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HomeMy WebLinkAbout72-0355 IN RE: ESTATE OF EDWARD EUGENE SA..1'1PSON, A HINOR IN THE ORPHANS' COURT OF C'L'MBERLAND COUNTY, ?ENNSYLVANIA NO. PETITION FOR APFOINTMENT OF GUARDIAN TO THE HONORABLE JUDGES OF SAID COURT: The Petition of Alice Z. Creager respectfully represents: 1. Your Petitioner is the Director of the Child Welfare Services of Cumberland County, Pennsylvania, and Edward Eugene Sampson is a retarded, physically handicapped minor, 19 years of age, born October 9, 1952. 2. By Order of the Court of the Quarter Sessions Court of Cumberland County, Pennsylvania sitting as a Juvenile Court by proceed1ngs filed to No. 27 December Sessions, 1953 dated November 6, 1953, said minor was placed in the care and custody of Child Welfare Services of Cumberland County, Pennsylvania. 3. Said ~inor is presently under the care, custody and supervision of said Child Welfare Services of Cumberland County, Pennsylvania. 4. The said minor is illegitimate and lived with his mother, Virginia Sampson Johnson at R .D. #l,GarTi:s1.e, Pennsylvania prior to his being placed in the custody of Child Welfare Services 0: Cumberland County, Pennsylvania. s. That said minor has no Guardian of his estate and it is necessary that such a Guardi.an be appointed so that publi.c assistance funds can be authorized to meet bis cost of maintenance. ~Of;'\ (~'i '/..'; Q~),",,', :~~ ,1'l~'... ~K: ,; " \: . ;; 4 . D ! > ! I j t M ~ t i ! t I I J...: ':';,",,' 6. It is contemplated that sald minor will have no other assets or bene~its. 7. Said minor may be entitled to receive a Public Assistance grant which can be payable only to a legally respcnsible relative or a Court appointed Guardian. Public Assistance personnel would conduct routine investigation as to the proper use of funds paid to the proposed Guardian. 8. Since said minor does not reside with a legally responsible relative, the Petitioner proposes as Guardians of the said minor, Paul and Margaret Mellinger, foster parents, with whom said minor . " "- has resided since November, 1953. 9. The proposed Guardians have consented to serve in such capacity by their consent which is attached hereton. 10. Said minor being physically handicapped and mentally retarded, it would not be for the best interest o~ said minor that he appear l ~ j f f ~ i ~ in Court. WHEREFORE, the said Petitioner prays your Honorable Court to appoint Paul and Margaret Mellinger, R.D. #1, Newville, Pennsylvania as Guardians of the Estate o~ thl3 said minor. (;//---:J..? /tL/t"t..."y.._. Director; Child Welfare Serv~ces !S[~ H9 t'liot S~~ I' r {.... . .....'...... .~~:~~ STATE OF PENNSYLVANIA COUNTY OF CUMBERLAND ss. t Alice Z~ Creager, Director or the Child Welrare Services of Cumberland County, Pennsylvania, as aroresaid, who be:l.ng duly sworn accordi.ng to law, deposes and says that the racts set rorth in the foregoing Petition are true and correct according to her knowledge, inrormation and belier. // .7, _ "7 v d (...../;..(.__. C.'~" ...;/ /L-'L.-':-v-~-,,-' ~......J..,,-- (Mrs.) Alice Z. Creager Director ~ ~ ~ -; Ii.' r , , ~, f " l ~ ~ . 5 i I . ~ ~ I i I r . i S~9,r.nG~nd subscribed to ," ':, I '. ,.' -10'. . It ,;Jb~i;~-e'1.t'his .:i!?:. day , ,'';"/:.;'" ',~:.<.;;>,:/~;,:~ .;~,.. . I,:":. 0~j;r~9.t"'-I:~. 'i,'~ 1972 ;", Q~ \ :;':-.':' ',' (,,' ~r,~:'~r ~:..\' .t, 4.~,:..- ...\: ",. tf'! p,. '"'.' .'; S n 'J l- .' "" ~: " ',-' "~j: '" ..." v:;..;. ,.r' .1 " ". 'l'ny 1"'1 t;J...'I11~ ~:./;;'.l . LL.t't t\ /Yn.--> ~ , '.'".':"':..:..:;!<..:',;,,(J flUOI1EY G, ADAMS NOTARY PUBLIC My Ccmmission EJpires May II. 19'/iV Ce!Ii~le. Pa. Cumberland Coun1t I j I I '-, ~:.. ..;:'1 " ,...(' '" );; j.'., . BOOK 99 'bGE &iU p It:~' ',',; ,..... " ., ~l,".":.:.'.;"'" ',.:"~ "1 m \ , .",,~ CONSENT OF PROPOSED GUARDIAN PAUL AND 11ARGARET MELLINGER, R. D. #1, Newville, Pennsylvania do hereby consent to serve as Guardians of the Estate of Edward Eugene Samp~on if they aI'e appoi nted in such capacity by the Orphans' Court Of Cumberland County pursuant to the Petition to which this Consent is attached. They certify that they are not the fiduciary of an estate in which the minor has an interest, nor tbe surety or such a. fiduciary and that they have no interest adverse to the minor. tLIJ ?~u:.J2/.~~~1,/ Pa.ul Mellinger' /J ',j!, (.,1' /1 ,"J "'-,) 1972 - )n l("ffM;*m.d.e.~?./", Marg at Mellinger , (r-" " c \ noo" 99 rLGt &:t2 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA Orphans Court Division IN RE: o (::;0 :Jt~~ G{~~< ~;(~ .::""5 __~J --I ..;.:.> co w s:- EDWARD E. SAMPSON, Incompetent Person NO. PETITION FOR ADJUDICATION OF INCAPACITY AND APPOINTMENT OF PLENARY GUARDIAN OF THE ESTATE AND PERSON OF EDWARD E. SAMPSON AND NOW COME Margaret Mellinger, Dorothy Kepner, Richard Kepner, and Darlene Ziegler ("Petitioners"), by and through their attorneys, David R. Getz, Esquire and the law firm of Wix, Wenger & Weidner, and, in accordance with 20 Pa. C.S.A. S5511, files this Petition for Adjudication of Incapacity and Appointment of Plenary Guardian of the Estate and Person of Edward E. Sampson, and in support thereof, state as follows: 1. Petitioner Margaret Mellinger is an adult individual residing at 8 Pine Road, Walnut Bottom, Pennsylvania 17266. Margaret Mellinger has been the next friend and primary caregiver of Edward E. "Eddie" Sampson ("Sampson") for over fifty (50) years. 2. Petitioner Dorothy Kepner, the sister of Margaret Mellinger, is an adult individual residing at 208 Shughart Avenue, Boiling Springs, Pennsylvania 17007. 3. Petitioner Richard Kepner, the brother-in-law of Margaret Mellinger, is an adult individual residing at 208 Shughart Avenue, Boiling Springs, Pennsylvania 17007. 4. Petitioner Darlene Ziegler, the daughter of Margaret Mellinger, is an adult individual residing at 1132 Centerville Road, Newville, Pennsylvania 17241. 5. Sampson is a 54 year old single man who was born on October 9, 1952, and who currently resides at Outlook Pointe, Shippensburg, Pennsylvania. - 1 - r--..:> c=:::> = C1'"\ o rr1 n I 0::> :tJoo ::: .::rJ ;:-=5 .., (.:) ::0 ':..:J rn CJ -- .~. c--) ._ :-..' .~~-F.l . -:.:: (~"''5 . fT1 (~) "f J 6. Sampson came to live with Margaret Mellinger and her late husband when he was about one year old. He was referred there by Cumberland County Children & Youth Services. 7. Apparently, the County never appointed a guardian for Sampson and he resided with Margaret Mellinger until she was no longer able to care for him. 8. Margaret Mellinger would like for Sampson to move to Cumberland Crossings in Carlisle, Pennsylvania. Sampson agrees to the extent he is able. 9. Cumberland Crossings is agreeable to admitting Sampson, but needs the consent of a guardian before accepting Sampson. 10. To the best of Petitioners' knowledge, information and belief, Sampson has no living next-of-kin. 11. The name and address of the institution providing residential services for Sampson is Outlook Point in Shippensburg, Pennsylvania. 12. To the extent known by Petitioners, Sampson's assets are valued at approximately $100.00, comprised of personal clothing and possessions. 13. Petitioners estimate Sampson's annual income to be Twelve Thousand Dollars ($12,000.00), consisting of monthly Social Security benefits of One Thousand Dollars ($1,000.00) per month. 14. Sampson was not a member of the armed services of the United States and is not receiving benefits from the United States Veterans' Administration. 15. Sampson suffers from cerebral palsy. As a result of the cerebral palsy, Sampson is mentally retarded, and suffers from arthritis and seizure disorder. A Medical Evaluation provided by Dr. Karen Bryson setting forth Sampson's medical history is attached as Exhibit "AU. 16. Because of his impaired mental and physical condition, Sampson is totally unable to manage his financial and personal affairs, and to make and communicate responsible decisions relating thereto, including the ability to communicate his need for assistance in these areas. 17. Because of his impaired mental and physical condition, Sampson lacks the capacity to make or communicate responsible decisions concerning his person and is unable to make decisions regarding his care, is unable to live alone or to seek needed medical services. - 2 - 18. There are no alternatives to the appointment of a guardian of the estate because of his mental condition. 19. The severity of Sampson's mental and/or physical condition and the lack of viable, less restrictive alternatives necessitate that a plenary guardian of his estate be appointed to manage and handle all aspects of Sampson's estate, specifically including, but not limited to: all issues relating to his cash, checks, and any bank or savings accounts held in his name, his stocks and bonds, his personal property, his real estate, his life and other insurance of which he is a beneficiary, his entitlement to any governmental and non-governmental benefit plans, federal, state, and local taxes, claims made or to be made on behalf of him or against him, the execution of documents, entry into contracts affecting him and the payment of reasonable compensation or costs to provide services for him. 20. Petitioners are not aware that Sampson signed any powers of attorney or advance health care directives or in any other way designated anyone to serve as his agent over any of his personal or financial affairs or as his surrogate over his medical care, or that he designated in writing his wishes with regard to health care, including the use or refusal of life-sustaining treatment. 21. The proposed plenary guardians of the person and of the estate of Sampson are Petitioners. Petitioner Margaret Mellinger has served as the primary caregiver and unofficial guardian of his estate for over 50 years. 22. Margaret Mellinger is 86 years of age and desires to become Sampson's legal guardian. Dorothy Kepner, Richard Kepner, and Darlene Ziegler desire to be named as co-guardians to provide Sampson with continuity of care. 23. The proposed plenary guardians have no interest adverse to Sampson. 24. The consents of the proposed plenary guardians are attached as Exhibit "B". 25. No other court has ever assumed jurisdiction in any proceeding to determine the capacity of Sampson. 