VIDA/SSDI X 636.00
7/24' 1 1787 S PAGA GENERAL ACCOU JULY FEE SAMPSON,VIDA/GUAR X -200.00
8/ 6' 1 1802 PAGA GENERAL ACCOU V.SAMPSON REI SAMPSON,VIDA/REIM X -10.00
8/15' 1 R7563 DEPOSIT SSDI SAMPSON,VIDA/SSDI X 19.00
8/15' 1 R7564 DEPOSIT SSDI SAMPSON,VIDA/SSDI X 637.00
8/16' 1 1819 SWAIM HEALTH CENTE VIDA SAMPSON SAMPSON, VIDA/COST X -1,249.00
8/17' 1 1825 S PAGA GENERAL ACCOU SAMPSON,VIDA/GUAR X -200.00
9/18' 1 R9009 DEPOSIT SSDI SAMPSON,VIDA/SSDI X 637.00
9/18' 1 1862 S PAGA GENERAL ACCOU SAMPSON,VIDA/GUAR X -200.00
9/22' 1 1892 SWAIM HEALTH CENTE VIDA SAMPSON SAMPSON, VIDA/COST X -628.00
10/18' 1 1920 S PAGA GENERAL ACCOU SAMPSON,VIDA/GUAR X -200.00
10/18' 1 1938 SWAIM HEALTH CENTE VIDA SAMPSON SAMPSON, VIDA/COST X -437.10
10/18' 1 R9050 DEPOSIT SSDI SAMPSON,VIDA/SSDI X 637.00
11/ 6' 1 R9113 DEPOSIT SSDI SAMPSON,VIDA/SSDI 637.00
11/ 6' 1 1976 S PAGA GENERAL ACCOU SAMPSON,VIDA/GUAR -200.00
11/30' 1 2033 SWAIM HEALTH CENTE VIDA SAMPSON SAMPSON, VIDA/COST -774.90
12/10' 1 2073 SWAIM HEALTH CENTE VIDA SAMPSON SAMPSON, VIDA/COST -606.00
1/15' 2 2121 SWAIM HEALTH CENTE VIDA SAMPSON SAMPSON, VIDA/COST -627.00
1/23' 2 R4835 DEPOSIT SSDI SAMPSON,VIDA/SSDI 654.00
2/13' 2 2202S PAGA PETTY CASH C REIMBURSE / C SAMPSON,VIDA/REIM -1.00
2/13' 2 2206 SWAIM HEALTH CENTE VIDA SAMPSON SAMPSON, VIDA/COST -606.00
3/ 7' 2 R4904 DEPOSIT SSDI SAMPSON,VIDA/SSDI 654.00
3/ 7' 2 R4905 DEPOSIT SSDI SAMPSON,VIDA/SSDI 654.00
4/22' 2 2346S PAGA GENERAL ACCOU GDN FEE SAMPSON,VIDA/GUAR -500.00
4/22' 2 R4977 DEPOSIT SSDI SAMPSON,VIDA/SSDI 654.00
5/13' 2 2421S PAGA PETTY CASH C REIMBURSE / C SAMPSON,VIDA/REIM -108.30
5/16' 2 2437 SWAIM HEALTH CENTE VIDA SAMPSON SAMPSON, VIDA/COST -581.00
6/10' 2 R5232 DEPOSIT SSDI SAMPSON,VIDA/SSDI 654.00
6/10' 2 R5287 DEPOSIT SSDI SAMPSON,VIDA/SSDI 654.00
6/11' 2 2482 SWAIM HEALTH CENTE VIDA SAMPSON SAMPSON, VIDA/COST -546.00
6/20' 2 2523S PAGA GENERAL ACCOU GDN FEE SAMPSON,VIDA/GUAR -300.00
7/ 9' 2 R5327 DEPOSIT SSDI SAMPSON,VIDA/SSDI 654.00
7/17' 2 2537 SWAIM HEALTH CENTE VIDA SAMPSON SAMPSON, VIDA/COST -557.00
8/15' 2 2634 SWAIM HEALTH CENTE VIDA SAMPSON SAMPSON, VIDA/COST -535.00
8/19' 2 R5396 DEPOSIT SSDI SAMPSON,VIDA/SSDI 654.00
8/20' 2 2643S PAGA GENERAL ACcOU GUARDIAN FEE SAMPSON,VIDA/GUAR -100.00
IN RE:
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
IN THE MATTER OF
AND ESTATE OF
VIDA P. SAMPSON, an
alleged incapacitated
person
ORPHANS' COURT DIVISION
21-01-75
ORDER OF COURT
AND NOW, this 2nd day of March, 2001, after hearing,
we do find that Vida P. Sampson is an incapacitated person. We
appoint Pennsylvania Guardianship Association, Inc., as permanent
plenary guardian of the person and estate of Vida P. Sampson.
By the Court,
Anthony L. DeLuca, Esquire
For the Petitioner
lt
.
.'
IN RE:
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
IN THE MATTER OF
AND ESTATE OF
VIDA P. SAMPSON, an
alleged incapacitated
person
ORPHANS' COURT DIVISION
21-01- 75
ORDER OF COURT
AND NOW, this ,{' day of f ),;-.t..J",,- ,2001, upon
consideration of the foregoing petition, our Order of March 2, 2001, is amended to
include the following:
The Pennsylvania Guardianship Association, Inc. is hereby authorized to
receive a reasonable fee for their services. This fee will be paid by the
income of the incapacitated person's estate in accordance with the current
Pennsylvania Guardianship Association, Inc. fee schedule.
~/
BY THE COURT:
/lZ"fC
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.~ J.
cc: Lindsay Dare Baird, Esquire
Anthony L. Deluca, Esquire
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ix;eCi
.
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IN RE:
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
~
IN THE MATTER OF
AND ESTATE OF
VIDA P. SAMPSON, an
alleged incapacitated
person
ORPHANS' COURT DIVISION
21-01-75
PETITION TO AMEND COURT ORDER TO AUTHORIZE PAYMENT
AND NOW, comes the Petitioner, Vida P. Sampson, an incapacitated person, by
and through her counsel, Lindsay Dare Baird, Esquire, and respectfully avers the
following:
1. After a hearing, Petitioner was adjudicated an incapacitated person by
Court Order of March 2, 2001. Order is attached and labeled Exhibit A.
2. Pennsylvania Guardianship Association, Inc., was appointed as permanent
plenary guardian of Petitioner by the same Order.
3. The Department of Public Welfare, Medical Assistance, announced a policy
clarification which requires, inter alia, that Court Orders establishing guardianship must
also specify the fee to be provided. Policy clarification is attached and labeled Exhibit
B.
WHEREFORE, Petitioner respectfully requests that the Order of Court of March
2, 2001, be amended to reflect the language requirement of the Department of Public
Welfare. A sample of the required language is provided for this Honorable Court's
consideration.
