Title 255--LOCAL
COURT RULESBEAVER COUNTY Local Procedural Rules; No. 537 of 2004 [34 Pa.B. 2690] Rule 14 and Appendices which follow are adopted, effective thirty (30) days after publication in the Pennsylvania Bulletin. The Clerk of the Orphans' Court shall submit certified copies of this order, Rule 14 and Appendices as follows: seven (7) to the Administrative Office of Pennsylvania Courts; two (2) to the Legislative Reference Bureau for publication in the Pennsylvania Bulletin; one (1) with the Orphans' Court Procedural Rules Committee of the Pennsylvania Supreme Court; one (1) copy with the Law Library of Beaver County; and one (1) copy shall be kept continuously available for public inspection and copying in the office of the Clerk of the Orphans' Court.
By the Court
ROBERT E. KUNSELMAN
President JudgeORPHANS' COURT DIVISION RULE 14 Rule 14. Incapacitated Persons; Guardians
L. R. 14.A. Local Rules.
The practice and procedure with respect to incapacitated persons' estates shall be as prescribed by local rules, which shall not be inconsistent with the Pennsylvania Supreme Court Orphans' Court Rules.
L. R. 14.B. Contents of Petition.
1. A petition for the appointment of a guardian of the estate or person of an alleged incapacitated person shall set forth:
a) The name, age, residence and post office address of the alleged incapacitated person;
b) the names and addresses of the spouse, parents and presumptive adult heirs of the alleged incapacitated person;
c) the name and address of the person or institution providing residential services to the alleged incapacitated person;
d) the names and addresses of other service providers;
e) the name and address of the person or entity whom petitioner asks to be appointed guardian;
f) an averment that the proposed guardian has no interest adverse to the alleged incapacitated person;
g) the reasons why guardianship is sought;
h) a description of the functional limitations and physical and mental condition of the alleged incapacitated person;
i) the steps taken to find less restrictive alternatives;
j) the specific areas of incapacity over which it is requested that the guardian be assigned powers; and
k) the qualifications of the proposed guardian.
2. If a limited or plenary guardian of the estate is sought, the petition shall also set forth:
a) The gross value of the estate and the net income of the alleged incapacitated person from all sources to the extent known;
b) the potential for conflict with regard to the issue of who will be appointed as guardian and with regard to the issue of capacity; and
c) the current status of the alleged incapacitated person (i.e. unconscious, unable to communicate due to a stroke, combative, etc.).
3. If an emergency guardian is sought, the petition shall also include an indication as to whether or not the condition of the alleged incapacitated person is one that will or will not be remedied within the first 72 hours.
4. A consent, signed by the proposed guardian, shall be attached to the petition in which the proposed guardian shall agree to act as guardian of the person or the estate of the alleged incapacitated person if appointed by the Court and shall state that the proposed guardian has no interest adverse to that of the alleged incapacitated person and is not a fiduciary of any estate, trust or similar fund in which the alleged incapacitated person has an interest. The form of consent shall be substantially as set out in Appendices A-1 and A-2 to this Rule.
5. The petition shall conclude with a prayer for the appointment of a guardian of the estate or person or both of the alleged incapacitated person and for the award of a citation directed to the alleged incapacitated person to show cause why he should not be adjudged an incapacitated person and why a guardian should not be appointed.
L. R. 14.C. Preliminary Order; Notice; Service
1. Upon presentation of a petition for the appointment of a guardian, the Court will enter a preliminary order awarding the citation prayed for. The form of the preliminary order shall be substantially as set out in Appendix B to this Rule.
2. Written notice of the petition and hearing, to which shall be attached the citation and a copy of the petition and preliminary order, shall be provided to the alleged incapacitated person. The written notice shall be in large type and in simple language and shall indicate the purpose and seriousness of the proceeding, the rights that can be lost as a result thereof, the date, time and place of the hearing, and that the alleged incapacitated person has the right to request the appointment of counsel, to have counsel appointed if the Court deems it appropriate, and to have such counsel paid for if it cannot be afforded. The form of written notice shall be substantially as set out in Appendix C to this Rule.
3. Personal service of the written notice, petition, citation and preliminary order shall be made on the alleged incapacitated person and the contents and terms of the petition shall be explained to such person to the maximum extent possible in language and terms the individual is most likely to understand. Service shall be no less than 20 days in advance of the hearing. In addition, notice of the petition and hearing shall be given in such manner as the Court shall direct to all persons residing within the Commonwealth who are sui juris and would be entitled to share in the estate of the alleged incapacitated person if he died intestate at that time, to the person or institution providing residential services to the alleged incapacitated person and to such other parties as the Court may direct, including other service providers. An Affidavit of Service shall be filed on or before the day of hearing.
L. R. 14.D. Notice of Retention of Counsel
1. Counsel retained by the person alleged to be incapacitated in a petition under 20 Pa.C.S.A. § 5511(a) shall enter an appearance and shall provide a copy thereof to the petitioner at least seven (7) days prior to the date set for hearing.
2. If petitioner does not receive notice under Rule 14.3(a) that counsel has entered an appearance on behalf of the alleged incapacitated person, petitioner shall notify the Court, in writing, at least seven (7) days prior to the date set for hearing that the alleged incapacitated person is not represented by counsel as set out in Appendix D to this Rule.
L. R. 14.E. Hearing
At the time fixed for the hearing on the petition, testimony shall be submitted in support of the petition (See 20 Pa.C.S.A. §§ 5512.1, 5518 and 5518.1). The alleged incapacitated person shall be present in court at such hearing unless (1) the Court is satisfied, upon the deposition or testimony of, or sworn statement by a physician or licensed psychologist, that his physical or mental condition would be harmed by his presence; or (2) it is impossible for him to be present because of his absence from the Commonwealth.
L. R. 14.F. Appointment of Guardian
1. Findings. In all cases, the Court, upon presentation of proper proof, shall consider and make specific findings of fact as required by 20 Pa.C.S.A. § 5512(a).
2. Final Orders. The Court shall determine whether a plenary or limited guardian of the person or estate of the alleged incapacitated person is required. The forms of final orders for the appointment of plenary and limited guardians are set out in Appendices E-1 and E-2 to this Rule.
3. There shall be attached to the final order as an exhibit the Statement of Rights, the form of which is set out in Appendix F to this Rule.
4. At the time of final hearing, the Petitioner shall submit to the Court the Pennsylvania Notification of Mental Health Commitment, the form of which is set out as Appendix G to this Rule.
