Free Form G-03 - rev. 10-13-06 - Annual Report of Guardian - Pennsylvania

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ANNUAL REPORT OF GUARDIAN OF THE PERSON

COURT OF COMMON PLEAS OF COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION

Estate of No.

, an Incapacitated Person

I.

INTRODUCTION , was appointed

Plenary dated

Limited Guardian of the Person by Decree of . 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 to for the following reason: 1. The death of the Incapacitated Person. Date of death: , ,

, J.,

(the "Report Period"), and is filed

2. The Guardianship was terminated by the Court by Decree of J., dated For a Final Report, omit Sections II through IV.
Form G-03 rev. 10.13.06

.

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Estate of II. PERSONAL DATA Age of the Incapacitated Person:

, an Incapacitated Person

Date of Birth:

III.

LIVING ARRANGEMENTS A. Current address of the Incapacitated Person:

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 . If the Incapacitated Person has moved within the past year, state prior residence and reason(s) for move:

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Estate of

, an Incapacitated Person

D. Name and address of the Incapacitated Person's primary caregiver:

IV.

MEDICAL INFORMATION A. The major medical or mental problems of the Incapacitated Person are as follows:

B. Specify what, if any, social, medical, psychological and support services the Incapacitated Person is receiving:

V.

GUARDIAN'S OPINION A. It is the opinion of the Guardian of the Person that the guardianship should: " continue " be modified " be terminated

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Estate of The reasons for the foregoing opinion are:

, an Incapacitated Person

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.

Date

Signature of Guardian of the Person

Name of Guardian of the Person (type or print)

Address

City, State, Zip

Telephone

Form G-03 rev. 10.13.06

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