Respectfully submitted,
/"
/,.,,~~"..-'
-r~n{0.. ' /kic (J(?:j--
Lindsay Dare Bird, Es<luire
37 South Hanover Street
Carlisle, PA 17013
(717)243-5.732
Attorney for Petitioner
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AUTHORITY TO PAY COURT APPOINTED COUNSEL
1. COURT 2. VOUCHER -
o District Justice o Common Pleas 0 Appellate o Other NQ 5503
3. FOR (D.J., C.P., APPELLATE) 4. AT (CITY/STATE) 5. BUDGET CODE
{J I-:J~/.< -I, L//..t} S~
6.IN THE ~1J(atft1 (f Y'~.i .L.,;/j~2k..,~t$t") 7. CHARGE/OFFENSE (PURDON CITATION) a. 0 PETTY OFFENSE
'j< . ':;> <("'. o FELONY 0 MISDEMEANOR
( Ji / d 4. 1" -.Ji..It{J'JY.5!. 01
9. PROCEEDINGS (Describe briefly) 11. PERSON REPRESENTED 1" ("'IVII NO
1 0 Delendant . Adult .::: __ oRPI/./IN.5. f (Ot~
/] . 41 2 0 Defendant. JU\lenile d/- 0/- ">~-
/' F J.r I-t (T;--, /rUYlt /) V'/l-["r 7 3 0 Appellant 13. CRIMINAL DOCKET NO
4 0 Appellee
(";;/i {Q (e(e- a, /5:<;.1<. (p 5 ~ Habeas Pelitioner
6 0 Matenal Witness
7 0 Parolee Charged With Violation
10. PERSON REPRESENTED (Full Name) 8 0 Probaltoner Charged With Violation 14. APPEALS DOCKET NO
C' 9 0 Other
/,// CVC>t P ~.f..I1t..IPS C:Y'L.>
/. cJ,C) '0/ 16. NAME OF ATTORNEY/PAYEE AND
Aoot Dale MAILING ADDRESS
~/. J-~ ( l. o/c) Lindsay Dare Baird
37 South Hanover Street
NAME OF COMMON PLEAS JUDGE ASSIGNED TO CASE CuriiJle, PA 170 '13-3307
17. TELEPHONE No. , 8. SOCIAL SECURITY NO OR EIN NO
;)cI 3 )" -:; l~ /45/ ~-u ~ .J-C/9
CLAIM FOR SERVICES OR EXPENSES
19. SERVICE HOURS DATES AMOUNTS CLAIMED
a. Arraignment and/or Plea Multiply rate per hour times total
b. Preliminary Hearing hours to obtain "In Court" com.
pensation. Enter total below.
c. Motions and Requests
~ d. Bail Hearings
a:
:J e. Sentence Hearings
0
U I. Trial
~
g. Revocation Hearings
h. Juvenile Hearings
i. Appeals Court 19A TOTAL IN COURT COMPo
~ Other (Specify on additional sheets)
TOTAL HOURS :::II X $SO PER HOUR =$
r-
20. a. Interviews and conferences f'a lis c;' la r<s ,')0 9. 0/ .- //-t'l Multiply rate per hour times total
b. Obtaining and reviewing records hours. Enter total "Out of Court"
~~ compensation below.
Oa: c. Legal research and brief writing (/y I-t h t"Yl , "7 '\ //. 1'-/ . 0 / h/~d
~:J
:JO d. Investigative and other work (Specify on additional sheets) 20A. TOTAL OUT OF COURT
Ou COMPo
~~ =$ ot -
TOTAL HOURS = /. ,;{ S- X-$4&PERHOUR .C;)
21. ITEMIZATION OF REIMBURSABLE EXPENSES AMT. PER ITEM
Mileaae $.25 oar mile x
a:
w
:r: 21 A. TOTAL ITEMIZED EXP.
....
0
"'$
22. CERTIFICATION OF ATTORNEY/PAYEE ~NO 23. GRAND TOTAL CLAIMED
Has compensation and/or reimbursement for work in this case previously been applied for? 0 YES ::$ ~& 'd-)-
II yes. were you paid? 0 YES Jil NO If yes. by whom were you paid? How much?
Has the person represented paid any money to you, or to your knowledge anyone else, In connection with the matter for 24. DEDUCT. PRIOR PYMTS.
which you were appointed to provide representation? 0 YES ~'NO ~;s,.~~e~ils on additi~nal sheets =$
I swear or affirm the truth or correctness If ;' .' /.l . </. (/ / 25. NET AMOUNT CLAIMED
of the above statements Signature of Atto~ Date =$ c.SZ d'-
26 M'PI10\ll('\ . ~. ~ DEe 7 2001 27. ':,M;. AnV~D v~"
. F OJ! Sognature 01 -
""YMl'.NI Judge ~ Date:
7.1"" ..
Copy 1 - Mall to Court AdmInistrator at completion of service
COPIES SENT TO COUNSEL - ORDER OF NOVEMBER 15, 2001
LINDSAY D. BAIRD, ESQUIRE - CARLISLE, PA
BRIAN BROOKS, ESQUIRE - YORK, PA
@
P.O. BOX 541
YORK, PENNSYLVANIA 17405
ANTHONY DELUCA, ESQUIRE - BOILING SPRINGS, P A
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IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY,
PENNSYLVANIA
ORPHANS' COURT DIVISION
IN RE:
VIDA P. SAMPSON
NO. 21-01-75
DA TE OF APPOINTMENT
03/02/01
INVENTORY OF ASSETS
DATE: 05/30/01
DESCRIPTION
SOCIAL SECURITY (MONTHL Y) 636.00
CUSTODIAL ACCOUNT @ PAGA 00.00
BANK / CHECKING ACCOUNT 00.00
PERSONAL NEEDS ACCOUNT 00.00
ANNUITY 00.00
TOTAL CASH ASSETS HELD FOR WARD 05/30/01 (BY PAGA) 00.00
TOTAL MONTHLY INCOME (AS OF 5/30/01) 636.00
TOTAL MONTHLY COST OF CARE 572.4
TOTAL MONTHLY GUARDIANSHIP FEE 200.00
$ AMOUNT
Narrative:
P AGA was appointed guardian of the person and the estate on 03/02/01.
P AGA has acquired or has documented all known assets for the ward. This wards Social Security
benefits have been redirected to come to P AGA.
***PAGA has investigated all assets of this ward. There is the matter ofa.5W/G interest in the
property where Mrs. Sampson lived that mayor may not be recoverable.
(1) Mrs. Sampson was the second wife of the deceased owner of the property.
(2) The estate of the owner was never opened
. ..,...
.. ~
(3) There are to our knowledge at least eight adult children who would have to be found')
notified and given the option to sign off on their right to be the executor of the estate.
P AGA has the address for one child.
(4) The presumed split of the estate would be very small due to the situation and condition of
the property in question.
(5) PAGA has approached several attorneys and firms regarding this matter. All have declined
any involvement due to the time and effort that this situation would require and the likely
fact that recovery of funds may not cover the cost.
(6) PAGA will not pursue this matter further unless ordered to due so by this court.
(7) Mrs. Samson's care will not be affected by this situation. She is receiving Medicaid
benefits and will be able to remain were she is currently at, indefinitely.
Pennsylvania Guardianship Association Inc.
PAGA
PO Box 541, York, PA 17405-0541 or 1253 Wabank Road, Lancaster, PA 17603
(717)-767-6963 I (717)-940-7599 I (717)-299-4568
FAX# (717)-299-5540
I certify under the penalties of 18 Pa. C.S. sls 4904 (relating to unsworn
falsification to authorities ) that the information contained in this report is true and
correct to the best of my knowledge, information and belief:
;,....-" ,/
DATE: ~ ,/ ii" .t~' /
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v/~l e .
/1 L JA..~.ct' {(
Po~ition
,,7/1//.t7
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(j ~\ 12. CIVIL DOCKET NO.
~ I. _
(/1->/ d/' 0/ C') ~
___,~> 13. CRIMINAL DOCKET NO
AUTHORITY TO PAY COURT APPOINTED COUNSEL
1. COURT
o District Justice
o Common Pleas
o Appellate 0 Other
4. AT (CITY/STATE)
3. FOR (D,J" C.P., APPELLATE)
.'--' 1 j
6. IN THE CASE=eF r~,rS{')-7 . -cS#tl't' CO
1/> rk( f~ vs, ~ FA' /1rl /) \' (.~{
9, PROCEEDINGS (Describe briefly) I
7. CHARGE/OFFENSE (PURDON CITATION)
11. PERSON REPRESENTED
1 0 Defendant - Adult
2 0 Defendant. Juvenile
3 0 Appellant
4 0 Appellee
5 ~ Habeas Petitioner
6 0 Matenal Witness
7 0 Parolee Charged With Violation
8 0 Probatooner Charged With Violation
9 0 Other
CU(~(!/cI 1/7~cy)a(') J? : '
11ft {(,/(4/1d1"1 )
10. PERSON REPRESE'N'TED (Full Name)
, ; ~.~ I,
L/l U t1 -f~ ~~)ti IlV'~;~~{1 L
j.;).c( C'J
16. NAME OF ATTORNEY/PAYEE AND
MAILING ADDRESS
Lindsay Dare Baird
37 South Hanover Street
Carlisle, PA 17013-3307
Appt Date
t\ / _,>~1l {oJ:j
NAME OF COMMON PLEAS JUDGE ASSIGNED TO CASE
17. TELEPHONE No.
t ..;)<:/.'-:r -- ~ ~ J J-
CLAIM FOR SERVICES OR EXPENSES
19.