26. No other guardian has been appointed for the estate or person of Sampson. WHEREFORE, Petitioners respectfully request that this Honorable Court award a citation directed to Edward E. Sampson, Sampson, and to such other persons as this Court may direct, to show cause why Edward E. Sampson should not be adjudged a - 3 - fully incapacitated person, and Margaret Mellinger, Dorothy Kepner, Richard Kepner, and Darlene Ziegler appointed plenary co-guardians of his person and of his estate. Respectfully submitted, WIX, WENGER & WEIDNER ....--~ ( ;'\. .)- . . / / \ '''j, By: "/>?'~cf <~/ ~- /(7-- David R. Getz, Esquire / Attorney 10 No. 34838 508 North Second Street P.O. Box 845 Harrisburg, PA 17108-0845 (717) 234-4182 Dated: ,( )([~~,\)~( '7,2006 F:\drg\7195 - Pro Bono\14200 - Sampson, Edward Eugene\Documents\Mellinger - Petition for Appointment of Guardian.doc - 4 - '"' . . , It'!' !Jl .~ iJ. ~ ;e ., I':" J ~ ~ ~ NO. d I - /.;~) - 3 s::; .~ /, :~ ~ ), ,;~ ~ ;1: :?: .;..-' ~ t 2 ~ '? '7t ~, I ! 4<; " IN RE: ESTATE OF EDWARD EUGENE IN THE ORPHANS' COURT OF SAHPSON, A MINOR CUMBERLAND COUNfY, Pr~NSYLVANIA ORDER OF COURT AND NOW, ~t.$f consJ. era l.on 0 1972, at o'clock _.M., ~ .~ ~ ~ ,~ . i ~ ! ~ ~ ~ ~ , " ~- 1 j i i " > ! i 1 i D E.D.S.T., upon the foregoing Petition and on motion of Henry L. Stuart, Esquire, attorney for Petitioner, PAUL MELLINGER AND MARGARET MELLINGER, his wife, or the survivor, of the Estate of Edward Eugene Sfu~pson, a retarded, physically handicapped minor, having been born October 9, 1952, for the sole purpose of applying for and receiving public assistance funds for said minor. No Bond to be required because of limited power of the Guardians and the Department of Public Assistance controls. ~ / J. \ \ I } i . 1 i ...., . ~... .......IJ!"'"'L .... V,",LUI"\ IIVI.. L--1 Nl:W L--1 UPDATED 1. MA RECIPIENT NUMBER 2. NAME OF APPLICANT (last, first, middle initial) LJ.t.....\~.,d L II !V\ Dr;- 3. SOCIAL SECURITY NO. I ct 8 'i L( 'J b ~7 8. PHYSICIAN LICENSE NUMBER l~lD '1-2 5 '7 10. For the purpose of determining my need for TITLE XIX INPATIENT CARE, Home and Community Based Services, and if applicable, my need for a sheller deduction, I aulhorize the release of any medical infonnation by the physician to the County Assistance Office, Slate Department of Public Welfare or its agents. 4. BIRTHDATE I (' I ~11 S..l 6. SEX 9. SIGNATURE - APPl.ICANT OR PERSON ACTING FOR APPUCANT DAlE 11. 13. IN EVENT OF AN EMERGENCY THE ~ATlENT CAN VACA o 1. IndependenUy 0 2. With Minimal Assistance 15. ICD-9-CM DIAGNOSTIC CODES 14. PATIENT IS CAPABLE OF ADM,NISTERING HISlHER OWN M lCATIONS o 1. Self 0 2. Under Supervision . PRIMARY (Principal) . SECONOARY . TERTIARY . . 3 ?Y) 16. P FESSIONAlAND TECHNICAl CARE NEEDED - CHECK'" EACH CATFGORY THAT IS APPLICABLE M ~cal Therapy 0 Speech Therapy 0 Occupational Therapy 0 Inhalation Therapy Q" Special Skin Care 0 Parenteral Fluids 0 Suctioning 0 Other (Specify) 17. PHYSICIAN ORDERS . . tl Medications .s-a> (;( t~ r: ~~ D. Special Dressings o lnigations Treatment Rehabilitative and Restorative Services Therapies C c. .- ~ Diet LOUI ~c[{;v; ,'VJ Activities 1\ <. tv/en. ~k4 . Ll -.. I/o x.. Social Services /.) '? /l;Ze(;WC- 10 ,1<1c;:{ ; .f..,,... C((.'\ ,.-v.,b,)/ ..., n;~^ .,/ 51: I /1 Special Procedures for Health and Safety or to Meet Objectives 18. PROG SIS - Ct-ECK '" ONLY ONE 1. Stable 0 2. Improving o 3. Deteriorating 19. REHABILITATION POTENTIAL o 1. Good ECK '" ONLY ONE o 3. Poor 20A PHYSICIAN'S ~OMMENDAnON NUISing Faciity Qinicaity Biglble Services to be provided athome Of in a nursing faality To the best of my knowledge, the patient's medical condition and related needs are essentially as indicated above. I recommend that the services and care to meet these needs can be provided at the level of care indicated _ check'" only one O Personal Care Home 0 ICFIMR Care 0 ICFIORC Care 0 Inpatient 0 Olher (Pleose Specify) Services proviaed in a Servioes to be provided at home Servioes to be provided at home Psychiatric Care Personal Care Home or in an Intermediate care fadlity or in an Jntennediale care facility for the mentally retarded for consumers with ORCs !OB. COMPLETE ONLY IF CONSUMER IS NURSING FACILITY ClINI'~ALLY.1 G/BLE AND WILL BE SERVED IN A NURSING FACILITY. ON THE BASIS OF PRESENT MEDICAL FINDINGS THE PATIENT 0 0 .. MAY EVENTUAlLY RETIRN HOME OR BE DISCHARGED. YES NO If Yes, Check'" Only One 1. Within 180 days OC. PHYSIC/AN'S SIGNATURE k-c;..;-e., {3.^~ '.?0 /1 PHYIllCIAN (PRINTED NAME) o 2. Over 180 days DE. [1FT'/ r~T~:~'E!\!T {r~F TELEPHONE /::--.. - () v) j"/---" .// L>{,-j..-Q.- ".Y") W / PHYSlCfAIoI SiGNATURE I J / ItJ;t; I OA r,~{.rr:~~) 2r;r~' c!~ ./.': r:-(;;," :,::,;" :,', ;,'!;-:... ". '_.t.,,_ ~: ." (;':.>:, '.~ ;-" oJ. :.,' i; . if(,;' I, A. MEDICALLY ELIGIBLE O Medically for Waiver Comments. Attach a separate sheet if additional comments are necessa DYes o No EXHIBIT Stay 0 Within 180 days 0 Over 180 days I A REVIEWER'S SIGNATURE AND TITLE ORIGINAL - MA51 .9/03 (PARC,nd ~rJsu A/\" .~, 0 .rptanJ ~ :h:rrn ~ ;CI J.AO' ~orkn' () < 1z;u Cl n fiv1 ; h's JI ''r Ao;J.1\. j , pxVent, H e~ , v Past Surgeries: f j)4~::RoIPSA I 'tf11~ Physical I I I I I I I I I I , , , I I I I I 1// h), ".i'\ Av .-- 1/ 1/ i/(Y'l: '/ I I I I I I I I ./ I I I I I I I I I I I I I I Code status: reI: S~O -/%0 I I I I I I I I I I I I IV onsvncke/? - . '.... Reason , , , I I I I I I I I I I I I I IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA Orphans Court Division IN RE: EDWARD E. SAMPSON, Incompetent Person NO. DECLARATION OF CONSENT 1. I, Margaret Mellinger, do hereby give my consent to petition this Court for the appointment of myself as co-guardian of the person and estate of Edward E. Sampson. 2. My current place of residence is 8 Pine Road, Walnut Bottom, Pennsylvania, and I have resided there for ~ years. 3. I am a citizen of the United States of America. 4. I speak, read, and write the English language. 5. I do not have any interests adverse to those of Edward E. Sampson. 6. I am not a fiduciary, or an officer or employee of a corporate fiduciary, of an estate in which Edward E. Sampson has an interest; nor am I a surety, or an officer or employee of a corporate surety of such a fiduciary. Dated: 1.;1 -.if .-.cl jj(.l b ~~tVtd-.s~~~~ Ma g r t Mellinger . F:ldrg17195 - Pro Bonol14200 - Sampson, Edward EugenelDocumentslDeclaration of Consent - MM.doc IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA Orphans Court Division IN RE: EDWARD E. SAMPSON, Incompetent Person NO. DECLARATION OF CONSENT 1. We, Dorothy Kepner and Richard Kepner, do hereby give our consent to petition this Court for the appointment of ourselves as co-guardians of the person and estate of Edward E. Sampson. 2. Our current place of residence is 208 Shughart Avenue, Boiling Springs, Pennsylvania, and we have resided there for 1.J.:t.years. 3. We are citizens of the United States of America. 4. We speak, read, and write the English language. 5. We do not have any interests adverse to those of Edward E. Sampson. 6. We are not a fiduciary, or an officer or employee of a corporate fiduciary, of an estate in which Edward E. Sampson has an interest; nor are we a surety, or an officer or employee of a corporate surety of such a fiduciary. Dated: ) a - .2. - 0 (P ~ ----\ Jr:~~ "/l1.~~/ Dorothy Kepner &J,.,)" j(~ Richard Kepner F:\drg\7195 - Pro 80no\14200 - Sampson. Edward Eugene\Documents\Declaration of Consent - Kepners.doc IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA Orphans Court Division IN RE: EDWARD E. SAMPSON, Incompetent Person NO. DECLARATION OF CONSENT 1. I, Darlene Ziegler, do hereby give my consent to petition this Court for the appointment of myself as co-guardian of the person and estate of Edward E. Sampson. 2. My current place of residence is 1132 Centerville Road, Newville, Pennsylvania, and I have resided there for ~ years. 3. I am a citizen of the United States of America. 4. I speak, read, and write the English language. 5. I do not have any interests adverse to those of Edward E. Sampson. 6. I am not a fiduciary, or an officer or employee of a corporate fiduciary, of an estate in which Edward E. Sampson has an interest; nor am I a surety, or an officer or employee of a corporate surety of such a fiduciary. Dated: 1Jo/'l)~J'{"L.!JIiJ0 ~4IY1dJi~/u LJy Darlene 2:Tegle;-' L "0' ~.- F:ldrg17195 - Pro Bonol 14200 - Sampson, Edward EugenelDocumentslDeclaration of Consent - DZ.doc VERIFICA liON I, Margaret Mellinger, Petitioner in the foregoing Petition for Adjudication of Incapacity and Appointment of Plenary Guardian of the Estate and Person of Edward E. Sampson, have read the foregoing Petition and hereby affirm and verify that it is true and correct to the best of my knowledge, information, and belief. I verify that all of the statements to which I have personal knowledge, information and belief are true and correct and that false statements made therein may subject me to the penalties of 18 Pa. C.S.A. 94904, relating to unsworn falsification to authorities. Dated: I d. -"/ .- j. () 0 t, . ' ~~UrdJ' ~~trJ/i) Ma ga t Mellinger J F:ldrg17195 - Pro Bonol14200 - Sampson, Edward EugenelDocumentslVerification - MM.doc VERIFICA liON We, Dorothy Kepner and Richard Kepner, Petitioners in the foregoing Petition for Adjudication of Incapacity and Appointment of Plenary Guardian of the Estate and Person of Edward E. Sampson, have read the foregoing Petition and hereby affirm and verify that it is true and correct to the best of our knowledge, information, and belief. We verify that all of the statements to which we have personal knowledge, information and belief are true and correct and that false statements made therein may subject us to the penalties of 18 Pa. C.S.A. 94904, relating to unsworn falsification to authorities. Dated: / d-- d - (Jt:, ~~.m~~ Dorothy Kepner ~",).