L. R. 14.G. Emergency Guardians
1. Petition. A petition for the appointment of an emergency guardian of the person or estate of the alleged incapacitated person shall both set forth the information required in 20 Pa.C.S.A. § 5511(e) and Rule 14.1, and shall be subject to the provisions of 20 Pa.C.S.A. § 5511 (including those relating to notification concerning the right to counsel and the appointment of such counsel for the alleged incapacitated person), unless the Court directs in its order setting the time of the emergency hearing that the preparation and inclusion of such information is not feasible under the circumstances. Such emergency petitions must, however, contain facts and information sufficient to enable the Court to determine that: (1) the person allegedly lacks capacity; (2) is in need of the appointment of an emergency guardian; and (3) the failure to make such appointment will result in irreparable harm to the person or estate of the alleged incapacitated person.
2. Citation. Upon presentation of an appropriate petition for the appointment of an emergency guardian of the person or estate of an alleged incapacitated person, the Court will enter an order awarding a citation, subject to the provisions of 20 Pa.C.S.A. § 5511(a), and will direct such notice as it shall determine to be feasible in the circumstances to persons appearing to be entitled to such notice. In addition to fixing a return day for the filing of a written answer to the petition (though such written answer shall not be mandatory), the order shall also fix a time and place for hearing on the petition. The citation, together with written notice of the petition, to which shall be attached a copy of the petition and the order, shall be served personally upon the alleged incapacitated person prior to the hearing. The forms of orders for the setting of a hearing upon a petition for appointment of an emergency guardian of the person or the estate of an alleged incapacitated person shall be substantially as provided in Appendix H to this Rule.
3. Hearing. At the time fixed for hearing on the petition for appointment of an emergency guardian, testimony shall be submitted in support of the petition (See 20 Pa.C.S.A. §§ 5513 and 5518). The alleged incapacitated person shall be present at the hearing unless: (1) the Court is satisfied, upon the deposition, testimony or sworn statement by a physician or licensed psychologist, that his physical or mental condition would be harmed by his presence, or (2) it is impossible for him to be present because of his absence from the Commonwealth.
4. Appointment of Emergency Guardian. Upon proper proof, the Court shall make a finding of incapacity and appoint an emergency guardian of the person or estate, or both, pursuant to 20 Pa.C.S.A. §§ 5512.1 and 5513 and, if the petition is for the appointment of an emergency guardian of the estate, will fix the amount of the surety bond, if any, to be filed by the guardian. The required bond must be submitted to the Court for approval and filed in the Clerk's Office before the order of appointment will be released by the Court. The emergency guardian of an alleged incapacitated person shall have only and be subject to such powers, duties and liabilities and serve for such time as the Court in its order of appointment shall direct. The forms of orders of appointment of an emergency guardian shall be substantially as provided in Appendices I-1 and I-2 to this Rule.
L. R. 14.H. Inventory
Within three (3) months after the real or personal property of the incapacitated person comes into his possession or as otherwise ordered by the Court, a guardian of the estate of an incapacitated person shall verify by oath and file with the Clerk an inventory and appraisement of personality and a statement of real estate, and a statement of any real or personal property which the guardian expects to acquire thereafter.
L. R. 14.I. Reports Required of Guardian
1. Each guardian of an incapacitated person shall file a report with the Court at least once within the first twelve (12) months of his appointment or such earlier time as may be set by the Court and at least annually thereafter.
2. The annual report of a guardian of the estate of an incapacitated person shall include:
a) Assets held by the guardian and the current value thereof.
b) All receipts and disbursements of principal and income since the date of appointment of the guardian, or, if later, since the date of the last annual report. The report shall identify expenditures which have been made since the date of appointment or, if later, the date of the last annual report, pursuant to any order for an allowance under 20 Pa.C.S.A. § 5536, or otherwise for the housing, maintenance, support, medical expenses, rehabilitation, education and other needs of the incapacitated person.
c) The estimated annual income from the assets held by the guardian and from other sources.
d) Notice of the filing of an annual report by the guardian of an estate shall be provided to the guardian's surety, the guardian of the person if someone other than the guardian of the estate, the incapacitated person and his or her counsel, if any, and such other interested parties as the Court may direct.
The form of the Report of a guardian of the estate shall be substantially as set out in Appendix J to this Rule.
3. Within sixty (60) days of the death of the incapacitated person or an adjudication of capacity and modification of existing orders, the guardian of the estate of such incapacitated person shall file a final report with the Court. The final report shall cover the period from the date of the appointment of the guardian of the estate to the date of death of the incapacitated person or the adjudication of capacity. Such final report shall be filed as an account of the guardian in the office of the Clerk as provided by 20 Pa.C.S.A. § 5532, and the practice and procedure concerning the filing and audit of such accounts, reviews, distribution and rights of distributees shall conform to the practice and procedure governing the administration as set forth in 20 Pa.C.S.A. § 5533 of a decedent's or minor's estate.
4. The annual report of guardian of the person of an incapacitated person shall include:
a) Current address, type of placement and living arrangements of the incapacitated person, e.g., private home, personal care facility, hospital, institution, etc.
b) Major medical or mental problems of the incapacitated person.
c) A brief description of the social, medical, psychological and other support services the incapacitated person is receiving.
d) The opinion of the guardian as to whether the guardianship should continue or be terminated or modified, and the reasons therefore.
e) The number and length of times the guardian visited the incapacitated person in the past year.
The form of the report of a guardian of the person shall be substantially as set out in Appendix K to this Rule.
5. Within sixty (60) days of the death of the incapacitated person or an adjudication of capacity and modification of existing orders, the guardian of the person shall file a final report with the Court, providing the address and type of placement of the incapacitated person as of the date of death or adjudication of capacity, number and length of times the guardian visited the incapacitated person since the last report, and the reason why the report is being filed. The form of the final report of the guardian of the person shall be substantially as set out in Appendix L to this Rule.
L. R. 14.J. Petition for Allowance
A petition under 20 Pa.C.S.A. § 5536 for an allowance from the incapacitated person's estate during incapacity, may be presented by the guardian or any interested party. The petition shall set forth:
1. The name of the guardian and the date of the guardian's appointment; if the petitioner is not the guardian, the petitioner's relationship to the incapacitated person or the nature of the petitioner's interest;
2. the nature and present value of the incapacitated person's estate and the net annual income therefrom;
3. the address of the incapacitated person;
4. the names and addresses of the incapacitated person's dependents, if any;
5. a statement of all claims of the incapacitated person's creditors known to the petitioner;
6. all previous allowances by decree; and
7. a prayer for the allowance requested.