SERVICE
HOURS
DATES
~
a:
::J
o
()
~
a. Arraignment and/or Plea
b, Preliminary Hearing
c. Motions and ReQuests
d. Bail Hearings
e. Sentence Hearings
f. Trial
g. Revocation Hearings
h. Juvenile Hearings
I. Appeals Court /' /
~ Other (Specify on additional sheets) /f'lI'Oj) /C;-;/U', jrf
I.rc;TAL HOURS =
/. ;-;.')
;. i~)
S..,)'C/
~-;-
~ PER HOUR
--.
a~
Ilfr;~ 0Jn
20. a Interviews and conferences
u.. ~ b. Obtaining and reviewing records
o a: c. Legal research and brief writing
~::J
6 8 d. Investigative and other work (Specily on additional sheets)
" -') ()
d ./3 C I
TOTAL HOURS =
) c>
V~
~ PER HOUR
21.
ITEMIZATION OF REIMBURSABLE EXPENSES
Mileage $.25 oer mile x
AMT. PER ITEM
a:
w
:I:
I-
o
22. CERTIFICATION OF ATTORNEY/PAYEE V
Has compensation and/or reimbursement for work In thIs cue previOUSly been applied for? 0 YES ~ NO
If yes. were you paid? 0 YES ~O If yes, by whom were you paid? How much?
Has the person represented paid any money to you, or to your kno~dge anyone else, In. connection with the matter for.
which you were appointed to provide representation? 0 YES )lJ... NO f' Ifhes, givJt ~et.il!S on additional sheets J
I swear or affirm the truth or correctness v....~ If t?y,;.y{~fl--r' yr, /if 'C'I
of the above statements ~ Slgnatur. ofAtt~~payee Date
26.^PP;~~~l[JI Signature of ~ ~ .~ 1j /1 :, / , I
P.YM~NT I Judge ",. :~~ .Oate: VI'!I?/ II,
e
I
Copy 1 - Mail to Court Administrator at completion of service
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2, VOUCHER
NQ 4 6 4 5
5'.,~UDG.~ CODE i ..c'
7' (,. .,4 :~& '1,-. 11.- (.--:1..
8. 0 PETTY OFFENSE
o FELONY 0 MISDEMEANOR
14. APPEALS DOCKET NO.
18. SOCIAL SECURITY N<:, O...RElr~O
/c::; ,1" J /~ . d'J-(?9
AMOUNTS CLAIMED
Multiply rate per hour limes Iota I
hours to obtain "In Court" com.
pensation. Enter total below.
19A. TOTAL IN COURT COMPo
=$
{ . -7 C:f-
.~~
Multiply rate per hour times total
hours. Enter tolal "Out of Court"
compensation below.
20A. TOTAL OUT OF COURT
COMPo
=$
d,:~ - ~ "C~\
21 A. TOTAL ITEMIZED EXP.
"'$
23. GRAND TOTAL CLAIMED
== $ / / /l Fnl C/( ( (.
24. DEDUCT. PRIOR PYMTS.
=$
25. NET AMOUNT CLAIME(> . /,
=$ /J?I \. ,'i/ j
7/ 'J 7.7) Il.,l :t....,
27. AMT. APPA)l,VED
= $ ~(). tHJ
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IN THE MATTER OF THE PERSON
AND ESTATE OF:
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
VIDA P. SAMPSON,
NO. 21-01-075
ORPHANS' COURT DIVISION
ORDER OF COURT
AND NOW, this 29TH day of JANUARY, 2001, Lindsay Dare Baird,
Esquire, is hereby court-appointed to represent the above
captioned alleged incapacitated person.
A hearing on this matter is scheduled for March 2, 2001, at
2:00 p.m. in Courtroom # 5.
By the Court,
c::,>;;:~l \
;;;;/ . ,'~'~'~
Edward E. Guido, J.
Lindsay D. Baird, Esquire
I ) 10.- ( ~ , ci
" . ....1 (" (,
. ~ "if f
(j (
('c.t "',
1- j,-)
, /' ~
Anthony L. DeLuca, Esquire . JJ j,I'll..j CT" d 'll~u. /.J" I ,./, -' -;!
:sld
IN RE:
VIDA P. SAMPSON
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NCt- 21-oj -,S ORPHANS' COURT
IMPORTANT NOTICE
CITA TION WITH NOTICE
A petition has been filed with this Court to have you declared an Incapacitated Person. If the Court
finds you to be an Incapacitated Person, your rights will be affected, including our right to manage money
ANTHONY L. DeLUCA, ESQ.
- - - - --~- - - --- --
I
A copy of the petition which has been filed by
is attached.
and property and to make decisions.
You are hereby ordered to appear at a hearing to be held In Court Room No. 2_, Cumberland
County Courthouse. Carlisle, Pennsylvania, on MARCH
2
2001.
,at 2:00 P.M. .M. to
te'l the Court why It should not find you to be an Incapacitated Person and appoint a Guardian to act on
your behalf.
To be an Incapacitated Person means that you are not able to receive and effectively
evaluate information and communicate decisions and that you are unable to manage your
money andlor other property, or to make necessary decisions about where you will live,
what medical care you will get, or how your money will be spent.
At the hearing, you have the right to appear, to be represented by an attorney, and
to request a jury trial. If you do not have an attorney, you have the right to request the
Court to appoint an attorney to represent you and to have the attorney's fees paid for you
if you cannot afford to pay them yourself. You also have the right to request that the Court
order that an independent evaluation be conducted as to your alleged incapacity.
If the Court decides that you are an Incapacitated Person, the Court may appoint a
Guardian for you, based on the nature of any condition or disability and your capacity to
~
..... 'li.,", .
'XI:. :;~:" "___0
. '. '.:~~'~:;:;:;~~~~~:~~~'::~;:":f:~;~(.:L:
';;'i~;;:l!~d~:!d:i~h~~l~i~"h':" .
'l:..~,o;tkl:.~11',J~_~~,:"J,..
:; :;.~~~~~s_"O
..J...~:,i.~..I..'..
make and communicate decisions. The Guardian will be of your person and/or your money
and other property and will have either limited or full powers to act for you.
If the court finds you are totally incapacitated, your legal rights will be affected and
you will not be able to make a contract or gift of your money or other property. If the court
finds that you are partially incapacitated, your legal rights will also be limited as directed
by the Court.
If you do not appear at the hearing (either in person or by an attorney representing yoo) the court
will still hold the hearing in your absence and may appoint the Guardian requested.
By:
~- .- r-\
'__ (i \t - _ )_1~_ -
illa.2l/ '-' utIU_l~j J..)l-<: It h,:., )Lc. ___
Clerk,/Orphans' Court 'Division .
Cumberland County, Carlisle, PA
My Commission Expires 1 st Monday,
January, 2002
DA TED:
Jan. 19,2001
j'; "
C'
---"
, '
G.L tl\ b.l wJ
IN THE COURT OF COMMON PLEAS OF Jl ~ _ .. COUNTY, PENNSYLVANIA
ORPHANS' COURT DNISION
IN RE: \l r~ (), ~o..~~ in~acitated person
FILE NO. ') ( ,6 ( r 7)
GUARDIAN OF THE EST ATE ANNUAL REPORT
[20 Pa.C.S.A. 5521 (e)]
FROM 1/eJ/oJ ,200_TO ;SId-Ie}] ,200_
t I I ,
1) I am the _Limited ~enary Guardian of the Estate of my ward, named above.