(>..J J(~ Rlc ard Kepner F:\drg\7195 - Pro Bono\14200 - Sampson, Edward Eugene\DocumentsWerification - Kepners.doc VERI FICA liON I, Darlene Ziegler, Petitioner in the foregoing Petition for Adjudication of Incapacity and Appointment of Plenary Guardian of the Estate and Person of Edward E. Sampson, have read the foregoing Petition and hereby affirm and verify that it is true and correct to the best of my knowledge, information, and belief. I verify that all of the statements to which I have personal knowledge, information and belief are true and correct and that false statements made therein may subject me to the penalties of 18 Pa. C.S.A. 94904, relating to unsworn falsification to authorities. Dated:&IJ!l1J~lIJI/XJY:, ~41Y1~J Darlene Ziegler F:ldrg17195 - Pro Bonol14200 - Sampson, Edward EugenelDocumentslVerification - DZ.doc ,.. ~ INRE: EDWARDE. SAMPSON, An Incompetent Person IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYL VANIA ORPHANS' COURT DIVISION NO. 72-355 ORPHANS' COURT ORDER OF COURT AND NOW, this 15th day of December, 2006, upon consideration of the Petition for Adjudication of Incapacity and Appointment of Plenary Guardian of the Estate and Person of Edward E. Sampson, a hearing is scheduled for Wednesday, January 24,2007, at 2:00 p.m., in Courtroom No.1, Cumberland County Courthouse, Carlisle, Pennsylvania. Notice of the said hearing shall be given to the allegedly incapacitated person by personal service at least twenty days before the hearing, and notice of the petition and hearing shall be given by regular mail at least twenty days before the said hearing. BY THE COURT, 1. David R. Getz, Esq. 508 North Second Street P.O. Box 845 Harrisburg, PA 17108-0845 Attorney for Petitioners o =-D l1 --0 r- . f"T) ::0 .'1 ^ "_-' C~ C-) )(j - )(= " .- ::5 :.u---/ ..;.-> /'..,3 t;;::') c:-:.) <::1"> a r'1 CJ Ul :ba ::z:: 9 Ul --.'.:1 r-; I (-., (.::) ~~~5 n-l C) ,J~ ,~/) :;~,"~ iF ORPHANS' COURT DIVISION COURT OF COMMON PLEAS OF In Re: EDWARD E. SAMPSON, AN ALLEGED INCAPACITATED PERSON CUMBERLAND COUNTY PENNSYL VANIA NO. 21-72-0355 CERTIFICATE OF SERVICE OF ORDER ORDER DATE: 12/15/06 JUDGE'S INITIALS: JWO TIME STAMP DATE: 12/15/06 IN RE: ORDER OF COURT """"""""""""""""""""""""""""','""""""""""""""""""."""""""""""""" SERVICE TO: DARLENE ZIEGLER RICHARD KEPNER DOROTHY KEPNER MARGARET MELLINGER EDWARD E. SAMPSON METHOD OF MAILING: ENVELOPES PROVIDED BY: ~ USPS DRRR D HAND DELIVERED DOTHER_ ~ PETITIONER D JUDGE D CLERK OF ORPHANS COURT MAILED: ] 2/15/2006 """""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" SERVICE TO: DA VID R GETZ. ESQ METHOD OF MAILING: ENVELOPES PROVIDED BY: ~ USPS DRRR D HAND DELIVERED DOTHER_ D PETITIONER D JUDGE ~ CLERK OF ORPHANS COURT MAILED: 12/15/06 ~dfirla)Ji~ Clerk of Orphans' Court ,J ... IN RE: EDWARD E. SAMPSON IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYL VANIA ORPHANS' COURT DIVISION An alleged incapacitated person NO. 21-72-355 IMPORTANT NOTICE CITATION WITH NOTICE A petition has been filed with the Court to have you declared an Incapacitated Person. If the Court finds you to be an Incapacitated Person, your rights will be affected, including your right to manage money and property and to make decisions. A copy of the petition which has been filed by Margaret Mellinger, Dorothy Kepner, Richard Kepner, and Darlene Ziegler is attached. You are hereby ordered to appear at a hearing to be held in Court Room No.1, Cumberland County Courthouse, Carlisle, Pennsylvania, on Wednesday, January 24 ,2006, at 2:00 P.M. to tell 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 and/or 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 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 .-.- ~" ,.,. make and communicate decisions. The Guardian will be of your person and/or your money and other property and will have either limited of 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 to 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 you) the court will still hold the hearing in your absence and may appoint the Guardian requested. . By: ~~~~ Clerk, ~ ans ourt Division . Cumberland County, Carlisle, P A My Commission Expires 1 st Monday, January, 2010 Date: 12-15-06 . ORPHANS' COURT DIVISION COURT OF COMMON PLEAS OF In Re: EDWARD E. SAMPSON, AN ALLEGED INCAPACITATED PERSON CUMBERLAND COUNTY PENNSYL VANIA NO. 21-72-0355 CERTIFICATE OF SERVICE OF ORDER ORDER DATE: 12/15/06 JUDGE'S INITIALS: JWO TIME STAMP DATE: 12/15/06 IN RE: CITATION """""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" SERVICE TO: DARLENE ZIEGLER RICHARD KEPNER DOROTHY KEPNER MARGARET MELLINGER EDWARD E. SAMPSON c/o Outlook Pointe METHOD OF MAILING: ENVELOPES PROVIDED BY: [2J USPS DRRR o HAND DELIVERED o OTHER_ [2J PETITIONER o JUDGE o CLERK OF ORPHANS COURT MAILED: 12/15/2006 """,.,.,""'""""""""""""",."""""""""""""""""""""""""""""""""""""""" SERVICE TO: DA VID R GETZ. ESO METHOD OF MAILING: ENVELOPES PROVIDED BY: [2J USPS DRRR o HAND DELIVERED o OTHER_ o PETITIONER o JUDGE [2J CLERK OF ORPHANS COURT MAILED: 12/15/06 ~. ~ J1#^- eputy Clerk of Orphans' Court ~ ii I IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA Orphans Court Division IN RE: EDWARD E. SAMPSON, Incompetent Person NO. 72-355 PROOF OF SERVICE Pursuant to Cumberland County Orphans' Court Rule 14.2-3, I hereby certify that the Petition for the Adjudication of Incapacity and Appointment of Plenary Guardianship of the Estate and Person of Edward E. Sampson, along with the Citation with Notice was personally served upon and read to Edward E. Sampson on theafday of Do~.. , 20~, and explained to him, to the maximum extent possible, in language and terms he is most likely to understand. cA~ ('") ~o ;Sj~ l~_~C~ ~ :-:-. .J.J/..... '~) C) c) .'";O-'~l :~.:)~ ::n --I ..;> F~\drg\7195 - Pro Bono\14200 - Sampson, Edward Eugene\Documents\Proof of Service.doc " ~ C;;:> ~ -...I '- ~ :;,z~ I .&:" -0 ~ N o IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA Orphans Court Division ,. ~. ~ IN RE: '" , " ..r:--~ EDWARD E. SAMPSON, Incompetent Person NO. 72-355 f""-.) r...) cr., ORDER AND NOW, this 2- '1-ll day of ---.1 7J')~ ~"l ' 2007, based upon the evidence received and the record, this Court finds, by clear and convincing evidence, that Edward E. Sampson has previously been adjudged a totally incapacitated person by Order dated July 5, ~972, and that he remains a totally incapacitated person. The Court finds that Edward E. Sampson continues to suffer from cerebral palsy, a condition or disability that totally impairs his capacity to receive and evaluate information effectively and to ma~ and communicate decisions concerning his management of financial affairsl.. to meet essential requirements for his physical health and safety, and, as a result, is sO"severely mentally impaired that he is unable to make, communicate or participate in any decision relating to his estate or person. Margaret Mellinger, Dorothy Kepner, Richard Kepner, and Darlene Ziegler are hereby appointed plenary co-guardians of the person of Edward E. Sampson and are hereby appointed as plenary co-guardians of the Estate of Edward E. Sampson. Said co-guardians may act alone, on one signature, without consultation with the others. No bond is required. Within 12 months of the date of this Decree and at least annually thereafter, the respective guardians shall file with this Court a report that includes all information as required pursuant to 20 Pa. C.S.A. 95521 (c). Edward E. Sampson has twenty (20) days from the date of this Decree to file exceptions. Failure to file exceptions within that time will result in this Decree becoming final. Edward E. Sampson has been advised of his right to appeal and to petition to modify or terminate the guardianship by copy of this Decree and by the Statement of Rights attached hereto. BY THE COURT: ;J1- ORPHANS' COURT DIVISION COURT OF COMMON PLEAS OF III Rc: EDWARD E. SAMPSON INCAPACITATED PERSON CUMBERLAND COUNTY PENNSYL VANIA NO. 21-1972-0355 CERTIFICATE OF SERVICE OF ORDER ORDER DATE: 01/24/07 JUDGE'S INITIALS: JWO TIME STAMP DATE: 01/24/07 IN RE: ORDER """"""""""""""""""""""""""""""""""""""""""""""""""""""""',""""" SERVICE TO: DA VID R. GETZ ESQ METHOD OF MAILING: ENVELOPES PROVIDED BY: D USPS D RRR ~ HAND DELIVERED D OTHER_ D PETITIONER D JUDGE D CLERK OF ORPHANS COURT MAILED: 01/24/2007 """""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" SERVICE TO: METHOD OF MAILING: ENVELOPES PROVIDED BY: D USPS DRRR D HAND DELIVERED DOTHER_ D PETITIONER D JU DG E D CLERK OF ORPHANS COURT MAILED: ~d/M#Jt;pJ 0""'" 15 ep u ty Clerk of Orphans' Court 4 ANNUAL REPORT OF GUARDIAN OF THE PERSON COURT OF COMMON PLEAS OF CUMBERLAND COUNTY PENNSYL VANIA , ORPHANS' COURT DIVISION Estate of EDWARD E. SAMPSON r....;' ~ ..::..:..:J .:= <- );:1JOo :ff'~ N -u ::r: N U1 N , an Incapacitated Person No. 72-355 I. INTRODUCTION HARGARET l'1ELLINGER, DOROTHY KEPNER, RICHARD KEPNER, and DARLENE ZIEGLER , miX ,;;~r~ted fZ]PlenaryDLimited Guardian of the Person by Decree of J. WESLEY OLER, JR. ,J., dated JANUARY 24, 2007 o A. This is the Annual Report for the period from JANUARY 24 2007 to JANUARY 23 , 2008 (the "Report Period"); or DB. 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, Farm G-03 rev. 10.1 J 06 Page 1 of 4 ~ Estate of EDWARD E. SAMPSON , an Incapacitated Person II. PERSONAL DATA Age of the Incapacitated Person: 55 Date of Birth: 10/9/1952 III. LIVING ARRANGEMENTS A. Current address of the Incapacitated Person: Elmcroft 129 Walnut Bottom Road Shippensburg, P A 17257 B. The Incapacitated Person's residence is: o own home / apartment o nursing home 1ZI boarding home / personal care home o Guardian's home / apartment o hospital or medical facility o relative's home (name, relationship and address) D other: C. The Incapacitated Person has been in the present residence since JANUARY 2002 . If the Incapacitated Person has moved within the past year, state prior residence and reason(s) for move: NOT APPLICABLE Form G-03 rev. 10.13.06 Page 2 of 4 Estate of EDWARD E. SAMPSON , an Incapacitated Person D. Name and address of the Incapacitated Person's primary caregiver: ELMCROFf 129 WALNUT BOTTOM ROAD SHIPPENSBURG, PA 17257 IV. MEDICAL INFORMATION A. The major medical or mental problems of the Incapacitated Person are as follows: MR. SAMPSON SUFFERS FROM CEREBRAL PALSY AND, AS A RESULT, IS MENTALLY RETARDED AND SUFFERS FROM ARTHRITIS AND SEIZURE DISORDER. B. Specify what, if any, social, medical, psychological and support services the Incapacitated Person is receiving: SOCIALLY, MR. SAMPSON ENJOYS TALKING ON THE TELEPHONE, WATCHING TV, GOING OUT TO EAT, AND PLAYS BINGO, WITH ASSISTANCE. MEDICALLY, MR. SAMPSON RECEIVES THE FOLLOWING MEDICA nONS: LISINOPRIL, HYDROXYZINE, CARBAMAZEPHINE, OMEPRAZOLE, NAPROXEN AND IBUPROFEN V. GUARDIAN'S OPINION A. It is the opinion of the Guardian of the Person that the guardianship should: IZI continue o be modified o be terminated Form G-03 rev. 10.13.06 Page 3 of 4 . Estate of EDWARD E. SAMPSON , an Incapacitated Person The reasons for the foregoing opinion are: MR. SAMPSON LACKS THE CAPACITY TO MAKE RESPONSIBLE DECISIONS CONCERNING HIS PERSON, CARE, AND IS UNABLE TO LIVE ALONE OR TO SEEK NEEDED MEDICAL SERVICES B. During the past year, the Guardian ofthe Person has visited the Incapacitated Person 60 times with the average visit lasting 1 hours, minutes. 