No order for an allowance out of an incapacitated person's estate shall be made without prior notice to the incapacitated person's guardian, if any.
L. R. 14.K. Sales, Mortgages, Leases, Exchanges and Options
A petition for the sale, mortgage, lease, exchange or option of an incapacitated person's real or personal property shall comply with 20 Pa.C.S.A. §§ 3353, 5155 and 5521(b), and the applicable provisions of Rules 12.9, 12.10 and 12.11 of this Court.
Notice of a sale or other transaction under this section shall be given to all persons who are sui juris and would be entitled to share in the estate of the incapacitated person if the incapacitated person died intestate at the time the petition is presented.
L. R. 14.L. Small Estates
1. When the entire real and personal estate, wherever located, of a resident or non-resident alleged incapacitated person has a gross value of $25,000 or less, a petition to have him adjudged incapacitated shall be filed in the form prescribed in Rule 14.1 of this Rule except that the appointment of a guardian of his estate shall not be requested. After the hearing on such a petition and upon presentation of the required evidence, the Court will make a finding of incapacity as to the alleged incapacitated person and may authorize the person or institution maintaining the person to receive and hold or dispose of the property of the person without the appointment of a guardian or the entry of security.
2. Without the appointment of a guardian, any amount in cash of a resident or non-resident incapacitated person may be ordered by the Court to be deposited in one or more savings accounts in the name of the person in banks, building and loan associations or savings and loan associations insured by a federal government agency, provided that the amount deposited in any one such savings institution shall not exceed the amount to which accounts are thus insured. Every such order shall contain a provision that no withdrawal can be made from any such account except as authorized by order of Court.
L. R. 14.M. Foreign or Successor Guardian
1. A foreign guardian shall file an exemplification of the record of the foreign guardianship in the office of the Register of Wills and thereafter a petition with the Court requesting full faith and credit to be given to the foreign adjudication of incompetency. The Court will enter a preliminary order awarding a citation directed to the alleged incapacitated person and providing that at least twenty days' written notice of the proceeding be given to all persons appearing to be entitled to such notice. In addition to fixing a return date for the citation, the order shall also fix a time and place for a hearing on the petition. The citation, together with a copy of the petition and order, shall be served personally on the alleged incapacitated person. Notice to other persons shall be given personally or by registered or certified mail.
2. The Court, after such notice to parties in interest as it shall direct, may without a hearing appoint a succeeding guardian to fill a vacancy in the office of guardian or may appoint a co-guardian of the estate of an incapacitated person. Where the vacating guardian was a parent who is now deceased, any testamentary nominee of the parent shall be given preference by the Court.
L. R. 14.N. Distribution of Principal (Estate Plan)
In all petitions brought under 20 Pa.C.S.A. § 5536(b), the Court will appoint a guardian ad litem to represent the interests of the incapacitated person at the hearing on the petition.
Alternate: In all petitions brought under 20 Pa.C.S.A. § 5536(b), petitioner shall (1) request the Court to appoint a guardian ad litem to represent the interests of the incapacitated person in the proceedings, or (2) assert facts and circumstances as to why such guardian need not be appointed.
L. R. 14.O. Testamentary Writings
All testamentary writings of the incapacitated person found by the guardian, or in the possession of any other person, shall, at the time of the filing of the inventory, be filed with the Clerk of the Orphans' Court and sealed, not to be opened without Order of Court.
L. R. 14.P. Accounts and Distribution
The practice and procedure with respect to the filing and audit of accounts, as well as the distribution of the assets comprising the estate, shall conform with the practice and procedure governing all other accounts.
APPENDIX A-1 Consent of Guardian of Person IN THE COURT OF COMMON PLEAS OF BEAVER COUNTY,
PENNSYLVANIA
ORPHANS' COURT DIVISIONIN RE: : : No. ______ of ______ _________________ ,
an Alleged Incapacitated Person:
:CONSENT OF THE PROPOSED GUARDIAN OF THE PERSON I, ______ , do hereby consent to be appointed as the Guardian of the Person of ______ , an alleged Incapacitated Person, if so appointed by the Court.
I understand that if I am appointed as Guardian, I will be serving for the benefit of ______ , an alleged Incapacitated Person, and I affirm that I will act in the best interests at all times of the alleged Incapacitated Person.
I further understand that if I am appointed as Guardian, I will be required to report to the Orphans' Court Division on my ward's personal affairs on at least an annual basis.
Dated: ______ _________________
Proposed GuardianAPPENDIX A-2 Consent of Guardian of Estate IN THE COURT OF COMMON PLEAS OF BEAVER COUNTY,
PENNSYLVANIA
ORPHANS' COURT DIVISIONIN RE: : : No. ______ of ______ _________________ ,
an Alleged Incapacitated Person:
:CONSENT OF THE PROPOSED GUARDIAN OF THE ESTATE I, ______ , do hereby consent to be appointed as the Guardian of the Estate of ______ , an alleged Incapacitated Person, if so appointed by the Court.
I understand that if I am appointed as Guardian, I will be serving for the benefit of ______ , an alleged Incapacitated Person, and I affirm that I will act in the best interests at all times of the alleged Incapacitated Person.
I further understand that if I am appointed as Guardian of the Estate, I am accepting fiduciary responsibility for the financial affairs of ______ , an alleged Incapacitated Person, and will be required to report to the Orphans' Court Division with regard to these financial affairs at least on an annual basis.
Dated: ______ _________________
Proposed GuardianAPPENDIX B Preliminary Order Awarding a Citation for Permanent Guardianship Under Rule 14.2(a) IN THE COURT OF COMMON PLEAS OF BEAVER COUNTY,
PENNSYLVANIA
ORPHANS' COURT DIVISIONIN RE: : : No. ______ of ______ _________________ ,
an Alleged Incapacitated Person:
:PRELIMINARY ORDER OF COURT (Non-Emergency Guardian) AND NOW, this _____ day of ______ , 20 ____ , the foregoing Petition having been presented in Open Court, and upon consideration thereof, and upon motion of ______ , Esquire, counsel for the Petitioner, IT IS ORDERED AND DECREED that a Citation be awarded directed to ______ . This Petition seeks to have ______ adjudged an Incapacitated Person and to have a Plenary/Limited Guardian of his/her person and estate appointed, returnable the ____ day of ______ , 20 ____ , at _____ o'clock ____ .M. prevailing time, at which time and place a hearing on the Petition for Appointment of a Plenary/Limited Guardian of the Person and of the Estate of the alleged Incapacitated Person will be held in Court Room No. ____ , Beaver County Court House, Beaver, Pennsylvania.