I was appointe<LGuardian by Order of the Court dated oJ,-).. ) 0 , , which
was ~was not modified by Court Order(s) dated I .
2) Is the incapacitated person still living? \1 e~
If no, answer the following: -----1
( a) Date of creath
(b) Place of Death G t'1, ~'. l' 'iIri!~~~..J;:e(
"-.... f I __ . V I ,
(c) Name of Administrator/trix of'Executo .
(d) Date Guardian of the Person filed the last Annual Report .!Y ~I 0 I - 02
PLEASE ANSWER THE FOLLOWING QUESTIONS WHETHER THE
INCAPACITATED PERSON IS LIVING OR DECEASED.
3) My initial Inventory was filed on 5/30/0 I and listed a total estate value of
$ .~. I I
The Inventory ~ted. a total monthly in~m~ of $ t9 5 i . aV comprised of the
following: /')D(x~\ ~ ~~
4) At the beginning date of this reporting period, my initial balance on hand was
$ ~, ,-lto
C.A. - 28
5) During this reporting period, the following reflects all sources of income (other than
social security) received by me for my ward: (Add additional pages if needed)
Date Received
Source of Income
Amount
1.
'1
""' .
,..,
.J.
4.
5.
6.
TOTAL
6) During this reporting period" the following reflects all payments I have made for my
ward: (Add additional pages if needed)
. Date
To Whom Paid
Reason for Payment Amount
1.
2.
3.
4.
5.
6.
TOTAL
7) The present principal assets of my ward are:
Description of Asset
Present Value
1.
2.
3.
4.
5.
6.
TOTAL
8) The present amount and sources of income for my ward are:
Source of Income
Amount of Income
(Indicate whether monthly,
quarterly, annually)
1.
2.
....
.).
4.
5.
6.
9) The regular monthly expenses of my ward which I pay are:
To Whom Paid
Amount
1.
2.
3.
4.
5.
6.
-- - ...- ~'.- ...-..~._._._----_. '--_.~-_._._----~--~--~ -----~----~---_._._-~_._-._--
10) I hav~le one) petitioned the Court for pennission to invade principal to
meet the needs of my ward.
(If applicable) The following expenses of my ward have been paid from principal:
To Whom Paid
" Puroose
Amount
1.
2.
3.
4.
5.
6.
11) I have/have not (circle one) paid myself compensation for services I rendered as
guardian.
The amount I Paid myself totaled $ and was"
calculated at the 'following rate: $ / ttf) · 0() per wee~irc1e one).
12) Check the correct response and complete, if appropriate.
_ There will be no need for extraordinary expenditures on behalf of my ward in
the next (12) months.
There well be a need for extraordinary expenditures on behalf of my ward in
the next (12) months because:
13) Check the correct response and complete, 'if appropriate.
_A. My ward receives monthly social security benefits directly.
_B. I am the designated payee to receive my ward's social security benefits.
~e designated payee of my ward's social rty beIJ.e~ts is 11_ .
-f'ft C:nuo.c ( ton ~fup ~~L.
whose address is
and i~CirCle one) [lated to my ward as
~lJ.Clr \~ (insert relationship).
14) Please note any concerns about the incapacitated person's physical or mental well
being or the finances that the Court should know.
15) I ~ am am not guardian of the incapacitated person's person. If yes,
report is attached.
I certify under the penalties of perjury that the information contained in this report is
true and correct to the best of my knowledge, information and belief.
Name: .
Address:
Telephone No. (Home) ZQ9- t.{Sk~
(Work)..;2QQ - to{ .SlR
PA GUARDIANSHIP ASSOC.
P.O.BOX 7295
Lancaster, PA 17604.7295
.. /~
; ;ii
/ I
ITEMIZED CATEGORY REPORT C__ ;
1/ l' 0 Through 2/28' 3
PAGA_CUS-PAGA Custodial Page 1
6/ 9' 3
Date Num Description Memo Category Clr Amount
-------- ------ ------------------ ------------- ----------------- - ---------
INCOME/EXPENSE
INCOME
SAMPSON, VIDA
------------
2/21' 1 R9161 DEPOSIT SSDI SAMPSON,VIDA/SSDI X 637.00
5/ 8' 1 1658 S PAGA GENERAL ACCOU MAY FEE SAMPSON,VIDA/GUAR X -200.00
5/ 9' 1 R7422 DEPOSIT SSDI SAMPSON,VIDA/SSDI X 636.00
6/ 7' 1 1701 S PAGA GENERAL ACCOU INITIAL/MARCH SAMPSON,VIDA/GUAR X -1,100.00
6/ 7' 1 R7453 DEPOSIT SSDI SAMPSON,VIDA/SSDI X 636.00
6/21' 1 1751 VIDA SAMPSON VIDA SMPSON P SAMPSON,VIDA/PNA X -60.00
6/21' 1 1752 PENN CREDIT CORP. VIDA SMPSON SAMPSON,VIDA/UTIL X -58.13
6/27' 1 R7491 DEPOSIT BANK TRANSFER SAMPSON,VIDA/CLOS X 1,616.81
6/27' 1 1754 SWAIM HEALTH CENTE VIDA SAMPSON SAMPSON, VIDA/COST X -691.40
6/27' 1 1755 VIDA SAMPSON C/O S PERSONAL NEED SAMPSON,VIDA/PNA X -100.00
7/ 2' 1 1761 AGWAY PEARL SAMPSON SAMPSON,VIDA/UTIL X -121.18
7/10' 1 R7514 DEPOSIT SSDI SAMPSON,VIDA/SSDI X 636.00
7/24' 1 1787 S PAGA GENERAL ACCOU JULY FEE SAMPSON,VIDA/GUAR X -200.00
8/ 6' 1 1802 PAGA GENERAL ACCOU V.SAMPSON REI SAMPSON,VIDA/REIM X -10.00
8/15' 1 R7563 DEPOSIT SSDI SAMPSON,VIDA/SSDI X 19.00
8/15' 1 R7564 DEPOSIT SSDI SAMPSON,VIDA/SSDI X 637.00
8/16' 1 1819 SWAIM HEALTH CENTE VIDA SAMPSON SAMPSON, VIDA/COST X -1,249.00
8/17' 1 1825 S PAGA GENERAL ACCOU SAMPSON,VIDA/GUAR X -200.00
9/18' 1 R9009 DEPOSIT SSDI SAMPSON,VIDA/SSDI X 637.00
9/18' 1 1862 S PAGA GENERAL ACCOU SAMPSON,VIDA/GUAR X -200.00
9/22' 1 1892 SWAIM HEALTH CENTE VIDA SAMPSON SAMPSON, VIDA/COST X -628.00
10/18' 1 1920 S PAGA GENERAL ACCOU SAMPSON,VIDA/GUAR X -200.00
10/18' 1 1938 SWAIM HEALTH CENTE VIDA SAMPSON SAMPSON, VIDA/COST X -437.10
10/18' 1 R9050 DEPOSIT SSDI SAMPSON,VIDA/SSDI X 637.00
11/ 6' 1 R9113 DEPOSIT SSDI SAMPSON,VIDA/SSDI 637.00
11/ 6' 1 1976 S PAGA GENERAL ACCOU SAMPSON,VIDA/GUAR -200.00
11/30' 1 2033 SWAIM HEALTH CENTE VIDA SAMPSON SAMPSON, VIDA/COST -774.90
12/10' 1 2073 SWAIM HEALTH CENTE VIDA SAMPSON SAMPSON, VIDA/COST -606.00
1/15' 2 2121 SWAIM HEALTH CENTE VIDA SAMPSON SAMPSON, VIDA/COST -627.00
1/23' 2 R4835 DEPOSIT SSDI SAMPSON,VIDA/SSDI 654.00
2/13' 2 2202S PAGA PETTY CASH C REIMBURSE / C SAMPSON,VIDA/REIM -1.00
2/13' 2 2206 SWAIM HEALTH CENTE VIDA SAMPSON SAMPSON, VIDA/COST -606.00
3/ 7' 2 R4904 DEPOSIT SSDI SAMPSON,VIDA/SSDI 654.00