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. S 4904 relative to unsworn falsification to authorities. 1- 1/--- ';;Lot/g' Dale f ~'I7~Rd. Address u)/tll1uf13tJrt-pm.a "/1:J~~ City, Scale, Zip I T~~2 J .6"'3 ~ -4 1-/ tP Form G-03 reI'. 10.13.06 Page 4 of4 f~ ... ANNUAL REPORT OF GUARDIAN OF THE ESTATE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYL VANIA ORPHANS' COURT DIVISION Estate of EDWARD E. SAMPSON () --0 :::rJ ~/p -71 No. 72-355 , an Incapacitated Person I. INTRODUCTION MARGARET MELLINGER, DOROTHY KEPNER, RICHARD KEPNER 7Wp.rF', and DARLENE ZIEGLE1l ,XOO{:; appomted IZ!Plenary DLimited Guardian of the Estate by Decree of J. WESLEY OLER, JR. , J., dated JANUARY 24, 2007 o A. This is the Annual Report for the period from JANUARY 24 2007 to JANUARY 23 , 2008 (the "Report Period"); or o 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 [--;) c." <-=> c= c... ::--.:;.:,,- r.-' -f-- v -"- (""-0 Ul ("^" ct Estate of EDWARD E. SAMPSON , An Incapacitated Person II. SUMMARY A. State the value of the estate reported on the Inventory $ 12.910.00 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.) $ 100.00 C. What is the total amount of income earned during the Report Period? $ 12.810.00 D. What is the total amount of income and principal spent for all purposes during the Report Period? $ 12.810.00 E. What are the balances remaining at the end of the Report Period? 1. Principal $ 100.00 2. Income $ 3. Total of Principal and Income $ 100.00 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.): PERSONAL PROPERTY OF MR. SAMPSON 2. Have there been any expenditures from the principal during the Report Period? ............................ lZJ Yes 0 No If yes: a. Have all expenditures from the principal been for the sole benefit of the Incapacitated Person? . . . . . . . . IZJ Yes [J No Form G-02 rev. 10.13.06 Page 2 of5 Estate of EDWARD E. SAMPSON , An Incapacitated Person b. List purpose and amount of expenditures: HOME CARE $ $ $ $ 12,810.00 c. Was Court approval received prior to expendingtheprincipal? ....................... DYes IZINo 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? ........... Cl Yes IZI No If yes: a. Was Court approval requested prior to receiving the additional principal? . . . . . . . . . . . . . . .. 0 Yes 0 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.): SOCIAL SECURITY/GOVERNMENT ASSISTANCE $ $ $ $ $ $ 12,810.00 Total income received during Report Period: $ 12,810.00 Form G-02 rev. 10.13.06 Page 3 of5 Estate of EDWARD E. SAMPSON 2. How is income currently invested? (Please specify, e.g., restricted bank accounts, client care account, etc.): N/A 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.): ELMCROFT - NURSING HOME RENT 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.) NONE E. Guardian's Commissions List amounts of compensation paid as Guardian's commission and state how amount was determined: Amount Method of Determination NO COMMISSION CLAIMED Form G-02 rev. 10.13.06 , An Incapacitated Person Court Approval Obtained DYes DNo DYes DNo Page 4 of5 ~. Estate of EDWARD E. SAMPSON , An Incapacitated Person F. Counsel Fee List amounts paid as counsel fee, and indicate whether Court approval was obtained. Amount Court Approval Obtained DYes DNo DYes DNo 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. 9 4904 relative to unsworn falsification to authorities. Dale /-1/- d-t>t? i' r f1/l1e Rd, Address W/Z 111 uY BPfft/nJ, f6. - /1'd- he, City, Slale, Zip I ( 7 J 1]) J31- -- ~ :L ( ~ Telephone Form G-02 rev. /0./3.06 Page 5 of 5 ,I' f GUARDIAN'S INVENTORY COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYL VANIA ORPHANS' COURT DIVISION Estate of EDWARD E. SAMPSON No. 72-355 1. Real Estate: (Location, by whom occupied and rental terms, if applicable) NONE Sub-Total for Real Estate: 2. Personal Property: PERSONAL CLOTHING AND POSSESSIONS 3. Jointly Held Property: (Selforlh real cmd personal property owned by /he Incapacilaled Person JOINTLY wilh any olherperson(s). S/a/e whe/her held as lenanlS by /he emirelies; I/"not. whe/her /he righl of sllrl'ivorship exis/s.) Jointly Held Property NONE Form G-04 reI'. 10.13.06 r........) CJ 23 '.; 0 c::> . '"j :1:) c.._ } 0 an Incapacja~L,d Per~ 0, . "~ , . , [',) , . a Mmor ,j .;::.. r" -;:J ,.......) <..11 (..,) Estimated Value: 0.00 Estimated Value: 100.00 Estimated Value: Page 10f2 ~ Estate of EDWARD E. SAMPSON }lZlan Incapacitated Person , Da Minor 4. Anticipated Assets: Estimated Value: (Set forth property of an)' kind expected to be acquired hereafter. together with anticipated date of acquisition.) Propert)' Allticipated Date of Acquisitioll SOCIAL SECURITY/ASSISTANCE 1/08 - 12/08 12,810.00 Sub-Total for Personal Estate: (A ttach additional sheets !f necessaJY) TOTAL OF ITEMS 1, 2, 3, and 4: .... . . . . . . . . . . . . . . . . . . . . . . . . . . 12,910.00 12,910.00 Commonwealth of Pennsylvania : ss. County of Guardian true and complete Inventory of the Estate of EDWARD E. SAMPSON , says that the foregoing is a full, the aforesaid Incapacitated Person or Minor; and that all of the information set forth herein is tITLe and correct to the best of the Guardian's knowledge and belief. I verify that the statements made in this ) Inventory are tITLe and correct. I under- ) stand that false statements herein are ) made subject to the penalties of ) 18 Pa.C.S. S 4904 relating to unsworn ) falsification to authOlities. ) Sk-~ 1? J1:jJ ~ A~a.e-nuardian .tu- r-' Attorney for Guardian: Supreme Court 1.0. No.: Address: 3'ix5f' Telephone: Form G-04 rev. J{1.I3.06 Page 2 of2 2~~9 J~.~d 23 a~9 f0~ SO ANNUAL REPORT OF ~,~ ~` ' ~ ~ ~ , , ~i ~~ GUARDIAN OF THE EST~4`t`E ~0~ COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION Estate of EDWARD E. SAMPSON an Incapacitated Person 72-355 I. INTRODUCTIOJN Margaret Me linger, Dorothy Kepner, Richard Kepner, and Darlene Zie¢ler Were xaea appointed D Plenary ~ Limited Guazdian of the Estate by Decree of J. WESLEY OLER, JR. J., dated JANUARY 24, 2007 ~ A. This is the Annual Report for the period from JANUARY 1 2008 to DECEMBER 31 2008 (the "Report Period"); or 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. 10.73.06 Page 1 of 5 ~~ Estate of EDWARD E. SAMPSON II. SUMMARY An Incapacitated Person A. State the value of the estate reported on the Inventory $ 186.25 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.) $ 100.00 C. What is the total amount of income earned during the Report Period? $ 34,754.88 D. What is the total amount of income and principal spent for all purposes during the Report Period? $ 34,668.63 E. What are the balances remaining at the end of the Report Period? 1. Principal $ 100.00 2. Income $ 86.25 3. Total of Principal and Income $ 186.25 III. ADDITIONAL INFORMATION (Ifmore space is needed, please attach additional pages.) A. Principal How is the principal balance listed above currently invested? (Please specify, e.g., real estate, certificates of deposit, restricted bank accounts, etc.): PERSONAL PROPERTY OF MR. SAMPSON 2. Have there been any expenditures from the principal during the Report Period'? ............................ ~ Yes ~ No If yes: a. Have all expenditures from the principal been for the sole benefit of the Incapacitated Person? ........ ^ Yes ^ No Form G-02 rev. 10.13.06 Page 2 of 5 Estate of EDWARD E. SAMPSON b. List purpose and amount of expenditures: An Incapacitated Person ~. 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? ........... ©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.): SOCIAL SECURITY/MEDICAL ASSISTANCE $_ 34,754.85 Total income received during Report Period: $ 34,75a.88 Form C-Ol rev. 70J3.06 Page 3 of 5 Estate of EDWARD E. SAMPSON , An Incapacitated Person 2. How is income currently invested? (Please specify, e.g., restricted bank accounts, client care account, etc.): PERSONAL CARE ACCOUNT 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.): NURSING HOME CARE 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.) MISCELLANEOUS PERSONAL CARE EXPENSES 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 NO COMMISSION CLAIMED ~ yes Q No Yes ONo Fo,m c-oz .~ ~o.~s.oe Page 4 of 5 Estate of EDWARD E. SAMPSON F. Counsel Fee List amounts paid as counsel fee, and indicate whether Court approval was obtained. Amount Yes ~ No An Incapacitated Person Court Approval Obtained 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. q ~')// / ~'f~~r p Uate - / /1 ~ -' CY- O ~ 9 , L C / L~~_~~ ~l~l ~,(~ ~ J~li/1 ~ do v mgnature pJ tjuordran of the E,rtat MARGARET S. MELLINGER name of Guardian of (he Estate (type or print) 8 PINE ROAD Address WALNUT BOTTOM, PA 17266 Cary, State, Zip (717)532-4216 Telephone Form G-02 rev. 10.13.06 Page 5 of 5 -, , ~~~C9.f;',.s 23 A~91p~ 49 ANNUAL REPORT OF ~ , , ~ , , GUARDIAN OF THE PERSON ~~~' ~ `~ .~~ ~~~r ~~~ COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION Estate of EDWARD E. SAMPSON , an Incapacitated Person 72-355 I. INTRODUCTION Margaret Mellinger, Dorothy Kepner, Richard Kepner, and Darlene Zie¢ler were. appointed Plenary Limited Guardian of the Person by Decree of J• ~/ESLEY OLER, JR. J dated JANUARY 24, 2007 ' A. This is the Annual Report for the period from JANUARY 1 2008 to DECEMBER 31 2008 (the "Report Period"); or ~ 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 For a Final Report, omit Sections II tlmough IV. Form G-03 rev. 10.!3.06 J., dated Page 1 of 4 ~~ I Estate of EDWARD E. SAMPSON , an Incapacitated Person II. PERSONAL DATA Age of the Incapacitated Person: 56 III. LIVING ARRANGEMENTS A. Current address of the Incapacitated Person: Date of Birth: 10/9/1952 CLAREMONT NURSING & REHAB CENTER 1000 CLAREMONT ROAD CARLISLE, PA 17013 B. The Incapacitated Person's residence is: 0 own home /apartment musing home boarding home /personal care home 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 residence since 9/3/2008 If the Incapacitated Person has moved within the past year, state prior residence and reason(s) for move: ELMCROFT, 129 WALNUT BOTTOM ROAD, SHIPPENSBURG, PA MOVED FROM PERSONAL CARE HOME TO NURSING HOME FOR THE PURPOSE OF_RECEIVING MORE SKILLED CARE Form G-03 rev. 10.13.06 Page 2 of 4 Estate of EDWARD E. SAMPSON an Incapacitated Person D. Name and address of the Incapacitated Person's primary caregiver: CLAREMONT NURSING & REHAB CENTER 1000 CLAREMONT ROAD CARLISLE, PA 17013 IV. MEDICAL INFORMATION A. The major medical or mental problems of the Incapacitated Person are as follows: MR. SAMPSON SUFFERS FROM CEREBRAL PALSY AND, AS A RESULT, IS MENTALLY RETARDED AND SUFFERS FROM ARTHRITIS AND SEIZURE DISORDER B. Specify what, if any, social, medical, psychological and support services the Incapacitated Person is receiving: SOCIALLY, MR. SAMPSON ENJOYS TALKING ON THE TELEPHONE, WATCHING TV, GOING OUT TO EAT, AND PLAYS BINGO, WITH _. ASSISTANCE. MEDICALLY, MR. SAMPSON RECEIVES THE FOLLOWING MEDICATIONS: CARBANAZEPINE, LISINOPRIL, MELOXICAM, METFORMIN, OMEPRAZOLE, PHENOBARBITAL, ANUCORT, AS WELL AS WEEKLY SKIN ASSESSMENTS AND DIABETIC FOOT CARE. V. GUARDIAN'S OPINION A. It is the opinion of the Guardian of the Person that the guardianship shoLdd: ®/ continue be modified be ternunated Form G-03 rev. 70.13.06 Page 3 of 4 Estate of EDWARD E. SAMPSON The reasons for the foregoing opinion aze: an Incapacitated Person MR. SAMPSON LACKS THE CAPACITY TO MAKE RESPONSIBLE DECISIONS CONCERNING HIS PERSON, CARE, AND IS UNABLE TO LIVE ALONE OR TO SEEK NEEDED MEDICAL SERVICES B. During the past yeaz, the Guardian of the Person has visited the Inc1ap~acitated Person ~~ times with the average visit lasting _~ hours, '~L> minutes. 