At least twenty (20) days' written notice of the hearing shall be given to ______ , the alleged Incapacitated Person, by serving him/her personally with a Citation and this Order of Court and a copy of the foregoing Petition, together with an explanation of the content and terms of the Petition. At least twenty (20) days' written notice of the Petition and hearing shall also be given to the next of kin and other parties in interest named in the Petition either personally or by registered or certified mail.
BY THE COURT:
_________________
J.APPENDIX C Important Notice to Alleged Incapacitated Person under Rule 14.2(b) IN THE COURT OF COMMON PLEAS OF BEAVER COUNTY,
PENNSYLVANIA
ORPHANS' COURT DIVISIONIN RE: : : No. ______ of ______ _________________ ,
an Alleged Incapacitated Person:
:IMPORTANT NOTICE TO: _________________ , an Alleged Incapacitated Person:
A PETITION HAS BEEN FILED BY ______ WITH THE ORPHANS' COURT DIVISION SEEKING TO HAVE YOU DECLARED AN INCAPACITATED PERSON AND A GUARDIAN APPOINTED FOR YOU. A HEARING ON THIS PETITION HAS BEEN SCHEDULED FOR THE ______ DAY OF ______ , 20 ______ , AT ______ O'CLOCK ______ .M., PREVAILING TIME IN COURT ROOM NO. ______ , BEAVER COUNTY COURT HOUSE, BEAVER, PENNSYLVANIA.
IF, AFTER THE HEARING, THE COURT GRANTS THIS PETITION, YOU MAY LOSE THE RIGHT TO MANAGE YOUR OWN FINANCIAL RESOURCES AND TO MAKE DECISIONS CONCERNING YOUR PHYSICAL HEALTH AND SAFETY, WHERE YOU LIVE OR OTHER RIGHTS IMPORTANT TO YOU.
YOU HAVE THE RIGHT TO ATTEND THE HEARING AND TO HAVE A LAWYER REPRESENT YOU. IF THE COURT DETERMINES THAT YOU CANNOT AFFORD A LAWYER, YOU HAVE THE RIGHT TO REQUEST THAT THE COURT APPOINT A LAWYER TO REPRESENT YOU AT NO COST TO YOU. YOU ALSO HAVE THE RIGHT TO REQUEST THAT THE COURT ORDER THAT AN INDEPENDENT EVALUATION BE CONDUCTED AS TO YOUR ALLEGED INCAPACITY. ADDITIONALLY, YOU HAVE ALL THE RIGHTS SET FORTH IN THE PROBATE, ESTATES AND FIDUCIARIES CODE AT 20 PENNSYLVANIA CONSOLIDATED STATUTES, SECTION 5101, WHICH GOVERNS GUARDIANSHIP PROCEEDINGS.
APPENDIX D Notification of Retention or Lack of Counsel Under Rule 14.3(b) (Date of Letter)
The Honorable ______
Court of Common Pleas of Beaver County
Orphans' Court Division
Beaver County Court House
Beaver, PA 15009Re: _________________
an Alleged Incapacitated Person
Docket No. _____ of _____
Date of Hearing: ______Dear Judge ______ :
With regard to the above captioned matter and in accordance with Beaver County Local Orphans' Court Rule 14.3(b), this letter is to inform you that to the best of my knowledge, information and belief, ______ is not presently represented by counsel in his/her own right in regard to the above referenced proceedings.
OR With regard to the above captioned matter and in accordance with Beaver County Local Orphans' Court Rule 14.3(b), this letter is to inform you that to the best of my knowledge, information and belief, ______ is presently represented by counsel in his/her own right in regard to the above referenced proceedings. An appearance has been entered on his/her behalf by ______ whose address is ______ and whose telephone number is ______ .
Very truly yours,
_________________
Attorney for PetitionerAPPENDIX E-1 Final Order Appointing Permanent Plenary Guardian Under Rule 14.5 (b) IN THE COURT OF COMMON PLEAS OF BEAVER COUNTY,
PENNSYLVANIA
ORPHANS' COURT DIVISIONIN RE: : : No. ______ of ______ _________________ ,
an Alleged Incapacitated Person:
:ORDER OF COURT DETERMINING INCAPACITY
AND APPOINTING PERMANENT PLENARY
GUARDIAN OF PERSON AND/OR ESTATEAND NOW, this ______ day of ______ , 20 ____ , a hearing in this case having been held on _____ , 20 ____ , and it appearing to the Court that ______ was served with a Notice of this hearing on ______ , 20 ____ , and was present at the hearing (or) the Court finds that the physical or mental condition of ______ would be harmed by his/her presence at the hearing, and further finds from the testimony as follows:
1. That ______ suffers from ______ , a condition or disability which totally impairs his/her capacity to receive and evaluate information effectively and to make and communicate decisions concerning his/her management of financial affairs or to meet essential requirements for his/her physical health and safety.
2. That there are insufficient supports available to assist ______ in overcoming such limitations and that there exists no less restrictive alternative mechanism for decision making than the appointment of a Plenary Guardian.
3. That based on the total incapacity of ______ to receive and evaluate information effectively and to make or communicate decisions, a Plenary Guardian of the Person and a Plenary Guardian of the Estate are required on a permanent basis.
NOW THEREFORE, based on the clear and convincing evidence supporting the foregoing findings, IT IS HEREBY ORDERED, ADJUDGED AND DECREED that ______ be and hereby is adjudged a totally incapacitated person.
______ is appointed Permanent Plenary Guardian of the Person of ______ and ______ is appointed Permanent Plenary Guardian of the Estate of ______ .
The Permanent Plenary Guardian of the Person shall have authority to consent to the general care, maintenance and custody of ______ without exception.
The Permanent Plenary Guardian of the Person shall assure that ______ receives appropriate services and shall assist him/her in developing self-reliance and independence.
The Permanent Plenary Guardian of the Estate shall have the authority to marshal all of ______ 's income and assets, pay his/her bills and manage his/her financial affairs as fully as ______ could do so himself/herself if he/she had not been adjudged incapacitated.
If there is a safe deposit box in the name of the Incapacitated Person alone or in the names of the Incapacitated Person and another or others, said safe deposit box shall not be entered by the Guardian except in the presence of a representative of the financial institution where the box is located or in the presence of a representative of the Orphans' Court Division. The representative present at the time of entry shall make or cause to be made a record of the Incapacitated Person's property, and said record shall be filed with the Clerk of the Orphans' Court Division. None of the Incapacitated Person's property may be removed until after the aforesaid inventory is completed.