3/ 7' 2 R4905 DEPOSIT SSDI SAMPSON,VIDA/SSDI 654.00
4/22' 2 2346S PAGA GENERAL ACCOU GDN FEE SAMPSON,VIDA/GUAR -500.00
4/22' 2 R4977 DEPOSIT SSDI SAMPSON,VIDA/SSDI 654.00
5/13' 2 2421S PAGA PETTY CASH C REIMBURSE / C SAMPSON,VIDA/REIM -108.30
5/16' 2 2437 SWAIM HEALTH CENTE VIDA SAMPSON SAMPSON, VIDA/COST -581.00
6/10' 2 R5232 DEPOSIT SSDI SAMPSON,VIDA/SSDI 654.00
6/10' 2 R5287 DEPOSIT SSDI SAMPSON,VIDA/SSDI 654.00
6/11' 2 2482 SWAIM HEALTH CENTE VIDA SAMPSON SAMPSON, VIDA/COST -546.00
6/20' 2 2523S PAGA GENERAL ACCOU GDN FEE SAMPSON,VIDA/GUAR -300.00
7/ 9' 2 R5327 DEPOSIT SSDI SAMPSON,VIDA/SSDI 654.00
7/17' 2 2537 SWAIM HEALTH CENTE VIDA SAMPSON SAMPSON, VIDA/COST -557.00
8/15' 2 2634 SWAIM HEALTH CENTE VIDA SAMPSON SAMPSON, VIDA/COST -535.00
8/19' 2 R5396 DEPOSIT SSDI SAMPSON,VIDA/SSDI 654.00
8/20' 2 26438 PAGA GENERAL ACCOU GUARDIAN FEE SAMPSON,VIDA/GUAR -100.00
~
ITEMIZED CATEGORY REPORT
1/ l' 0 Through 2/28' 3
PAGA_CUS-PAGA Custodial Page 2
6/ 9' 3
Date Num Description Memo Category Clr Amount
-------- ------ ------------------ ------------- ----------------- - ---------
9/16' 2 2694 SWAIM HEALTH CENTE VIDA SAMPSON SAMPSON, VIDA/COST -554.00
10/14' 2 2730 SWAIM HEALTH CENTE VIDA SAMPSON SAMPSON, VIDA/COST -535.00
10/14' 2 R5487 DEPOSIT SSDI SAMPSON,VIDA/SSDI 654.00
10/14' 2 R5488 DEPOSIT SSDI SAMPSON,VIDA/SSDI 654.00
10/15' 2 2762S PAGA GENERAL ACCOU GUARDIAN FEE SAMPSON,VIDA/GUAR -200.00
11/11' 2 R5554 DEPOSIT SSDI SAMPSON,VIDA/SSDI 654.00
11/12' 2 2792S PAGA GENERAL ACCOU GUARDIAN FEE SAMPSON,VIDA/GUAR -100.00
11/14' 2 2820 SWAIM HEALTH CENTE VIDA SAMPSON SAMPSON, VIDA/COST -546.00
12/10' 2 2884 SWAIM HEALTH CENTE VIDA SAMPSON SAMPSON, VIDA/COST -535.00
12/11' 2 2893S PAGA GENERAL ACCOU GUARDIAN FEE SAMPSON,VIDA/GUAR -100.00
12/12' 2 R5613 DEPOSIT SSDI SAMPSON,VIDA/SSDI 654.00
1/17' 3 2976 SWAIM HEALTH CENTE VIDA SAMPSON SAMPSON, VIDA/COST -551.00
1/30' 3 R5665 DEPOSIT SSDI SAMPSON,VIDA/SSDI 663.00
2/ 6' 3 3003S PAGA GENERAL ACCOU GUARDIAN FEE SAMPSON,VIDA/GUAR -200.00
2/ 6' 3 R5709 DEPOSIT SSDI SAMPSON,VIDA/SSDI 663.00
2/18' 3 3058 SWAIM HEALTH CENTE VIDA SAMPSON SAMPSON, VIDA/COST -533.04
---------
TOTAL SAMPSON, VIDA 551.76
---------
TOTAL INCOME 551.76
---------
TOTAL INCOME/EXPENSE 551.76
---------
---------
c_
~~
- ,.
. ~rkwA
IN THE COURT OF COMMON PLEAS OF lJ.. . __ COUNTY, PENNSYLVANIA
ORPHANS' COURT DMSION
IN RE: ~CI.. P. ~ yyt>Sti'l, an incapacitated person Fll.E NO. cJ \ -6 \ - 7S-
GUARDIAN OF PERSON~~ REPORT
[20 Pa. C.S.A. 5521 (c)]
FROM 3 Jc1, J 03, 200 TO 5 / 10/'03, 200
,. - I I --
I. I am the _ Limited --2S Plenary Guardian of the Person of my ward, named above.
2. I was appointed Guardian by Order of the Court dated ~, which _was
~as not modified by Court Order(s) dated
3. Is the incapacitated person still living? N 0
If no, answer the following:. ~_ ,.,
(a) Date ofDeath?__ S / 16 ~5 _ r Jt
(b) Place ofDeath? 6 h{e ( I dtv. ~. \\c.<~ f S~l1' I' k,J -lit ~ :r
(c) Name of Administrator or Ex~tor? .
(d) Date Guardian of the Person tiled the last AnnualReport? 3 Ie.! /c cJ. - 0 3
I I
4. If the incapacitated person is still living, answer the following questions:
(a) Date Guardian of the Person filed the last Annual Report? 5/~/o J - c~ cillo
, ,
(b) Current address of the incapacitated person
(c) Current age
Date of birth of incapacitated person
(d) The incapacitated person's residence is:
Ward's own residence
_ Nursing Home
_ Hospital or Medical Facility
_ My home/apartment
Relative's Home
_ Boarding Home
( e) The incapacitated person has been living there since
If moved within the past year, state from where and the reason for the change
l
C.A. - 27
q
f
\ ~
(f) I rate hislher living arrangement as:
_ Excellent _ Average
Explain:
_ Below Average
(g) I believe he/she is:
~content with the living situation
_unhappy with the living situation
~__ unaware of the living situation
5. Physical health
(a) Current physical condition of the incapacitated person is:
_ Excellent _ Good ~air _ Poor
(b) His/her major physical health problems are as follows: _______ _
( c) During the past year, hislher physical condition has:
remained about the same.
_ improved. Explain
__ worsened. Explain
(d) During the past year, he/she received the following medical treatment (include
check-ups and dental work):
Date
Ailment
Type of treatment
Doctor's name
6. Mental Health
(a) The incapacitated person's condition is
excellent _ good
_ poor
(b) His/her major mental health problems are as follows: __
(c) During the past year, his/her mental condition has:
o r~ained about the same.
~proved. Explain
_ Worsened. Explain
(d) During the past ~, treatment or evaluation by a psychiatrist, psychologist or social
worker _ was ~as not provided. Such mental health services are briefly
described as: '
7. Social Activities / Services
(a) Hislher current social condition is:
excellent _ good
1fair
_ poor
(b) During the past year, his/her social condition has:
~. remained about the same.
_ improved. Explain.
__ worsened. Explain.
(c) During th~ past year he/she has parti ipated .
~ recreational l ~ J.j
~ educational --
social
I occupational
no activities available.
_ he/she refuses to participate in any activities.
_ helshe is unable to participate in any activities.
8. Visitation
(al During the east year" I visited him/her as follows:
(b) The average amount of time I spent on each visit was --1. S-/ cJOt1Lff1 "
( c) The last time I visited was on 09;/ C/ 3
date
9. During the ltE W hav.e
person: (f\ a
"
Fa
~
.
1
10. I believe he/she has the following unmet needs:
11. The .guardianship _ should -4 sboul~ot be ~ without modification
because. aLQ .
'- -
12. Please note any concerns about the InCapacitated person's physical or mental well being or
the finances that the Court should know.