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. /-- /y~_~~_09 Dale ~llyo~ro ~S ~'L-e.~c- Sig ire j ardian ojthe Perso~ MARGARET S. MELLINGER Name of Guardian of the Persar (type or prin!) 8 PINE ROAD Address WALNUT BOTTOM, PA 17266 City, Stare, Zip (717)532-4216 Telephone Form e-03 rev. 10./3.06 Page 4 of 4 ~ ~ -. GUARDIAN'S INVENTORY ~~"";9 Ji"'~ 7.3 ~,19I~f~ 5I COURT OF COMMON PLEAS OF CUMBERLAND ~I~~~TY, PENNSYLVANIA ORPHANS' COURT DIVI~~]'V' ~ ~~~ ~ '~~ Estate of EDWARD E. SAMPSON 10 an Incapacitated Person ' J ©a Minor Nn 72-355 1. Real Estate: (Location, by whom occupied and rental Estimated Value: terms, if applicable) Sub-Total for Real Estate: 0.00 2. Personal Property; Estimated Value: PERSONAL CLOTHING AND POSSESSIONS 100.00 3. Jointly Held Property: (Set forth real and personal ro er ownedb~ Estimated Value: other person(s). Slate whether held as tenantsbythe entrenes~zfnot, whe~/~he~gh(of survivorship exists.) Jainr[y Held Property roNE Form G-04 rev. 10./3.06 Page 1 of 2 U ' Estate of EDWARD E. SAMPSON 1~/~an Incapacitated Person a Minor 4. Anticipated Assets: Estimated Value: (Set fm~th property of any kind expected to be acquired hereaJteq together with anticipated date of acguisition.J Property AnfrcipaledDate ojAcgaisilion SOCIAL SECURITY/ASSISTANCE 1/09 - 12/09 74,925.12 Sub-Total for Personal Estate: 75,025.12 (Attach additional sheets if necessary) TOTAL OF ITEMS 1, 2, 3, and 4 :.............................. 75,025.12 Commonwealth of Pennsylvania County of ss. MARGARET S. MELLINGER says that the foregoing is a full, G2tardian true and complete Inventory of the Estate of EDWARD E. SAMPSON the aforesaid Incapacitated Person or Minor; and that all of the information set forth herein is true and correct to the best of the Guardian's knowledge and belief. I verify that the statements made in this ) Inventory are true and correct. I under- ) stand that false statements herein aze ) made subject to the penalties of ) 18 Pa.C.S. § 4904 relating to unswom ) falsification to authorities. ) Attorney for Guardian; Supreme Court LD. Nc Address: WIX, WENGER & WEIDNER PO Box 845, Harrisburg, PA 17108-0845 Telephone: (717) 234-4182 Form G-04 rev. IOJ3.06 Page 2 of 2 r i i GUARDIAN' S INVENTORY COURT OF COMMON PLEAS OF CUMBERLAND ORPHANS' COURT DIVISION COUNTY, PENNSYLVANIA EDWARD E. SAMPSON ~ an Incapacitated Person Estate of ' ~ ~ a Minor ~.,, n ~, No. 72-355 C~ T yy - F ~.,.F.,J' '~ .~~ ~ ~~ ~~ ~~ '~ 1. Real Estate: (Location, by whom occupied and rental EstimatIi~e: ~ terms, if applicable) ~ ~ =~ b NONE Sub-Total for Real Estate: 2. Personal Property: PERSONAL CLOTHING AND POSSESSIONS 3. Jointly Held Property: (Set forth real and personal property owned by the Incapacitated Person JOINTLY with any other person(s). State whether held as tenants by the entireties.; if not, whether the right of survivorship exists.) Jointly Held Property NONE Form G-04 rev. 10.13.06 -..,s 0.00 Estimated Value: 100.00 Estimated Value: Page 1 of 2 _m~_,, =' ~~~ '~-~1 ~~4 j ~j ~T; ;~ r~~ ~'r- •_::°~ :~ x EDWARD E. SAMPSON 1~ an Incapacitated Person Estate of 0 a Minor 4. Anticipated Assets: Estimated Value: (Set forth property of any kind expected to be acquired hereafter, together with anticipated date of acquisition.) Property Anticipated Date of Acquisition SOCIAL SECURITY/ASSISTANCE 1/09 - 12/09 $74,137.40 Sub-Total for Personal Estate: 7 4 ,13 7.40 (Attach additional sheets if necessary) TOTAL OF ITEMS 1, 2, 3, and 4:.......... ................... 74, 237.40 Commonwealth of Pennsylvania ss. County of ~ ~~ ~\n~~t, MARGARET S. MELLINGER ,says that the foregoing is a full, Guardian true and complete Inventory of the Estate of EDWARD E. SAMPSON , the aforesaid Incapacitated Person or Minor; and that all of the information set forth herein is true and correct to the best of the Guardian's knowledge and belief. I verify that the statements made in this ) Inventory are true and correct. I under- ) stand that false statements herein are ) made subject to the penalties of ) 18 Pa.C.S. § 4904 relating to unsworn ) falsification to authorities. ) Attorney for Guardian Supreme Court I.D. No.: 34838 Address: WIX, WENGER & WEIDNER 508 N 2ND ST/POB 845, HARRISBURG, PA 17108 Telephone: (717) 234-4182 Form G-04 rev. 10.13.06 Page 2 Of 2 1 N _.... ANNUAL REPORT OF ~ ° ~'' r..=~ ~=--' GUARDIAN OF THE ESTATE -.~~ : :~ ~-- , r , , , 4.-~ , , ,'' CIS ;;'~~ t+y. _. _..-. t~"7 ~ _.~~ ~ - ~: ~.r~ COURT OF COMMON PLEAS OF ~ ~ r....... ~:..~-~ ~~`~-' ;?~' PENNSYLVANIA CUMBERLAND COUNTY ~ ~ © `:jam , ORPHANS' COURT DIVISION ---~ Estate of EDWARD E. SAMPSON , an Incapacitated Person No. 72-355 I. INTRODUCTION Margaret Mellinger, Dorothy Kepner, were Richard Keener. and Darlene Ziegler ,appointed Plenary 0 Limited Guardian of the Estate by Decree of J• WESLEY OLER, JR. ~ J., dated JANUARY 24, 2007 A. This is the Annual Report for the period from JANUARY 1 , 2009 to DECEMBER 31 2009 (the "Report Period"); or 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 i Estate of EDWARD E. SAMPSON 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? $ 74,237.40 $ 100.00 $ 74,137.40 74,031.94 E. What are the balances remaining at the end of the Report Period? 1. Principal $ 1~•~ 2. Income $ 5.10 3. Total of Principal and Income $ 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.): PERSONAL PROPERTY OF MR. SAMPSON 105.10. 2. Have there been any expenditures from the principal during the Report Period? ............................ ~ Yes ~ No If yes: a. Have all expenditures from the principal been for the sole benefit of the Incapacitated Person? ........ ~ Yes ~ No Form G-02 rev. 10.13.06 Page 2 of 5 Estate of EDWARD E. SAMPSON _ , An Incapacitated Person b. List purpose and amount of expenditures: HOME CARE $ 73597.40 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? ................ 0 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.): SOCIAL SECURITYlGOVERNMENT ASSISTANCE $ 7 4 ,13 7.40 Total income received during Report Period: ~ 7 4 ,13 7.40 Form G-02 rev. 10.13.06 Page 3 of 5 Estate of EDWARD E. SAMPSON , An Incapacitated Person 2. How is income currently invested? (Please specify, e.g., restricted bank accounts, client care account, etc.): N/A C. Expenses for Care and Maintenance Specify what expendihires were made from the principal and income for the care and maintenance of the Incapacitated Person (e.g., clothing, nursing home, medicine, support, etc.): ELMCROFT -NURSING HOME RENT 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.) NONE 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 NO COMMISSION CLAIMED ~ Yes ~ No Yes ~ No Form G-02 rev. 10.13.06 Page 4 of 5 h Estate of EDWARD E. SAMPSON , An Incapacitated Person F. Counsel Fee List amounts paid as counsel fee, and indicate whether Court approval was obtained. Amount Court Approval Obtained NONE ~ 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. r Date Telephone Form G-02 rev. 10.13.06 Signa re f ardian of the Est e MARGARET S. MELLINGER Name of Guardian of the Estate (type or print) 8 PINE ROAD Address WALNUT BOTTOM, PA 17266 City, State, Zip (717) 532-4216 Page 5 of 5 r-~ ~ ,~ - ~, ~ ~ ,; ? ANNUAL REPORT OF ~ ~ ~ `~' ~ t GUARDIAN OF THE ESTATE ~~ r~; ~ - -~, ~; r..-. COURT OF COMMON PLEAS OF ~.y., ~,r, "=n O CUMBERLAND COUNTY, PENNSYLVANIA ~^=" ORPHANS' COURT DIVISION Estate of EDWARD E. SAMPSON No. 72-355 an Incapacitated Person I. INTRODUCTION were Margaret Mellinger, Dorothy Kepner, xi Hard Kepner and Da--' ° Z~gl er appointed Plenary ~ Limited Guardian of the Estate by Decree of J• WESLEY OLER, JR. ~ J., dated JANUARY 24, 2007 A. This is the Annual Report for the period from JANUARY 1 ~ 2010 to DECEMBER 31 2010 (the "Report Period"); or 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.!3.06 Page 1 of 5 Estate of EDWARD E. SAMPSON II. SUMMARY An Incapacitated Person A. State the value of the estate reported on the Inventory $ 74, 235.86 B. State the value(s) of principal assets at the beginning of the Report Period. (Same as Inventory if first Report, 100.00 otherwise, ending balance from last Report.) $ C. What is the total amount of income earned during the Report Period? $ 74,135.86 D. What is the total amount of income and principal 74, 087.63 spent for all purposes during the Report Period? $ E. What are the balances remaining at the end of the Report Period? 1. Principal $ 148.23 2. Income $ 0.00 3. Total of Principal and Income $ 148.23 xg~g 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.): Personal property of Mr. Sampson, including personal account maintained•at'Claremont 2. Have there been any expenditures from the principal during the Report Period? ............................ ~ Yes No If yes: a. Have all expenditures from the principal been for the sole benefit of the Incapacitated Person? ........ ~ Yes ~ No Form G-O2 rev. 10.13.06 Page 2 of 5 Estate of EDWARD E. SAMPSON b. List purpose and amount of expenditures: HOME CARE An Incapacitated Person $ 73,595.86 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? ........... ~ 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.): SOCIAL SECURITY/GOVERNMENT ASSISTANCE Total income received during Report Period: Form G-02 rev. /0./3.06 $ 74,135.86 $ 74,135.86 x40 Page 3 of 5 Estate of EDWARD E. SAMPSON 2. How is income currently invested? (Please specify, e.g., restricted bank accounts, client care account, etc.): N/A An Incapacitated Person 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.): NURSING HOME RENT 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.) NONE E. Guardian's Commissions List amounts of compensation paid as Guardian's commission and state how amount was determined: Amount Method of Determination NO COMMISSION CLAIMED Court Approval Obtained Yes ~No Yes No Fo,m c-oz .ev. ~0.~3.06 Page 4 of 5 Estate of EDWARD E. SAMPSON An Incapacitated Person F. Counsel Fee List amounts paid as counsel fee, and indicate whether Court approval was obtained. Amount None Court Approval Obtained 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. d Date Signa e o ardian of the Estate MARGARET S. MELLINGER Name of Guardian of the Estate (type or print) 8 PINE ROAD Address WALNUT BOTTOM, PA 17266 City, State, Zip (717) 532-4216 Telephone Form G-O2 rev. 10.13.06 Page 5 of 5 ANNUAL REPORT OF GUARDIAN OF THE PERSON COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION Estate of EDWARD E. SAMPSON No, 72-355 ~:w L' 9 s~ O ~- r ~ ~ -~ C'~ c:a ,, v,~1-~.. r-- - ' Js-, ~7 t.: r3 "C3 an Incapacitated Person I. INTRODUCTION Margaret Mellinger, Dorothy Kepner, Richard Kepner and Darlene Zl~gler were was appointed Plenary Limited Guardian of the Person by Decree of J• WESLEY OLER, JR. dated JANUARY 24, 2007 ~ J•~ A. This is the Annual Report for the period from JANUARY 1 2010 to DECEMBER 31 2010 (the "Report Period) or 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 IY. Form G-03 rev. IO.J3.06 Page 1 of 4 Estate of EDWARD E. SAMPSON II. PERSONAL DATA an Incapacitated Person Age of the Incapacitated Person: 58 Date of Birth: 10/9/1952 III. LIVING ARRANGEMENTS A. Current address of the Incapacitated Person: CLAREMONT NURSING & REHAB CENTER 1000 CLAREMONT ROAD CARLISLE, PA 17013 B. The Incapacitated Person's residence is: own home / aparment nursing home boarding home /personal care home 0 Guardian's home /apartment Q hospital or medical facility relative's home (name, relationship and address) other: C. The Incapacitated Person has been in the present residence since 9/3/2008 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 EDWARD E. SAMPSON an Incapacitated Person D. Name and address of the Incapacitated Person's primary caregiver: CLAREMONT NURSING & REHAB CENTER 1000 CLAREMONT ROAD CARLISLE, PA 17013 IV. MEDICAL INFORMATION A. The major medical or mental problems of the Incapacitated Person are as follows: MR. SAMPSON SUFFERS FROM CEREBRAL PALSY AND, AS A RESULT, IS MENTALLY RETARDED AND SUFFERS FROM ARTHRITIS AND SEIZURE DISORDER. B. Specify what, if any, social, medical, psychological and support services the Incapacitated Person is receiving: SOCIALLY, MR. SAMPSON ENJOYS TALKING ON THE PHONE, WATCHING TV, GOING OUT TO EAT, AND PLAYS BINGO, WITH ASSISTANCE. MEDICALLY, MR. SAMPSON RECEIVES THE FOLLOWING MEDICATIONS: CARBANAZEPINE, LISINOPRIL, MELOXICAM, METFORMIN, OMEPPRAZOLE, PHENOBARBITAL, ANUCORT, AS WELL AS WEEKLY SKIN ASSESSMENTS AND DIABETIC FOOT CARE. V. GUARDIAN'S OPINION A. It is the opinion of the Guardian of the Person that the guardianship should: continue 0 be modified be terminated Form G-03 rev. 10.13.06 Page 3 of 4 Estate of EDWARD E. SAMPSON The reasons for the foregoing opinion are: an Incapacitated Person MR. SAMPSON LACKS THE CAPACITY TO MAKE RESPONSIBLE DECISIONS CONCERNING HIS PERSONAL CARE, AND IS UNABLE TO LIVE ALONE OR TO SEEK MEDICAL SERVICES. B. During the past year, the Guardian of the Person has visited the Incapacitated Person f ~~`' times with the average visit lasting ~ - ~ hours, minutes. 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. ° OlC Date Signature of u than of the Person MARGARET S. MELLINGER Name of Guardian of the Person (type or print) 8 PINE ROAD Address WALNUT BOTTOM, PA 17266 City, State, Zip (717)532-4216 Telephone Form G-03 rev. /0. /3.06 Page 4 of 4 GUARDIAN' S INVENTORY COURT OF COMMON PLEAS OF CUMBERLAND ORPHANS' COURT DIVISION Estate of EDWARD E. SAMPSON No. 72-355 ~° -=~ ~-a rry~ COUNTY, PENN~.~NI~' `:~~~ c~ :~ _ v~ '~Qp ~ .. ~~ ~-r, .. an Incap~itated Perm ' ~ a Minor 1. Real Estate: (Location, by whom occupied and rental Estimated Value: terms, if applicable) NONE Sub-Total for Real Estate: 0.00 2. Personal Property: Estimated Value: PERSONAL CLOTHING AND POSSESSIONS 100.00 3. Jointly Held Property: Estimated Value: (Set forth real and personal property owned by the Incapacitated Person JOINTLY with any other person(s). State whether held as tenants by the entireties; if nor, whether the right of survivorship exists.) Jointly Held Property NONE z~ ;-~-, r-n C"7 `C_', i =~ ;~ :`~ .45 ti~ Cd -n Form G-04 rev. 10.13.06 Page 1 of 2 i Estate of EDWARD E. SAMPSON 4. Anticipated Assets: (Set forth property of any kind expected to be acquired hereafter, together with anticipated date of acquisition.) Property Anticipated Date of Acquisition SOCIAL SECURITY/ASSISTANCE 1/10 - 12/10 (Attach additional sheets if necessary) TOTAL OF ITEMS 1, 2, 3, and 4 :.............................. 74 , 235.86 Commonwealth of Pennsylvania County of Dauphin Estimated Value: 74,135.86 Sub-Total for Personal Estate: 74,135.86 ss. MARGARET S. MELLINGER ~~ an Incapacitated Person a Minor says that the foregoing is a full, Guardian true and complete Inventory of the Estate of EDWARD E. SAMPSON the aforesaid Incapacitated Person or Minor; and that all of the information set forth herein is true and correct to the best of the Guardian's knowledge and belief. I verify that the statements made in this ) Inventory are true and correct. I under- ) stand that false statements herein are ) l made subject to the penalties of ) 18 Pa.C.S. § 4904 relating to unsworn ) Gu di n falsification to authorities. ) Attorney for Guardian: a 34838 Supreme Court I.D. No.: Address: WIX, WENGER & WEIDNER 508 N 2ND ST/POB 845, HARRISBURG, PA 17108 Telephone: (717) 234-4182 Farm c-oa rev. 10.13.06 Page 2 of 2 ~FC~~F~'~~ ~=r=~~E OF ~.~...., `,~,~ a..~ ?C~?.:~~J 27 Pi 2~ 2€i ANNUAL REPORT OF CORK ~F GUARDIAN OF THE PERSON ~~~~~;~ CQURt GIIME~~E,L~;~,E; Cp., PA COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIV[SION Estate of EDWARD E. SAMPSON , an Incapacitated .Person No. 72-355 I. INTRODUCTION Margaret Mellinger, Dorothy Kepner, were Richard Kepner, and Darlene Ziegler ,~i#~appointed Plenary OLimited Guardian of the Person by Decree of J. WESLEY OLER, JR. J dated JANUARY 24, 2007 A. This is the Annual Report for the period from JANUARY 1 2011 to DECEMBER 31 20l 1 (the "Report Period"); or ~ B. This is the Final Report for the period from , to (the "Report Period"), and is filed for the following reason: l . 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. F~orr,c-o~ ,•e,~. ro.i3.o6 Page 1 of4 t ~ Estate of EDWARD E. SAMPSON II. PERSONAL DATA Age of the Incapacitated Person: 59 III. LIVING ARRANGEMENTS A. Current address of the Incapacitated Person: an Incapacitated Person Date of Birth: 10l$f1952 CLAREMONT NURSING & REHAB CENTER 1000 CLAREMONT ROAD CARLISLE, PA 17013 B. The Incapacitated Person's residence is: © own home /apartment nursing home boarding home /personal care home 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 residence since 9/3/2008 If the Incapacitated Person has moved within the past year, state prior residence and reason(s) for move: NOT APPLICABLE Form G-03 rev. /0. /3.06 Page 2 of 4 .. Estate of EDWARD E. SAMPSON an Incapacitated Person D. Name and address of the Incapacitated Person's primary caregiver: CLAREMONT NURSING & REHAB CENTER 1000 CLAREMONT ROAD CARLISLE, PA 17013 IV. MEDICAL INFORMATION A. The major medical or mental problems of the Incapacitated Person are as follows: MR. SAMPSON SUFFERS FROM. CEREBRAL PALSY AND, AS A RESULT, IS MENTALLY RETARDED AND SUFFERS FROM ARTHRITIS AND SEIZURE DISORDER. B. Specify what, if any, social, medical, psychological and support services the Incapacitated Person is receiving: SOCIALLY, MR. SAMPSON ENJOYS TALKING ON THE TELEPHONE, WATCHING TV, GOING OUT TO EAT, AND PLAYS BINGO, WITH ASSISTANCE. MEDICALLY, MR. SAMPSON RECEIVES THE FOLLOWING MEDICATIONS: CARBANAZEPINE, LISINOPRIL, MELOXICAM, METFORMIN, OMEPPRAZOLE, PHENOBARBITAL, ANUCORT, AS WELL AS WEEKLY SKIN ASSESSMENTS AND DIABETIC FOOT CARE. V. GUARDIAN'S OPINION A. It is the opinion of the Guardian of the Person that the guardianship should: continue ~ be modified be terminated i~o~ c-o3 rev. ~0.13.0~ Page 3 of 4 r ~ R Estate of EDWARD E. SAMPSON an Incapacitated Person The reasons for the foregoing opinion are: MR. SAMPSON LACKS THE CAPACITY TO MAKE RESPONSIBLE DECISIONS CONCERNING HIS PERSON, CARE, AND IS UNABLE TO LIVE ALONE OR TO SEEK NEEDED MEDICAL SERVICES B. During the past year, the Guardian of the Person has visited the Incapacitated Person _~_ times with the average visit lasting ~_ hours, minutes. 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. e Date Sfgn ur o ,uardian of the Pers n MARGARET S. MELLINGER Narne oJ'Guardian of the Person (type or prr'nt) 8 PINE ROAD Address WALNUT BOTTOM, PA 17266 C'ily, Stale, Zip (717) 532-4216 7 clephone Form G-03 rev. 10.13.06 Page 4 of 4 ~ K' / t ~FCi)~'~I~ft E-~r~~~ ?0~~,{Atd 27 Pi°E 2~ 2c~ ANNUAL REPORT OF GUARDIAN OF THE ESTATE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION Estate of EDWARD E. SAMPSON CLERK OF ORPHAN'S CC~IJRT ~1MBE~L~',N~ C(J , PA an Incapacitated Person No. 72-355 I. INTRODUCTION Margaret Mellinger, Dorothy Kepner, /were Richard Kepner, and Darlene Ziegler 5 appointed ~ Plenary ~ Limited Guardian of the Estate by Decree of J. WESLEY OLER, JR. J dated JANUARY 24, 2007 ® A. This is the Annual Report for the period from JANUARY 1 2011 to DECEMBER 31 201.1 (the "Report Period"); or B. This is the Final Report for the period from to (the "Report Period"), and is filed for the following reason: l . The death of the Incapacitated Person. Date of death: Name of Personal Representative: 2. The Guardianship was terminated by the Court by Decree of Form C-02 rev. IOJ3.Oh I., dated Page 1 of 5 ~~ Estate of EDWARD E. SAMPSON 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 $ 312.48 2. Income $ 3. Total of Principal and Income III. ADDITIONAL INFORMATION (If more space is needed, please attach additio»al pages.) A. Principal An Incapacitated Person $ 312.48 $ 148.23 $75,715.40 $75,175.40 312,48 1. How is the principal balance listed above currently invested? (Please specify, e.g., real estate, certificates of deposit, restricted bank accounts, etc.): PERSONAL PROPERTY OF MR. SAMPSON, INCLUDING PERSONAL ACCOUNT MALTAINED AT CLAREMONT 2. Have there been any expenditures from the principal during the Report Period? ............................ m Yes ~ No If yes: a. Have all expenditures from the principal been for the sole benefit of the Incapacitated Person? ........ m Yes ~ No Form G-02 rev. !o. ~~. oh Page 2 of 5 Estate of EDWARD E. SAMPSON b. List purpose and amount of expenditures: HOME CARE PERSONAL USE An Incapacitated Person $ 75,175.40 $ 375.75 c. Was Court approval received prior to expending the principal? ....................... 0 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? ........... ~ 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.): SOCIAL SECURITY/GOVERNMENT ASSISTANCE Total income received during Report Period: $ 75,715.40 $ $ 75,715.40 Form c-oz rev. 10.13.06 Page 3 of 5 ~• Estate of EDWARD E. SAMPSON , An Incapacitated Person 2. How is income currently invested? (Please specify, e.g., restricted bank accounts, client care account, etc.): N/A 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.): NURSING HOME RENT PERSONAL USE 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.) NONE 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 NO COMMISSION CLAIMED Yes ©No Yes ~ No Foy c-oz re~•. ro.~s.o~s Page 4 of 5 ~,. ;. Estate of EDWARD E. SAMPSON An Incapacitated Person F. Counsel Fee List amounts paid as counsel fee, and indicate whether Court approval was obtained. Court Amount Approval Obtained Yes ~ No Yes ^ No Ncrrne o~'Guardian of the Esrale (type or print) 8 PINE ROAD Address WALNUT BOTTOM, PA 17266 l~;~v, state. zip (717)532-4216 ~clephone 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 tom~~//u~~nswor~~Jn'~f7a~lsi,~f/i'c~ation to authorities. ~~ Date Sigr t e o Guardian of the E ate ~""~ MARGARET S. MELLINGER Form G-U2 rev. 1!1.13.06 Page 5 of 5 .~ ~. GUARDIAN'S INVENTORS ~jE,~~ !~~?l' ~ ~`_ ~;~(;~ / .__uJ COURT OF COMMON PLEAS OF CUMBERLAND COU~T~~',~~~1~1~IS`~~V~I~1~ ORPHANS' COURT DlVIS10N CLERr~ QF ORPHAN'S GJI~RT ~~RERI >;r~i~ C(} . pA Estate of EDWARD E. SAMPSON an Incapacitated Person ' ~ ~ a Minor No. 72-355 1. Real Estate: (Location, by whom occupied and rental Estimated Value: terms, if applicable) NONE O.OU Sub-Total for Real Estate: 0.00 2. Personal Property: Estimated Value: NURSING HOME PERSONAL USE ACCOUNT 312.48 3. Jointly Held Property: Estimated Value: (Set_forrh real and persona! properly owned by the Incapacitated Person Jl)IN!'LY with any other person(sy. State whether held as tenants by the entireties; iJYzat, whether the right <~/' san~ivorship exists. j Jointly Held Property NONE 0.00 Form C,-04 rev. 10.13.06 Page ~ Of 2 a - -~ Estate of EDWARD E. SAMPSON 4. Anticipated Assets: (Set forth property aJ'uny kind expected to be acquired hereafter, toKether N~ith anticipated date of acquisition.) Property Anticipated Date of Acquisition ®an Incapacitated Person a Minor Sub-Total for Personal Estate: (Attach additional sheets if necessary) TOTAL OF ITEMS 1, 2, 3, and 4 : ............................. . Commonwealth of Pennsylvania ss. County of CUMBERLAND Estimated Value: 312.48 312.48 MARGARET MELLINGER ,says that the foregoing is a full, Guardian true and complete Inventory of the Estate of EDWARD E. SAMPSON the aforesaid Incapacitated Person or Minor; and that all. of the information set forth. herein is true and correct to the best of the Guardian's knowledge and belief. I verify that the statements made in this ) Inventory are true and correct. I under- } stand that false statements herein are ) made subject to the penalties of } 18 Pa.C.S. § 4904 relating to unsworn falsification to authorities. ) ~, Guardi Attorney for Guardian: DAVID R. GETZ, ESQ. Supreme Court I.D. No.: 34838 Address: WIX, WENGER & WEIDNER P.O. BOX 845, HARRISBURG, PA 17108-0845 Telephone: ~~ 17) 234-4182 warm c-oa rev. 10.13.06 Page 2 of 2 ANNUAL REPORT OF :~- GUARDIAN OF THE PERSON ~ d ~' -..- d~ --- c, ..~_ ~ ~"' ...,, ~-~ ;..,~ rv ~ c ~ ~.,-~ COURT OF COMMON PLEAS OF ~~ _ ~,~ CUMBERLAND COUNTY, PENNSYLVANIAr - - ORPHANS' COURT DLVISION _ . - ~ ~ , . ~~ '; `s 3 `~ Estate of EDWARD E. SAMPSON No. 72-355 an Incapacitated Person I. INTRODUCTION Margaret Mellinger, Dorothy Kepner, Richard Kepner and Darlene Ziegler ,was appointed ~ Plenary ^Limited Guardian of the Person by Decree of J. WESLEY OLER, JR. J., dated JANUARY 24, 2007 ® A. This is the Annual Report for the period from JANUARY 1 , 2012 to DECEMBER 31 2012 (the "Report Period"); or ^ B. This is the Final Report for the period. from , to (the "Report Period"), and is filed for the following reason: l . 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-o3 rev. 10.13.06 Page 1 Of 4 Estate of EDWARD E. SAMPSON II. PERSONAL DATA Age of the Incapacitated Person: 60 III. LIVING ARRANGEMENTS A. Current address of the Incapacitated Person: Shippensburg Health Care Center 121 Walnut Bottom Road Shippensburg, PA 17257 an Incapacitated Person Date of Birth: 10/9/1952 B. The Incapacitated Person's residence is: own home /apartment ®nursing home boarding home /personal care home ~ Guardian's home /apartment Q hospital or medical facility relative's home (name, relationship and address) other: C. The Incapacitated Person has been in the present residence since 3/27/2012 . If the Incapacitated Person has moved within the past year, state prior residence and reason(s) for move: Claremont Nursing and Rehab Center 1000 Claremont Road, Carlisle, PA 17013 Mr. Sampson moved in order to be closer to family members and to reduce long distance telephone charges. Form G-03 rev. 10.13.06 Page 2 of 4 Estate of EDWARD E. SAMPSON , an Incapacitated Person D. Name and address of the Incapacitated Person's primary caregiver: SHIPPENSBURG HEALTH CARE CENTER 121 WALNUT BOTTOM ROAD SHIPPENSBURG, PA 17257 IV. MEDICAL INFORMATION A. The major medical or mental problems of the Incapacitated Person are as follows: MR. SAMPSON SUFFERS FROM CEREBRAL PALSY AND, AS A RESt1LT, SUFFERS FROM AN INTELLECTUAL DISABILITY. IVIR. SAMPSON ALSO SUFFERS FROM ARTHRITIS AND SEIZl1RE DISORDER. B. Specify what, if any, social, medical, psychological and support services the Incapacitated Person is receiving: SOCIALLY, MR. SAMPSON ENJOYS TALKING ON THE TELEPHONE, WATCHING TV, GOING OUT TO EAT, AND PLAYS BINGO, WITH ASSISTANCE. MEDICALLY, MR. SAMPSON RECEIVES THE FOLLOWING MEDICATIONS: CARBANAZEPINE, L[SINOPRIL, MELOXICAM, METFORMIN, OMEPPRAZOLE, PHENOBARBITAL, ANUCORT, AS WELL AS WEEKLY SKIN ASSESSMENTS AND DIABETIC FOOT CARE. V. GUARDIAN'S OPINION A. It is the opinion of the Guardian of the Person that the guardianship should: m continue be modified be terminated Norm G-03 rev. 10.13.06 Page 3 of 4 Estate of EDWARD E. SAMPSON , an Incapacitated Person The reasons for the foregoing opinion are: MR. SAMPSON LACKS THE CAPACITY TO MAKE RESPONSIBLE DECISIONS CONCERNING HIS PERSON, CARE, AND IS UNABLE TO LIVE ALONE OR TO SEEK NEEDED MEDICAL SERVICES B. During the past year, the Guardian of the Person has visited the Incapacitated Person 50 + times with the average visit lasting 1 hours, ~ ~ ~ minutes. 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. 8 -~ ~ ~ x«te tii~;n r:sr of uardian of the Person MARGARET S. MELLINGER Name gJ'G~~ardian of the Person (type or print) 8 PINE ROAD t9ddress WALNUT BOTTOM, PA 17266 ('itv, Stale. Zip {7 t 7) 532-4216 'I elepha~c Form <,-o~ re~•. l0.1~.06 Page 4 of 4 .• r n ::~": ~ ~ ~ ~ rn ANNUAL REPORT OF ~ ° .. ~~- ~ GUARDIAN OF THE ESTATE _ rn •:r~ [~ ~ ~' - _ .. , x `~ `~~' ~ ~.~ r- ~ a ; ,~ d"' ~ i CY:.+ :.:..T COURT OF COMMON PLEAS OF ~ -'. CUMBERLAND COUNTY, PENNSYLVA NIA Y ORPHANS' COURT DIVISION ~ _ : ~~ ,~ Estate of EDWARD E. SAMPSON I. INTRODUCTION Margaret Mellinger, Dorothy Kepner, Richard Kepner, and Darlene Ziegler ,was appointed Q Plenary ^ Limited Guardian of the Estate by Decree of ~• WESLEY OLER, JR. ~ ~ , dated JANUARY 24, 2007 © A. This is the Annual Report for the period from JANUARY 1 2012 to DECEMBER 31 2012 (the "Report Period"); or ^ B. This is the Final Report for the period from , to (the "Report Period"), and is filed for the following reason: l . 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 rec. 10.13.06 an Incapacitated Person No. 72-355 Page 1 of 5 Estate of EDWARD E. SAMPSON 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 III. ADDITIONAL INFORMATION (If more space is needed, please attach additional pages.) A. Principal An Incapacitated Person $ 235.17 $ 312.48 $ 5,508.11 ~ 5,585.42 $ 235.17 1. How is the principal balance listed above currently invested? (Please specify, e.g., real estate, certificates of deposit, restricted bank accounts, etc.): Personal account maintained at Shippensburg Health Care Center 2. Have there been any expenditures from the principal during the Report Period? ............................ ~ Yes ~ No If yes: a. Have all expenditures from the principal been for the sole benefit of the Incapacitated Person? ........ /0 Yes ~ No Form G-D? rev. 10.13.06 Page 2 of 5 Estate of EDWARD E. SAMPSON An Incapacitated Person b. List purpose and amount of expenditures: HOME CARE ~ 4,907.00 PERSONAL USE ~ 678.42 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? .... ....... ^ Yes 0 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 I . State sources and amounts of income received during the Report Period (e.g., Social Security, pension, rents, etc.): SOCIAL SECURITY/GOVERNMENT ASSISTANCE Total income received during Report Period: ~ S,so8.11 ~ 5,508.11 f~'ormG-o2 rev. ~o.