If the safe deposit box is jointly owned, five (5) days' notice of the proposed entry shall be given to the other owners by the Guardian.
An Inventory must be filed within ninety (90) days. A report by the Guardian of the Person and Estate shall be filed within ______ days and annually thereafter in a form approved by the Orphans' Court Division.
Within sixty (60) days of the death of the Incapacitated Person or an adjudication of capacity and modification of existing orders, the Guardian of the Estate shall file a final report with the Court in the form prescribed for accounts and shall cover the period from the date of the appointment of the Guardian of the Estate to the date of death of the Incapacitated Person or the adjudication of capacity.
A surety bond in the amount of $ ______ shall be presented for approval by the Guardian of the Estate within five (5) days of the date of this Order.
______ , an Incapacitated Person, has the right to appeal this Order of Court by filing exceptions with the Clerk of the Orphans' Court Division within twenty (20) days of the date of this Order or by filing an appeal with the Prothonotary's Office of the Superior Court of Pennsylvania within thirty (30) days of the date of this Order or to petition this Court for a hearing to review or terminate the adjudication of incapacity and guardianship herein established.
If ______ was not present at the hearing on the adjudication of his/her incapacity and the appointment of a Guardian, then Petitioner shall serve upon, and read to ______ , the Statement of Rights attached to this Order of Court and marked as Exhibit A. Proof of service of the Statement of Rights shall be filed by the Guardian with the Clerk of the Orphans' Court within ten (10) days of the date of this Order.
COURT:
_________________
J.APPENDIX E-2 Final Order Appointing Permanent Limited Guardian Under Rule 14.5 (b) IN THE COURT OF COMMON PLEAS OF BEAVER COUNTY,
PENNSYLVANIA
ORPHANS' COURT DIVISIONIN RE: : : No. ______ of ______ _________________ ,
an Alleged Incapacitated Person:
:ORDER OF COURT DETERMINING PARTIAL
INCAPACITY AND APPOINTING LIMITED PERMANENT
GUARDIAN OF PERSON AND/OR ESTATEAND NOW, this _____ day of ____ , 20 ____ , a hearing in this case having been held on ______ , 20 ____ , and it appearing to the Court that ______ was served with a Citation and Notice of the hearing on _____ , 20 ____ , and was present at the hearing (or) the Court finds that the physical or mental condition of ______ would be harmed by his/her presence at the hearing, and further finds from the testimony as follows:
1. That ______ suffers from ______ , a condition or disability which partially impairs his/her capacity to receive and evaluate information effectively and to make and communicate decisions concerning his/her health and safety.
2. That there are insufficient supports available to assist ______ in overcoming such limitations and that there exists no less restrictive alternative mechanism for decision making than the appointment of a Limited Guardian.
3. That based on the partial incapacity of ______ , to receive and evaluate information effectively and to make or communicate decisions, a Limited Guardian of the Person and a Limited Guardian of the Estate are required on a permanent basis.
NOW THEREFORE, based on the clear and convincing evidence supporting the foregoing findings, IT IS HEREBY ORDERED, ADJUDGED AND DECREED that ______ be and hereby is adjudged a partially Incapacitated Person.
______ is appointed Limited Permanent Guardian of the Person of ______ and ______ is appointed Limited Permanent Guardian of the Estate of ______ .
The Limited Permanent Guardian of the Person shall have authority to consent to the general care, maintenance and custody of ______ with the exception of: _________________ .
The Limited Guardian of the Person shall assure that ______ receives appropriate services and shall assist him/her in developing self-reliance and independence.
The Limited Guardian of the Estate shall have the authority to marshal all of ______ 's income and assets except that ______ , the Incapacitated Person, shall retain the following power and authority to act on his/her own behalf: _________________ .
If there is a safe deposit box in the name of the Incapacitated Person alone, or in the names of the Incapacitated Person and another or others, said safe deposit box shall not be entered by the Guardian except in the presence of a representative of the financial institution where the box is located or in the presence of a representative of the Orphans' Court Division. The representative present at the time of entry shall make, or cause to be made, a record of the Incapacitated Person's property, and said record shall be filed with the Clerk of the Orphans' Court Division. None of the Incapacitated Person's property may be removed until after the aforesaid inventory is completed.
If the safe deposit box is jointly owned, five (5) days' notice of the proposed entry shall be given to the other owners by the Guardian.
An Inventory must be filed within ninety (90) days. A report by the Guardian of the Person and Estate shall be filed within ______ days and annually thereafter in a form approved by the Orphans' Court Division.
Within sixty (60) days of the death of the Incapacitated Person or an adjudication of capacity and modification of existing orders, the Guardian of the Estate shall file a final accounting.
A surety bond in the amount of $ ______ shall be presented for approval by the Guardian of the Estate within five (5) days of the date of this Order.
______ , an Incapacitated Person, has the right to appeal this Order of Court by filing exceptions with the Clerk of the Orphans' Court Division within twenty (20) days of the date of this Order or by filing an appeal with the Prothonotary's Office of the Superior Court of Pennsylvania within thirty (30) days of the date of this Order or to petition this Court for a hearing to review or terminate the adjudication of incapacity and guardianship herein established.
If ______ was not present at the hearing on the adjudication of his/her incapacity and the appointment of a Guardian, then Petitioner shall serve upon, and read to ______ , the Statement of Rights attached to this Order of Court and marked as Exhibit A. Proof of service of the Statement of Rights shall be filed by the Guardian with the Clerk of the Orphans' Court within ten (10) days of the date of this Order.
BY THE COURT:
_________________
J.APPENDIX F Statement of Rights STATEMENT OF RIGHTS AN ORDER HAS BEEN ENTERED BY A JUDGE OF THE COURT OF COMMON PLEAS OF BEAVER COUNTY, ORPHANS' COURT DIVISION, WHEREBY YOU HAVE BEEN ADJUDICATED AN INCAPACITATED PERSON AND UNABLE TO CARE FOR YOURSELF AND/OR MANAGE YOUR PERSONAL AFFAIRS. YOU HAVE THE RIGHT TO FILE EXCEPTIONS WITHIN TWENTY (20) DAYS OF THE DATE OF THE COURT'S ORDER WITH THE ORPHANS' COURT OR THE RIGHT TO FILE AN APPEAL WITHIN THIRTY (30) DAYS OF THE DATE OF THE COURT'S ORDER WITH THE SUPERIOR COURT OF PENNSYLVANIA. IN THE EVENT THAT YOU FILE EXCEPTIONS AND THEY ARE DENIED, YOU HAVE A RIGHT TO FILE AN APPEAL TO THE SUPERIOR COURT OF PENNSYLVANIA WITHIN THIRTY (30) DAYS OF THE DATE OF THE DENIAL OF THE EXCEPTIONS.