13. I ~ am _ am not guardian of the incapacitated person's estate. If yes, my report is
attached
I certify under the penalties of perjury that the information contained in this report is true
and correct to the best of my knowledge, information and belief.
Date:
CPJ:,3
Name: ~P1'c-1k
Address:
PA GUARDIANSHIP ASSOC.
P.O.BOX 7295
lancaster, PA 17604.7295
. Telephone # (Home) tfJ cr 7.- ~~?c?
(Work) d CJq- {I)(v,?
c
. · (l~( ttrd
IN THE COURT OF COMMON PLEAS OF Ii LUll COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
IN RE: V', du.. ~. ..~ an incapacitated person FILE NO..) I-(J I - 1.5
GUARDIAN OF PERSON ANNUAL REPORT
[20 Pa. C.S.A. 5521 (c)]
FROM ~/;) )0 (,200_ TO .3/;;/6'd ,200_
1. I am the _ Limited L Plenary Guardian of the Person of my ward, named above.
2. I was appointed Guardian by Order of the Court dated i d.. / Q I , which was
v was not modified by Court Order( s) dated
3. Is the incapacitated person still living? y C"....s
If no, answer the following:
(a) Date of Death?
(b) Place of Death?
(c) Name of Administrator or Executor?
(d) Date Guardian of the Person filed the last Annual.Report? \-'4 :;.\-
4. If the incapacitated person is still living, answer the following questions:
(a) Date Guardian of the Person filed the last Annual Report? t' \ ''i. +
(b) Current address of-the incapac~ted. pe~on _
6( ( f/\ tc \ <i o<r \J, \ \ ()~ c~e (- ~v.x" 0 Ce r-J--eJ
(c) Current age ~ Date of birth of incapacitated person
f /;;0/ L/~/
/ I
(d) The incapacitated person's residence is:
Ward's own residence _ My home/apartment
~ Nursing Home Relative's Home
_ Hospital or Medical Facility _ Boarding Home
(e) The incapacitated person has been living there since ill ~1 .Jl i Y-wJ.. f)"
If moved within the past year, state from where ~eas fc#the change
C.A. - 27
(f) I rate his/her living arrangement as:
-:.- Excellent .A- Average
Explain:
_ Below Average
(g) I beli€;rve he/she is:
~ content with the living situation
_unhappy with the living situation
_unaware of the living situation
5. Physical health
(a) Current physical condition of the incagacitated person is:
_ Excellent _ Good ~ Fair _ Poor
(b) Hislher major physical health problems are as follows:
(c) During the past year, hislher physical condition has:
X- remained about the same.
_ improved. Explain
_ worsened. Explain
(d) During the past year, he/she received the following medical treatment (include
check-ups and dental work):
Ailment
Doctor's name
6. Mental Health
( a) The incapacitated person's condition is
_ excellent ~. good _ poor
!.
(b) His/her major mental health problems are as follows: ~/1V\D !~c.k\, (~
(c) During the past year, hislher mental condition has:
* remained about the same.
_ Improved. Explain
_ Worsened. Explain
(d) ~e past year, trea1ment or evaluation by a psychiatrist, psychologist or social
worker was _ was not provided. Such mental health services are briefly
desc~ ~ - tk
~~ ~ ven \ ~ f ~~ .
.
7. Social Activities / Services
(a) Hislher current social condition is:
excellent '4- good
fair
_ poor
(b) During the past year, hislher social condition has:
~ remained about the same.
-=--- improved. Explain.
_ worsened. Explain.
(c) Duringl.. p. ast year he/she has participated in the following activities:
recreational
educational
~social
~. occupational
no activities available.
_ he/she refuses to participate in any activities.
_ he/she is unable to participate in any activities.
8. Visitation .' 11 - 1/1 ~
(al During the east year. I visited bimlher as follows: (l Lfi}\.Yf rv~
<
(b) The average amount of time I spent on each visit was '1 ~s-~ () 0 V'1Le('\
(c) The last time I visited was on 3/~~~
date
9. During the 1
person: /l\.a- . ,
. ~
10. I believe he/she has the following unmet needs:
11. The guardianship <J should _ should not be continued without modification
because: ---f-
12. Please note any concerns about the Incapacitated person's physical or mental well being or
the finances that the Court should know.
13. I $ am _ am not guardian of the incapacitated person's estate. If yes, my report is
attached.
I certify under the penalties of perjury that the information contained in this report is true
and correct to the best of my knowledge, information and belief.
Date: r;1910?~
Name: . Telephone # (Home) lffCI- C( Jt'tL
Address: (Work~ q9- L/J7Lff
PA GUARDIANSHIP ASSOC.
P.O.BOX 7295
Lancaster, PA 17604-7295
IN THE MATTER OF THE PERSON AND : IN THE COURT OF COMMON PLEAS OF
ESTATE OF: : CUMBERLAND COUNTY, PENNSYLVANIA
VIDA P. SAMPSON,
AN ALLEGED INCAPACITATED PERSON: ORPHANS' COURT DIVISION
NO.cJ..I_ DI- D 15
PRELIMINARY DECREE
AND NOW, this 1$ t/J day of u,,/VJ, 2001, upon consideration of
the annexed Petition, it is hereby ORDERED AND DECREED that a Hearing on this
matter is set for the J.. N,J, day of ~"r ~, 2001, at ~ ,.0C1 1. M.
O'clock in Courtroom No.5 at the Cumberland County Courthouse, 1 Courthouse
Square, Carlisle, Pennsylvania, and that a Citation be issued to Vida P. Sampson
commanding her to appear at the aforementioned hearing pursuant to the Petition of the
Area Agency on Aging to have Vida P. Sampson adjudicated an incapacitated person and
to have plenary guardians appointed for her person and estate. Notice of the hearing shall
be given to Vida P. Sampson by counsel for the Petitioner in accordance with 20 P. S.
Sec. 5511(a) not less than twenty (20) days prior to the hearing.
E "'"""ulr:r:..... .I~
J.
IN THE MA TIER OF THE PERSON : IN THE COURT OF COMMON PLEAS
AND ESTATE OF: : CUMBERLAND COUNlY, PENNSYLVANIA
VIDA P. SAMPSON,
NO.
ORPHANS' COURT 2000
AN ALLEGED INCAPACIATED
PERSON
PETITION FOR APPOINTMENT OF PERMANENT PLENARY GUARDIANS
OF THE PERSON AND ESTATE
AND NOW COMES THE PETITIONER, the Area Agency on Aging, in and for
Cumberland County, Pennsylvania, by its attorney, Anthony L. DeLuca, Esquire, and
represents and avers as follows:
1.
The Petitioner is the Area Agency on Aging, in and for Cumberland County, with
its office located at 16 West High Street, Carlisle, Cumberland County, Pennsylvania.
2.
The alleged incapacitated person is Vida P. Sampson, 92 years of age, who
resides at 103 Claremont Drive, Carlisle, Cumberland County, Pennsylvania and has
resided at that address since 1950.
3.
Vida P. Sampson is the widow of Harvey Sampson and the stepmother of nine
children by the previous marriage of her husband.
4.
The Petitioner has attempted to contact several known stepchildren for assistance
in this matter but none of them are able to help Vida P. Sampson, the alleged
incapacitated person.
5.
Vida P. Sampson has, for at least four (4) months, been incapable of managing
and caring for herself.
6.
Vida P. Sampson exhibits symptoms of mental incapacity.
7.
Vida P. Sampson's mental incapacity prevents her from managing and caring for
the affairs of her person and estate.
8.
On or about December 12,2000, Vida P. Sampson was admitted to Carlisle
Hospital and, during her stay there, was evaluated by a psychiatrist, the results of which
are attached hereto, marked as Exhibit "A", and incorporated herein by reference.
9.
Vida P. Sampson's condition, prior to her hospitalization on December 12, 2000,
had deteriorated in that:
a. Her appearance was poor;
b. She was unkempt and disheveled;
c. She appeared disoriented and confused; and
d. She was unable to manage her financial affairs.