~~.o~ Page 3 of 5 ~ ~ Estate of EDWARD E. SAMPSON 2. How is income currently invested? (}'lease specify, e.g., restricted bank accounts, client care account, etc.): N/A An Incapacitated Person C. Expenses for Care and Maintenance Specify what expenditures were made from the principal and income for the care and maintenance of the lncapacitated Person (e.g., clothing, nursing home, medicine, support, etc.): Nursing home and personal use 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.) NONE E. Guardian's Commissions List amounts of compensation paid as Guardian's commission and state how amount was determined: Amount Method of Determination NO COMMISSION CLAIMED Form G-OZ rev. 10.13.06 Court Approval Obtained ^Yes ^No ^Yes ~ No Page 4 of 5 Estate of EDWARD E. SAMPSON , An Incapacitated Person F. Counsel Fee List amounts paid as counsel fee, and indicate whether Court approval was obtained. Court Amount Approval Obtained Yes ^ No ^ Yes 0 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. ~, ~ to Sid; adr~r of uardian of the Estate MARGARET S. MELLINGER Ncnne oJ'Gr~ardian of the F_srate (type or print) 8 P1NE ROAD Addres-' _ __ WALNUT BOTTOM, PA 17266 (`itv, SYn1e. Zip (717) 532-4216 Telephone Form Cr-U2 rev. 10.13.06 Page 5 Of 5 GUARDIAN' S IN`~ENTORY COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PF,NNSYLVANIA ORPHANS' COURT DIVISION n ~.= ~._~ ~ m s~ ~ ° ~_ ~,, rte' ®~ T~~citd Pets Estate of EDWARD E. SAMPSON } fir' r1~ ,~~ r ~s-~ No.72-355 °"~- - %~ ~' .-~ , -_~ .._ ~_..a _.. .:. ..I:~ ~- J V`i`Y .: s. O ~"r1 1. Real Estate: (Location, by whom occupied anc:l rental Estimated Value: terms, if applicable) NONE Sub-Total for Real Estate: 2. Personal Property: PERSONAL CLOTHING AND POSSESSIONS NURSING HOME PERSONAL USE ACCOUNT 3. Jointly Held Property: (Set forth real and persona! property owned by the Incapacitated Pensor~ ./(.)I,N7LY wilh anv ether person(s). State whether held as tenants by the entireties: if'nol, a Jielher the right of .°un~ivorship exists,) Jointly Held Property NONE Form G-0~J rev. !0.13.06 0.00 Estimated Value: o.oo 235.17 Estimated Value: 0.00 Page 1 of 2 Estate of EDWARD E. SAMPSON 4. Anticipated Assets: (Set forth property of any kind expec4ed to be acy~rired hereafter, tok>ether ti~rrh antiefpated date ofaegtrisitron.) Property Anticipated Date nfAcyaisition SOCIAL SECURITY/ASSISTANCE 1/13 - 12/13 1~an Incapacitated Person I^a Minor Sub-Total for Personal Estate: (Attach additional sheets if necessary) TOTAL OF ITEMS 1, 2, 3, and 4: .......... ................... . Commonwealth of Pennsylvania ss. County of Estimated Value: 235.17 235.17 MARGARET S. MELLINGER ,says that the foregoing is a full, Guardian true and complete Inventory of the Estate of EDWARD E. SAMPSON the aforesaid Incapacitated Person or Minor; and that all of the information set forth herein is true and correct to the best of the Guardian's knowledge and belief. I verify that the statements made in this ) Inventory are true and correct. I under- ) stand that false statements herein are ) ~ ~ made subject to the penalties of ) 18 Pa.C.S. § 4904 relating to unsworn ) G artii falsification to authorities. ) R ~: "' -- Attorney for Guardian: Supreme Court LD. No.: 34838 Address: WIX, WENGER & WEIDNER 508 N 2ND ST/POB 845, HARRISBURG, PA 17108 Telephone: (717) 234-4182 Fern ~J-o~ rev. !o. ~3 0~ Page 2 of 2 _ 1 RECORDED OFFICE OF ANNUAL REPORT OF REGISTER OF WILLS 12 28 GUARDIAN OF THE PERSON 10'3 "di" 21 F(1 CLERK OF ORPHANS' COURT COURT OF COMMON PLEAS OF CUMBERLAND CO., PA CUMBERLAND COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION Estate of EDWARD E. SAMPSON an Incapacitated Person No. 72-355 I. INTRODUCTION Margaret Mellinger, Dorothy Kepner, were Richard Kepner, and Darlene Ziegler /appointed ®Plenary ElLimited Guardian of the Person by Decree of J. WESLEY OLER,JR. J. dated JANUARY 24,2007 Q A. This is the Annual Report for the period from to (the"Report Period"); or B. This is the Final Report for the period from JANUARY 1 2013 SEPTEMBER 9, " to 2013 (the"Report Period"), and is filed for the following reason: 1. The death of the Incapacitated Person. Date of death: 09/02/2013 _..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 m.10.13.06 Page I of 4 ^ Estate of EDWARD E. SAMPSON an Incapacitated Person II. PERSONAL DATA Age of the Incapacitated Person: 60 Date of Birth: 10/9/1952 Date of Death: 9/2/2013 III. LIVING ARRANGEMENTS Last A. Gwmxt address of the Incapacitated Person: Shippensburg Health Care Center 121 Walnut Bottom Road Shippensburg, PA 17257 B. The Incapacitated Person's residence*x was: ❑own home/apartment ®nursing home El boarding home/personal care home M 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 residence since 3/27/2012 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 EDWARD E. SAMPSON an Incapacitated Person D. Name and address of the Incapacitated Person's primary caregiver: Shippensburg Health Care Center 121 Walnut Bottom Road Shippensburg, PA 17257 IV. MEDICAL INFORMATION A. The major medical or mental problems of the Incapacitated Person are as follows: DECEASED 9/2/2013 B. Specify what, if any, social,medical, psychological and support services the Incapacitated Person is receiving: DECEASED 9/2/2013 V. GUARDIAN'S OPINION A. It is the opinion of the Guardian of the Person that the guardianship should: Q continue 0 be modified - Elbe terminated Form G-03 rev.10.13.06 Page 3 of 4 _ _ _ Y : �r � i i ; , � � - � .�. oo I ' i I j I • i _ � i , � '. r.,. i ' i i 1 I i i i Estate of EDWARD E. SAMPSON an Incapacitated Person The reasons for the foregoing opinion are: Mr. Sampson passed away on September 2, 2013. B. During the past year,the Guardian of the Person has visited the Incapacitated Person times with the average visit lasting hours, minutes. 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 unswom falsification to authorities. 0,nr /14 '�dl� �n Date Z Signa6e of*ardian of the Person MARGARET S. MELLINGER Name of Guardian of the Person(type or print) 8 PINE ROAD Address I WALNUT BOTTOM,PA 17266 City,State.Zip . (717) 532-4216 Telephone Form G-03 r".10.13.06 Page 4 of 4 RECORDED OFFICE OF REGISTER OF WILLS ANNUAL REPORT OF GUARDIAN Oiftft4jkfj 28 CLERK OF COURT OF COP CU RT CUMBERLAND C& qM ! SxVAkIA ORPHANS' COURT DIVISION Estate of EDWARD E. SAMPSON an Incapacitated Person No.-72-355 I. INTRODUCTION were Margaret Mellinger, Dorothy Kepner, Richard Kepner, VilVappointed and Darlene Ziegler 1Z Plenary 0 Limited Guardian of the Estate by Decree of J. WESLEY OLER,JR. J dated JANUARY 24,2007 0 A. This is the Annual Report for the period from to (the "Report Period"); or © B. This is the Final Report for the period from JANUARY 1 2013 to SEPTEMBER 9, 2013 2013 (the "Report Period"), and is filed for the following reason: 1. The death of the Incapacitated Person. Date of death: 09/02/2013 Name of Personal Representative: Margaret Mellinger 2. The Guardianship was terminated by the Court by Decree of J., dated Form G-02 rev.!0.!3.06 Page 1 of 5 J� Estate of EDWARD E. SAMPSON An Incapacitated Person II. SUMMARY A. State the value of the estate reported on the Inventory $ 0.00 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.) $ 235.17 C. What is the total amount of income earned during the Report Period? $ 4,221.66 D. What is the total amount of income and principal spent for all purposes during the Report Period? $ 4,456.83 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.): N/A 2. Have there been any expenditures from the principal during the Report Period? . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes ❑No — If yes: a. Have all expenditures from the principal been for the sole benefit of the Incapacitated Person? . . . . . . . . ®Yes 0 No Fosm c-02 rev.10.13.06 Page 2 of 5 a Estate of EDWARD E. SAMPSON An Incapacitated Person b. List purpose and amount of expenditures: HOME CARE , EYE/DENTAL INS./ $ 4,456.83 PERSONAL USE $ 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? . . . . . . . . . . . ©Yes 0 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.): SOCIAL SECURITY/GOVERNMENT ASSISTANCE $ $ $ Total income received during Report Period: $ 4,221.66_._ Form c-02 rev.!0.!3.06 Page 3 of 5 Estate of EDWARD E. SAMPSON An Incapacitated Person 2. How is income currently invested? (Please specify,e.g.,restricted bank accounts, client care account, etc.): N/A 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.): Nursing home and personal use 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.) None 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 NO COMMISSION CLAIMED ❑Yes ❑No ❑Yes []No ... Form G-02 rev.10.13.06 - Page 4 of 5 Estate of EDWARD E. SAMPSON An Incapacitated Person F. Counsel Fee List amounts paid as counsel fee, and indicate whether Court approval was obtained. Court Amount Approval Obtained NO FEES PAID [I Yes n No El Yes 0 N 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. GzSaq Date J Sign re r uardian ofthe Estate MARGARET S. MELLINGER Name of Guardian of the Estate(type or print) 8 PINE ROAD Address WALNUT BOTTOM, PA 17266 City,State.Zip (717) 532-4216 Telephone Fortn G-02 m.10.13.06 Page 5 of GUARDIAN'S INVENTORY COURT OF COMMON PLEAS OF CUMBERLAND COUNTY,PENNSYLVANIA ORPHANS' COURT DIVISION Estate of EDWARD E. SAMPSON i an Incapacitated Person 40 a Minor No 72-355 1. Real Estate: {Location,by whom occupied and rental Estimated Value: terms,if applicable} NONE Sub-Total for Real Estate: 0.00 2. Personal Property: Estimated Value! PERSONAL CLOTHING AND POSSESSIONS 0.00 A rn 1/ C) 3. Jointly Held Property: Estimated Val ' ' ° (Set forth real and personal property owned by the Incapacitated Person JOINTLYwith any other person(s). State whether held as tenants by the entireties;if not,whether the right of survivorship exrsis.) Joindy Held Praperiv NONE Form G-04 rev.10.13.06 Page I of 0 d`; .. �`> ', Estate of EDWARD E. SAMPSON iOan Incapacitated Person r0a Minor 4. Anticipated Assets: Estimated Value: (Set forth property of any kind expected io be acquired hereafter,together with anticipated date ofacquisition.) Property Art6cipated Date of Acquisition None - Deceased 9/2/2013 0.00 Sub-Total for Personal Estate: (Attach additional sheets if necessary) TOTAL OF ITEMS 1,2,3, and 4: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Commonwealth of Pennsylvania : : ss. County of MARGARET S.MELLINGER says that the foregoing is a full, Guardian true and complete Inventory of the Estate of EDWARD E. SAMPSON the aforesaid Incapacitated Person or Minor; and that all of the information set forth herein is true and correct to the best of the Guardian's knowledge and belief. I verify that the statements made in this ) Inventory are true and correct. I under- ) stand that false statements herein are �� made subject to the penalties of ) r a 18 Pa.C.S. § 4904 relating to unsworn ) GuaMiaq falsification to authorities. ) (i Attorney for Guardian: Supreme Court I.D.No.: 34838 Address: WIX,WENGER&WEIDNER 508 N 2ND SUPOB 845,HARRISBURG, PA 17108 Telephone: (717)234-4182 Form G-04 rev.10,13.06 Page 2 of 2 f 1 i ' T',' _1 �1� �� �