IN ADDITION, YOU MAY PETITION THE COURT AT ANY FUTURE TIME TO MODIFY OR TO TERMINATE THE GUARDIANSHIP IF THERE IS A CHANGE IN YOUR CAPACITY OR IF YOUR GUARDIAN FAILS TO PERFORM HIS/HER DUTIES IN ACCORDANCE WITH THE COURT'S ORDER.
IF YOU WISH TO APPEAL THE ORDER OR TO PETITION THE COURT TO MODIFY OR TERMINATE THE GUARDIANSHIP, YOU ARE ENTITLED TO BE REPRESENTED BY AN ATTORNEY. IF YOU DO NOT HAVE AN ATTORNEY, THE COURT MAY APPOINT ONE TO REPRESENT YOU. IF YOU CANNOT AFFORD AN ATTORNEY, THE SERVICES OF AN ATTORNEY WHOM THE COURT MAY APPOINT FOR YOU WILL BE PROVIDED AT NO COST TO YOU.2
APPENDIX G Notification of Mental Health Commitment State Police Gun Control Notification: See Form ''Notification of Mental Health Commitment'' from the Commonwealth of Pennsylvania.
[Continued on next Web Page]
[Continued from previous Web Page] APPENDIX H Preliminary Order Awarding a Citation for Emergency and Permanent Guardian Under Rule 14.2(a) and 14.6(a) IN THE COURT OF COMMON PLEAS OF BEAVER COUNTY,
PENNSYLVANIA
ORPHANS' COURT DIVISIONIN RE: : : No. ______ of ______ _________________ ,
an Alleged Incapacitated Person:
:PRELIMINARY ORDER OF COURT
(Emergency and Permanent Guardian)AND NOW, this _____ day of ______ , 20 ____ , the foregoing Petition having been presented in Open Court, upon consideration thereof and on motion of ______ , counsel for Petitioner, IT IS HEREBY ORDERED AND DECREED that a Citation be awarded, directed to ______ . This Petition seeks to have ______ adjudged an Incapacitated Person and to have a Plenary/Limited Guardian of his/her Person and Estate appointed. The Citation shall be returnable and an emergency and permanent hearing on the Petition, and any answer thereto, shall be held on the following dates and times:
Emergency Guardianship Permanent Guardianship Return Date: Return date: Hearing Date: Hearing Date: Hearing Time: Hearing Time: Courtroom No. Courtroom No. The alleged Incapacitated Person shall be given notice of the hearing on appointment of an Emergency Guardian of his/her Person and Estate by serving him/her personally with the Citation, this Order of Court and a copy of the foregoing Petition prior to the time of such emergency hearing.
OR
The Court finds that service of notice of the hearing on appointment of an Emergency Guardian upon the alleged Incapacitated Person is not feasible under the circumstances and is, therefore, waived pursuant to 20 Pa.C.S.A. § 5513.
Any Answer or other response to the Petition shall be filed at the Office of the Register of Wills of Beaver County sitting as Clerk of the Orphans' Court, Beaver County Court House, Beaver, Pennsylvania 15009. Hearing shall be held in Court Room No. _____ , Beaver County Court House, Beaver, Pennsylvania.
The Court finds that strict compliance with 20 Pa.C.S.A. § 5511(e) and Rule 14.1 of the Beaver County Orphans' Court Division Rules (both relating to contents of the Petition) are not feasible under the circumstances and are waived for the purpose of the hearing on appointment of an Emergency Guardian of the alleged Incapacitated Person.
The Court further finds that strict compliance with 20 Pa.C.S.A. § 5511(a) (relating to notification concerning the right to counsel and the appointment of counsel for the alleged Incapacitated Person) are not feasible under the circumstances and are waived for the purpose of the hearing on appointment of an Emergency Guardian of the alleged Incapacitated Person.
At least twenty (20) days' written notice of the hearing on appointment of a Permanent Guardian shall be given to ______ , the alleged Incapacitated Person, by serving him/her personally with a copy of the Petition, the Citation and this Order of Court, together with an explanation of their contents. At least twenty (20) days' written notice of the petition and hearing on the appointment of a Permanent Guardian shall be given to the next of kin and other parties in interest in the petition, either personally or by registered or certified mail.
BY THE COURT:
_________________
J.APPENDIX I-1 Order Appointing Emergency Plenary Guardian Under Rule 14.6(d) IN THE COURT OF COMMON PLEAS OF BEAVER COUNTY,
PENNSYLVANIA
ORPHANS' COURT DIVISIONIN RE: : : No. ______ of ______ _________________ ,
an Alleged Incapacitated Person:
:ORDER OF COURT DETERMINING INCAPACITY
AND APPOINTING EMERGENCY PLENARY
GUARDIAN OF PERSON AND/OR ESTATEAND NOW, this _____ day of _____ , 20 ____ , a hearing in this case having been held on ______ , 20 ____ , and it appearing to the Court that ______ was served with a Notice of this hearing on _____ , 20 ____ , and was present at the hearing (or) the Court finds that the physical or mental condition of ______ would be harmed by his/her presence at the hearing, and further finds from the testimony as follows:
1. That ______ suffers from ______ , a condition or disability which totally impairs his/her capacity to receive and evaluate information effectively and to make and communicate decisions concerning his/her management of financial affairs or to meet essential requirements for his/her physical health and safety.
2. That there are insufficient supports available to assist ______ in overcoming such limitations and that there exists no less restrictive alternative mechanism for decision making than the appointment of an Emergency Plenary Guardian.
3. That based on the total incapacity of ______ , to receive and evaluate information effectively and to make or communicate decisions, a Plenary Guardian of the Person and a Plenary Guardian of the Estate are required on an emergency basis.
NOW THEREFORE, based on the clear and convincing evidence supporting the foregoing findings, IT IS HEREBY ORDERED, ADJUDGED AND DECREED that ______ be and hereby is adjudged a totally Incapacitated Person.
______ is appointed Emergency Plenary Guardian of the Person of ______ and ______ is appointed Emergency Plenary Guardian of the Estate of ______ .
The Emergency Plenary Guardian of the Person shall have authority to consent to the general care, maintenance and custody of ______ without exception.