10.
On or about December 13, 2000, an authorized representative of the Petitioner
visited the home of Vida P. Sampson and made the following observations:
a. There was a makeshift roof made of heavy plastic;
b. The porch was cluttered with refrigerators and a stove, all of which were
unclean~
c. The kitchen was cluttered with the floor being stained and covered with
miscellaneous debris~
d. The living room had the smell of feces as well as being cluttered and
unclean;
e. The home had a noticeable oder which was more pungent in the living
room and bedroom areas;
f Another room was used to house a rooster that also contained feces and
feathers~ and
g. There is no indoor plumbing.
11.
On or about December 14, 2000, the alleged incapacitated person, Vida P.
Sampson, was discharged from Carlisle Hospital and was admitted to Swaim Health
Center where she is currently.
12.
Vida P. Sampson has previously executed a Power of Attorney wherein she
appointed one Anne Olmstead of 47 E. Street, Carlisle, Pennsylvania as her Power of
Attorney.
13.
Anne Olmstead is unable to perform her duties as a Power of Attorney due to very
serious health problems.
14.
Less restrictive alternatives are not available because there is no one able to care
for her.
15.
The approximate gross value of the Estate of Vida P. Sampson depends upon
what legal interest she has in her residence which was assessed in 2000 for $36,700.00
and her monthly income, consisting of social security, is estimated to be $636.00.
16.
The Petitioner and the proposed Guardian have no interest adverse to the alleged
incapacitated person.
17.
Pennsylvania Guardianship Association, P.O. Box 541, York, York County,
Pennsylvania 17405 is agreeable to assume the responsibility of Plenary Guardian of the
Person and Estate of Vida P. Sampson.
18.
No application, to the knowledge of Petitioner, has been made for the Order
herein asked for.
19.
No other Court has ever assumed jurisdiction in any proceeding to determine the
incapacity of Vida P. Sampson.
20.
The failure to appoint Pennsylvania Guardianship Association as Permanent
Plenary Guardian of the Person and Estate of Vida P. Sampson will result in irreparable
harm to the person and estate of Vida P. Sampson.
WHEREFORE, Petitioner prays that this Honorable Court determine whether
Vida P. Sampson is an Incapacitated Person and, if so, appoint Pennsylvania
Guardianship Association to be the Permanent Plenary Guardian of the Person and
Estate of Vida P. Sampson.
Respectfully Submitted", _
a~. .' .. V../' C/
// .. lc ..Ct( c/,.)f ~. .I"-(-~'~ X./t" . (~ c'-
Anthony L. D~uca, Esquire
113 Front Street
P.O. Box 358
Boiling Springs, P A 17007
(717) 258-6844
VERIFICATION
I hereby verify that the facts and information set forth in the foregoing Petition for
Appointment of Permanent Plenary Guardians of the Person and Estate of Vida P.
Sampson are true and correct to the best of my knowledge, information, and belief I
understand that any false statements contained herein are subject to the penalties of 18
Pa. C.S. Section 4904, relating to unsworn falsification to authorities.
Dated: I i
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IN THE COURT OF COMMON PLEAS OP trT TOur n r COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
IN RE: \A d l () - S/1lMi1Vi1, an in~acitated person
FILE NO.~ ,.- 01 ,.. 7J-
GUARDIAN OF THE ESTATE ANNUAL REPORT
[20 Pa.C.S.A. 5521 (c)]
FROM~2/V I ,200 TO 3/J-JoJ- ,200_
/ - I I
1) I am the _ Limited~lenary Guardian of the Estate of my ward, named above.
I was appointed Guardian by Order of the Court dated 3 J;;J jD I , which
was ~ was not modified by Court Order(s) dated .
2) Is the incapacitated person stillliving?
If no, answer the following:
(a) Date ofIYeath
(b) Place of Death
(c) Name of Administrator/trix or Executor/trix
(d) Date Guardian of the Person filed the last Annual Report
"fCS
t=-,"c ~-\-
PLEASE ANSWER THE FOLLOWING QUESTIONS WHETHER THE
INCAPACITATED PERSON IS LIVING OR DECEASED.
3) My initial Inventory was filed on ~ /301 0 I and listed a total estate value of
$ ~. '
The ~ventory listed a total monthly ~~e of $ ~;3Cs,. ($0 comprised of the
followmg: .see \0..\ ~D~
:) At the ~ date of this reporting period, my initial balance on hand was
C.A. - 28
-
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rth
JlQ W (UJ~f) Q-\
t.t
5) During this reporting period, the following reflects all sources of income (other than
social security) received by me for my ward: (Add additional pages if needed)
Date Received
Source of Income
Amount
1.
2.
3.
4.
5.
6.
TOTAL
6) During this reporting period, ,the following reflects all payments I have made for my
ward: (Add additional pages if needed)
-Date
To Whom Paid
Reason for Pavment Amount
1.
2.
..,
.).
4.
5.
6.
TOTAL
7) The present principal assets of my ward are:
Description of Asset
Present Value
1.
')
.....
-
3.
4.
5.
6.
TOTAL
8) The present amount and sources of income for my ward are:
Source of Income
Amount of Income
(Indicate whether monthly,
quarterly, annually)
1.
2.
..,
..).
4.
5.
6.
9) The regular monthly expenses of my ward which I pay are:
To Whom Paid
Amount
1.
2.
3.
4.
5.
6.
~_._.._--"._~_._-_._-_.._-_._--~-"_._----_.._-~-_._----_._-----_.__.~~-----------
10) I haV~ (circle one) petitioned the Court for permission to invade principal to
meet the needs of my ward.
(If applicable) The following expenses of my ward have been paid from principal:
To Whom Paid
. Purpose
Amount
1.
2.
'"
,j.
4.
5.
6.
11) I havelhave not ( circle one) paid myself compensation for services I rendered as
guardian.
The amount I Paid myself totaled $ and was
calculated at the following rate: $ /otJ,. Cr() per weekl~( circle one).
12) Check the correct response and complete, if appropriate.
_ There will be no need for extraordinary expenditures on behalf of my ward in
the next (12) months.
_ There well be a need for extraordinary expenditures on behalf of my ward in
the next (12) months because:
13) Check the correct response and complete, 'if appropriate.
_A. My ward receives monthly social security benefits directly.
B. I am the designated payee to receive my ward's social security benefits.
L The designated payee of mx ward's social~ecurity _bp,1~fi~is
1> f\- 6 ck.G\.( llt.\ <Ml ~ k~t:L (
whose address is
and is@ (circle oUf) related to my ward as
~ ULGl r eM ~ (insert relati~nship).
14) Please note any concerns about the incapacitated person's physical or mental well
being or the finances that the Court should know.
15) I ~ am am not guardian of the incapacitated person's person. If yes,
report is attached.
I certify under the penalties of perjury that the information contained in this report is
true and correct to the best of my knowledge, information and belief.
Name: .
Address:
Telephone No. (Home) ~4 - ~~1u 7
{Work)~'1~-4 ~wt?
PA GUARDIANSHIP ASSOC.