The Emergency Plenary Guardian of the Person shall assure that ______ receives appropriate services and shall assist him/her in developing self-reliance and independence.
The Emergency Plenary Guardian of the Estate shall have the authority to marshal all of ______ 's income and assets, pay his/her bills and manage his/her financial affairs as fully as ______ could do so himself/herself if he/she had not been adjudged incapacitated.
If there is a safe deposit box in the name of the Incapacitated Person alone or in the names of the Incapacitated Person and another or others, said safe deposit box shall not be entered by the Guardian except in the presence of a representative of the financial institution where the box is located or in the presence of a representative of the Orphans' Court Division. The representative present at the time of entry shall make or cause to be made a record of the Incapacitated Person's property, and said record shall be filed with the Clerk of the Orphans' Court Division. None of the Incapacitated Person's property may be removed until after the aforesaid inventory is completed.
If the safe deposit box is jointly owned, five (5) days' notice of the proposed entry shall be given to the other owners by the Guardian.
The appointment of the Emergency Plenary Guardian of the Person and Estate shall remain in effect until further Order of Court.
NO BOND REQUIRED ON EMERGENCY PLENARY GUARDIAN APPOINTMENT.
______ , an Incapacitated Person, has the right to appeal this Order of Court by filing exceptions with the Clerk of the Orphans' Court Division within twenty (20) days of the date of this Order or by filing an appeal with the Prothonotary's Office of the Superior Court of Pennsylvania within thirty (30) days of the date of this Order or to petition this Court for a hearing to review or terminate the adjudication of incapacity and guardianship herein established.
If ______ was not present at the hearing on the adjudication of his/her incapacity and the appointment of a Guardian, then Petitioner shall serve upon, and read to ______ , the Statement of Rights attached to this Order of Court and marked as Exhibit A. Proof of service of the Statement of Rights shall be filed by the Guardian with the Clerk of the Orphans' Court within ten (10) days of the date of this Order.
BY THE COURT:
_________________
J.APPENDIX I-2 Order Appointing Emergency Limited Guardian Under Rule 14.6(d) IN THE COURT OF COMMON PLEAS OF BEAVER COUNTY,
PENNSYLVANIA
ORPHANS' COURT DIVISIONIN RE: : : No. ______ of ______ _________________ ,
an Alleged Incapacitated Person:
:ORDER OF COURT DETERMINING INCAPACITY
AND APPOINTING EMERGENCY LIMITED
GUARDIAN OF PERSON AND/OR ESTATEAND NOW, this _____ day of ______ , 20 ____ , a hearing in this case having been held on ______ , 20 ____ , and it appearing to the Court that ______ was served with a Notice of this hearing on ______ , 20 ____ , and was present at the hearing (or) the Court finds that the physical or mental condition of ______ would be harmed by his/her presence at the hearing and further finds from the testimony as follows:
1. That ______ suffers from ______ , a condition or disability which partially impairs his/her capacity to receive and evaluate information effectively and to make and communicate decisions concerning his/her management of financial affairs or to meet essential requirements for his/her physical health and safety.
2. That there are insufficient supports available to assist ______ in overcoming such limitations and that there exists no less restrictive alternative mechanism for decision making than the appointment of a Limited Guardian.
3. That based on the partial incapacity of ______ to receive and evaluate information effectively and to make or communicate decisions, a Limited Guardian of the Person and Limited Guardian of the Estate are required on an emergency basis.
NOW THEREFORE, based on the clear and convincing evidence supporting the foregoing findings, IT IS HEREBY ORDERED, ADJUDGED AND DECREED that ______ be and hereby is adjudged a Partially Incapacitated Person.
______ is appointed Emergency Limited Guardian of the Person of ______ and ______ is appointed Emergency Limited Guardian of the Estate of ______ .
The Emergency Limited Guardian of the Person shall have authority to consent to the general care, maintenance and custody of ______ with the exception of: _________________ .
The Emergency Limited Guardian of the Person shall assure that ______ receives appropriate services and shall assist him/her in developing self-reliance and independence.
The Emergency Limited Guardian of the Estate shall have the authority to marshal all of ______ 's income and assets except that ______ , the Incapacitated Person, shall retain the following power and authority to act on his/her own behalf: _____________________________________ .
If there is a safe deposit box in the name of the Incapacitated Person alone or in the names of the Incapacitated Person and another or others, said safe deposit box shall not be entered by the Guardian except in the presence of a representative of the financial institution where the box is located or in the presence of a representative of the Orphans' Court Division. The representative present at the time of entry shall make or cause to be made a record of the Incapacitated Person's property, and said record shall be filed with the Clerk of the Orphans' Court Division. None of the Incapacitated Person's property may be removed until after the aforesaid inventory is completed.
If the safe deposit box is jointly owned, five (5) days' notice of the proposed entry shall be given to the other owners by the Guardian.
NO BOND REQUIRED ON EMERGENCY LIMITED GUARDIAN APPOINTMENT.
______ , an Incapacitated Person, has the right to appeal this Order of Court by filing exceptions with the Clerk of the Orphans' Court Division within twenty (20) days of the date of this Order or by filing an appeal with the Prothonotary's Office of the Superior Court of Pennsylvania within thirty (30) days of the date of this Order or to petition this Court for a hearing to review or terminate the adjudication of incapacity and guardianship herein established.
If ______ was not represent at the hearing on the adjudication of his/her incapacity and the appointment of a Guardian, then Petitioner shall serve upon, and read to ______ the Statement of Rights attached to this Order of Court and marked as Exhibit A. Proof of service of the Statement of Rights shall be filed by the Guardian with the Clerk of the Orphans' Court within ten (10) days of the date of this Order.
BY THE COURT:
_________________
J.APPENDIX J Guardian of the Estate Annual Report IN THE COURT OF COMMON PLEAS OF BEAVER COUNTY,
PENNSYLVANIA
ORPHANS' COURT DIVISIONIN RE: : : No. ______ of ______ _________________ ,
an Incapacitated Person:
:GUARDIAN OF THE ESTATE ANNUAL REPORT FROM ______ , 20 ____, to ______ , 20 ____ .
1. I am the _____ Limited _____ Plenary Guardian of the Estate of my ward, named above. I was appointed Guardian by the Order of the Court dated ______ , 20 ____ , which was _____ was not _____ modified by Court Order(s) dated _________________ .
2. If the Incapacitated Person still living? _____
If no, answer the following:
a. Date of Death: ______
b. Place of Death: _________________
c. Name of Administrator or Executor: ______
___________________________d. Date Guardian of the Estate filed the last Annual Report:
___________________________PLEASE ANSWER THE FOLLOWING QUESTIONS WHETHER THE INCAPACITATED PERSON IS LIVING OR DECEASED:
3. My initial inventory was filed on ______ , 20 ____ , and listed a total estate value of $ ______ . The inventory listed a total monthly income of $ ______ comprised of the following:
_____________________________________
_____________________________________
_____________________________________4. At the beginning date of this reporting period, my initial balance on hand was $ ______ .
5. During this reporting period, the following reflects all sources of income (other than social security) received by me for my ward: (add additional pages, if needed)
Date Received Source of Income Amount (1) ______ _________________ $ ______ (2) ______ _________________ $ ______ (3) ______ _________________ $ ______ (4) ______ _________________ $ ______ (5) ______ _________________ $ ______ (6) ______ _________________ $ ______ TOTAL: $ ______ 6. During this reporting period, the following reflects all payments I have made for my ward: (add additional pages, if needed)
Date To Whom Paid Reason for Pmt. Amount (1) ______ _________________ ______ $ ______ (2) ______ _________________ ______ $ ______ (3) ______ _________________ ______ $ ______ (4) ______ _________________ ______ $ ______ (5) ______ _________________ ______ $ ______ (6) ______ _________________ ______ $ ______ TOTAL: $ ______ 7. The present principal assets of my ward are:
Description of Asset Present Value (1) _________________ $ ______ (2) _________________ $ ______ (3) _________________ $ ______ (4) _________________ $ ______ (5) _________________ $ ______ (6) _________________ $ ______ TOTAL: $ ______ 8. The present amount and sources of income for my ward are:
Sources of Income Amount (1) _________________ $ ______ (2) _________________ $ ______ (3) _________________ $ ______ (4) _________________ $ ______ (5) _________________ $ ______ (6) _________________ $ ______ TOTAL: $ ______ 9. The regular monthly expenses of my ward which I pay are:
To Whom Paid Amount (1) _________________ $ ______ (2) _________________ $ ______ (3) _________________ $ ______ (4) _________________ $ ______ (5) _________________ $ ______ (6) _________________ $ ______ TOTAL: $ ______ 10. I have/have not (circle one) petitioned the Court for permission to invade principal to meet the needs of my ward.
(If applicable) The following expenses of my ward have not been paid from principal:
To Whom Paid Purpose Amount (1) ______ _________________ $ ______ (2) ______ _________________ $ ______ (3) ______ _________________ $ ______ (4) ______ _________________ $ ______ (5) ______ _________________ $ ______ (6) ______ _________________ $ ______ TOTAL: $ ______ 11. I have/have not (circle one) paid myself compensation for services I rendered as guardian.
The amount I paid myself totaled $ ______ and was calculated at the following rate: $ ______ per week/month (circle one).
12. Circle the correct response and complete, if applicable.
There will be no need for extraordinary expenditures on behalf of my ward in the next twelve (12) months.
There will be a need for extraordinary expenditures on behalf of my ward in the next twelve (12) months because:
_______________________________________________
_______________________________________________ .13. Circle the correct response and complete, if appropriate.
a. My ward receives monthly social security benefits.
b. I am the designated payee to receive my ward's social security benefits.
c. The designated payee of my ward's social security benefits is:
_________________ , whose address is
___________________________
and is/is not (circle one) related to my ward as ______
_________________ (insert relationship).14. Please note any concerns about the Incapacitated Person's physical or mental well being or the finances that the Court should know.
_______________________________________________
_______________________________________________15. I am _____ /am not _____ Guardian of the Incapacitated Person's person. If yes, my report is attached.
I certify under penalties of perjury that the information contained in this report is true and correct to the best of my knowledge, information and belief.
Date: ______ _________________
Signature of Guardian of the EstateName: _________________
Address: _________________
_________________
Phone: Home-- _________________
Work-- _________________
APPENDIX K Guardian of the Person Annual Report IN THE COURT OF COMMON PLEAS OF BEAVER COUNTY,
PENNSYLVANIA
ORPHANS' COURT DIVISIONIN RE: : : No. ______ of ______ _________________ ,
an Incapacitated Person:
:GUARDIAN OF THE PERSON ANNUAL REPORT 1. Current address of the Incapacitated Person:
_______________________________________________
_______________________________________________
2. Describe the type of placement and living arrangements of the Incapacitated Person, e.g., private residence, personal care of nursing home, institution, hospital, etc.
_______________________________________________
_______________________________________________
3. Briefly describe the Incapacitated Person's medical care and any social, psychological or other support services he/she receives.
_______________________________________________
_______________________________________________
4. As Guardian of the Person, do you think the guardianship of the Person should continue, be terminated or
modified? _________________Reason:
_______________________________________________
_______________________________________________
5. Number and length of times you have visited the Incapacitated Person since your appointment or last report.
Date Duration _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ Date: ______ _________________
Guardian's signatureGuardian's address: _________________
_________________
Daytime Telephone No. ______
RECEIVED: ______
APPROVED: ______
SIGNATURE: _________________
APPENDIX L Final Report of the Guardian of the Person Under Rule 14, Section 8(e) IN THE COURT OF COMMON PLEAS OF BEAVER COUNTY,
PENNSYLVANIA
ORPHANS' COURT DIVISIONIN RE: : : No. ______ of ______ _________________ ,
an Alleged Incapacitated Person:
:FINAL REPORT OF THE GUARDIAN OF THE PERSON 1. Reason for this Final Report is: _________________
The Incapacitated Person died on _________________ .
The adjudication of capacity has been entered by Decree of this Court dated _________________ .
2. If the Incapacitated Person died, the cause of death was: _________________.
3. The address of the Incapacitated Person as of the date of death or adjudication of capacity: ______
_______________________________________________ .4. Describe the type of facility and living arrangements that the Incapacitated Person was placed as of the date of death or adjudication of capacity:
A. Private home ______
B. Personal Care of Nursing Home ______
C. Hospital ______
D. Institution ______5. Number and length of times you visited the Incapacitated Person from the date of the last report to the date of death or adjudication of capacity:
Date Duration _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ _________________ Date: ______ _________________
Guardian's signatureGuardian's address: _________________
_________________
Daytime Telephone No. _________________RECEIVED: ______
ACCEPTED: ______
SIGNATURE: _________________
[Pa.B. Doc. No. 04-898. Filed for public inspection May 21, 2004, 9:00 a.m.]