P.O.BOX 7295
Lancastr:r, PA ,7604-7295
(T)
-~
ITEMIZED CATEGORY REPORT
1/ l' 0 Through 2/28' 2
PAGA_CUS-PAGA Custodial Page 1
6/ 9' 3
Date Num Description Memo Category Clr Amount
-------- ------ ------------------ ------------- ----------------- - ---------
INCOME/EXPENSE
INCOME
SAMPSON, VIDA
------------
2/21' 1 R9161 DEPOSIT SSDI SAMPSON,VIDA/SSDI X 637.00
5/ 8' 1 1658 S PAGA GENERAL ACCOU MAY FEE SAMPSON,VIDA/GUAR X -200.00
5/ 9' 1 R7422 DEPOSIT SSDI SAMPSON,VIDA/SSDI X 636.00
6/ 7' 1 1701 S PAGA GENERAL ACCOU INITIAL/MARCH SAMPSON,VIDA/GUAR X -1,100.00
6/ 7' 1 R7453 DEPOSIT SSDI SAMPSON,VIDA/SSDI X 636.00
6/21' 1 1751 VIDA SAMPSON VIDA SMPSON P SAMPSON,VIDA/PNA X -60.00
6/21' 1 1752 PENN CREDIT CORP. VIDA SMPSON SAMPSON,VIDA/UTIL X -58.13
6/27' 1 R7491 DEPOSIT BANK TRANSFER SAMPSON,VIDA/CLOS X 1,616.81
6/27' 1 1754 SWAIM HEALTH CENTE VIDA SAMPSON SAMPSON, VIDA/COST X -691.40
6/27' 1 1755 VIDA SAMPSON C/O S PERSONAL NEED SAMPSON,VIDA/PNA X -100.00
7/ 2' 1 1761 AGWAY PEARL SAMPSON SAMPSON,VIDA/UTIL X -121.18
7/10' 1 R7514 DEPOSIT SSDI SAMPSON,VIDA/SSDI X 636.00
7/24' 1 1787 S PAGA GENERAL ACCOU JULY FEE SAMPSON,VIDA/GUAR X -200.00
8/ 6' 1 1802 PAGA GENERAL ACCOU V.SAMPSON REI SAMPSON,VIDA/REIM X -10.00
8/15' 1 R7563 DEPOSIT SSDI SAMPSON,VIDA/SSDI X 19.00
8/15' 1 R7564 DEPOSIT SSDI SAMPSON,VIDA/SSDI X 637.00
8/16' 1 1819 SWAIM HEALTH CENTE VIDA SAMPSON SAMPSON, VIDA/COST X -1,249.00
8/17' 1 1825 S PAGA GENERAL ACCOU SAMPSON,VIDA/GUAR X -200.00
9/18' 1 R9009 DEPOSIT SSDI SAMPSON,VIDA/SSDI X 637.00
9/18' 1 1862 S PAGA GENERAL ACCOU SAMPSON,VIDA/GUAR X -200.00
9/22' 1 1892 SWAIM HEALTH CENTE VIDA SAMPSON SAMPSON, VIDA/COST X -628.00
10/18' 1 1920 S PAGA GENERAL ACCOU SAMPSON,VIDA/GUAR X -200.00
10/18' 1 1938 SWAIM HEALTH CENTE VIDA SAMPSON SAMPSON, VIDA/COST X -437.10
10/18' 1 R9050 DEPOSIT SSDI SAMPSON,VIDA/SSDI X 637.00
11/ 6' 1 R9113 DEPOSIT SSDI SAMPSON,VIDA/SSDI 637.00
11/ 6' 1 1976 S PAGA GENERAL ACCOU SAMPSON,VIDA/GUAR -200.00
11/30' 1 2033 SWAIM HEALTH CENTE VIDA SAMPSON SAMPSON, VIDA/COST -774.90
12/10' 1 2073 SWAIM HEALTH CENTE VIDA SAMPSON SAMPSON, VIDA/COST -606.00
1/15' 2 2121 SWAIM HEALTH CENTE VIDA SAMPSON SAMPSON, VIDA/COST -627.00
1/23' 2 R4835 DEPOSIT SSDI SAMPSON,VIDA/SSDI 654.00
2/13' 2 2202S PAGA PETTY CASH C REIMBURSE / C SAMPSON,VIDA/REIM -1.00
2/13' 2 2206 SWAIM HEALTH CENTE VIDA SAMPSON SAMPSON, VIDA/COST -606.00
---------
TOTAL SAMPSON, VIDA -886.90
---------
TOTAL INCOME -886.90
---------
TOTAL INCOME/EXPENSE -886.90
---------
---------
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IN THE COURT OF COMMON PLEAS OF COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
IN RE: V i dCl. P. &~v1 , an incapacitated person FILE NO. d ) -bl- -rs
GUARDIAN OF PERSON ANNUAL REPORT
[20 Pa. C.S.A. 5521 (c)]
FROM '?J /;ljOJ.. 200_ TO 3/lJo'3 ,200_
1. I am the _ Limited 1- Plenary Guardian of the Perso~ of my war~ named above.
2. I was appointed Guardian by Order of the Court dated 3/~ J 0 ( , which was
'V\vas not modified by Court Order(s) dated ' ,
3. Is the incapacitated person still living? ~
If no, answer the following:
(a) Date ofDeath?___.__
(b) Place of Death?
(c) Name of Administrator or Executor? .
(d) Date Guardiin of the Person filed the last Annual.Report? ~Jb \ - tA:t
4. If the incapacitated person is still living, answer the following questions:
(a) Date Guardian of the Person filed the last Annual Report? #b/ - 0 :;2
(b~Current ad4r~s Ofthe..~. capacita. l~ person ~
u1t --f2 f' () c{ { Ch~. V ~ \ /~J.J LLi (\ c...UU e- (
----------
C1 ~
( c) Current age ~ Date of birth of incapacitated person 1
(d) The incapacitated person's residence is:
Ward's own residence _ My home/apartment
/Nursing Home Relative's Home
_ Hospital or Medical Facility _ Boarding Home
(e) The incapacitated person has been living there since /J1tA.t0d tL.et< r5'
If moved within the past year, state from where and the r~n fir" the change
l
C.A. - 27
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(f) I rate his/her living ~ent as:
_ Excellent ~ Average
Explain:
_ Below Average
(g) I believe he/she is:
L content with the living situation
I~unhappy with the living situation
_unaware of the living situation
5. Physical health
(a) Current physical condition of the incapacitated person is:
Excellent Good p- Fair Poor
(b) Hislher major physical health problems are as follows: ~ rN.U Q f. ~ .
(c) During the past year, bis/her physical condition has:
~ remained about the same.
. _ improved. Explain
__ worsened. Explain
(d) During the past year, he/she received the following medical treatment (include
check-ups and dental work):
Date
Ailment
Type of treatment Doctor's name
~~~~
~~E~~~~L
6. Mental Health
(a) The incapacitated person's condition is
excellent X good
poor
JSJ;~D--
(b) His/her major mental health problems are as follows:
(c) p the past year, hislher mental condition has:
remained about the same.
_ Improved. Explain
_ Worsened. Explain
(d) During the past year, treatment or evaluation by a psychiatrist, psychologist or social
worker _ w~ was not provided. Such mental health services are briefly
described as: '
7. Social Activities I Services
(a) His/her current social condition is:
excellent _ good
){- fair
_poor
(b) During the past year, his/her social condition has:
~ _ remained about the same.
_ improved. Explain.
_ worsened. Explain.
(c) During the past year helshe has participated in the following activities:
ft. .~ recreational
.., educational
I social
-+2- occup~~o~al .
. no actiVIties available.
_ he/she refuses to participate in any activities.
_ he/she is unable to participate in any activities.
8. Visitation
(a1 During the east year. I visited himlher as follows:
(b) The average amount of time I spent on each visit was f 5 ~ dO ~ \ (\
(c) The last time I visited was on /;; c) /0 3
date
9. During th~l~t ye3f I have performed the follO)Ving activities. on behalf the incapacitated
person: ttj .\~dttu;h.A1UO I ~e-<l1L\'l~rY~~MJtv':>,
10. I believe he/she has the following unmet needs:
11. The guardianshiP~ should _ should not be continued without modification
because:
12. Please note any concerns about the InCapacitated person's physical or mental well being or
the finances that the Court should know.
,.
13. I ,x, am _ am not guardian of the incapacitated person's estate. If yes, my report is
attached.
I certify under the penalties of perjury that the information contained in this report is true
and correct to the best of my knowledge, information and belief.
Date: 019 /03-'-
S'
Name: \) r 1 evil b ~kr
Address:
PA GUARDIANS~fP ASSOC.
P .O.BOX 7295
Lancaster, PA 17604.7295
. Telephone # (Home) !~"E( -- Vfu-p
(Work) d ope; - '1 TlrL/p