COURT OF COMMON PLEAS

_____________ COUNTY, PENNSYLVANIA

ORPHANS' COURT DIVISION

GUARDIAN'S INVENTORY FOR AN INCAPACITATED PERSON

Estate of: _________________________________________________________, an Incapacitated Person

Name of Incapacitated Person

Case File No: _____________________

DATE COURT APPOINTED YOU AS GUARDIAN: _____________________________________________________

Inventory type:

 ̈ Initial

 ̈ Amended

PART I: INTRODUCTION

1. List all bank accounts, real estate, burial accounts, and other personal property below. If the property is owned 

by both the incapacitated person and others, indicate in the last column the name of the co-owner.

Asset Value Name of Co-Owner(s)

$

$

$

$

$

$

$

$

$

$

$

$

TOTAL $

PART II: ASSETS (PRINCIPAL)

Form G-05 (Effective January 1, 2023) Page 1 of 9
Is any property (specifically bank accounts or real estate) co-owned by the Incapacitated Person and the 

guardian?

2.

Yes

No

If yes:

a. On what date was the property acquired?

b. On what date was the guardian's name added?

c. The guardian is:

________________________

________________________

an individual having access or control over the account

an owner of the account

 ̈

 ̈

 ̈

 ̈

If yes:

a. Carrier:

b. Coverage period:

3. Does the Incapacitated Person have a homeowners insurance policy for real property?

Yes(Copy of policy to be provided upon request)

 ̈ No

 ̈

If yes:

a. Carrier:

b. Coverage period:

Does the Incapacitated Person have an automobile insurance policy?

Yes(Copy of policy to be provided upon request)

No

4.

 ̈

 ̈

5. Does the Incapacitated Person have a safe deposit box?

 ̈ Yes, in sole name

 ̈ Yes, in joint name(s).

 ̈ No

 ̈ Yes

b. Are there plans to inventory the contents?

a. Location of safe deposit box: _______________________________________

If yes:

 ̈ No

Form G-05 (Effective January 1, 2023) Page 2 of 9

List the name(s) of joint owner(s): 
1. List all sources of income for the Incapacitated Person:

Does the Incapacitated Person receive any of the following as income? Specify Amount

Alimony or Support  ̈ Yes No  ̈ $

Annuity Payments  ̈ Yes No  ̈ $

Dividends  ̈ Yes No  ̈ $

Interest Income  ̈ Yes No  ̈ $

IRA Distributions  ̈ Yes No  ̈ $

Long Term Care Insurance Benefits  ̈ Yes No  ̈ $

Pension/Retirement Benefits (for example: 401(k), 403(b), etc.)  ̈ Yes No  ̈ $

Public Assistance  ̈ Yes No  ̈ $

Rental Property Income  ̈ Yes No  ̈ $

Royalties (including from mineral and land rights)  ̈ Yes No  ̈ $

Social Security Benefits (Retirement, Disability, SSI)  ̈ Yes No  ̈ $

Tax Refund  ̈ Yes No  ̈ $

Trust Income  ̈ Yes No  ̈ $

Veterans Benefits (disability/pension/aid and attendance)  ̈ Yes No  ̈ $

Wages  ̈ Yes No  ̈ $

Worker's Compensation Benefits  ̈ Yes No  ̈ $

Other  ̈ Yes No  ̈ $

TOTAL $

PART III: ANNUAL INCOME

Form G-05 (Effective January 1, 2023) Page 3 of 9
Liabilities/Debts Lender Value

TOTAL DEBTS:

1. List all debts the Incapacitated Person owes, including mortgages, loans, credit card debt, etc.

PART IV: LIABILITIES / DEBTS

PART V: GUARDIAN COVERAGE

Yes

No

If yes, do you have professional liability coverage?

 ̈ Yes (Please attach a copy of the insurance policy)

 ̈ No

If no, explain: ________________________________________________________

 ̈

 ̈

1. Was a surety bond required by the decree appointing you as guardian?

 ̈ Yes (Please attach a copy of the bond)

 ̈ No

2. Are you a professional guardianship agency or an attorney serving as a guardian?

Form G-05 (Effective January 1, 2023) Page 4 of 9

$

$

$

$

$

$

$

$
 ̈ Yes

 ̈ No

 ̈ N/A - The Incapacitated Person is already in a supervised residential setting

1. Can the Incapacitated Person remain in his or her current residence with assistance, or in the home of a relative?

PART VI: PERSONAL CARE PLAN

If yes:

a. List the name of the responsible family member:

b. What services does the Incapacitated Person require?

______________________________________________________

Services from local Area Agency on Aging

Private Companion/Assistance Service

Assistance from family members

Number of days per week: __________

Number of hours per week: __________

Will compensation be provided?

Yes

No

If yes, indicate compensation amount: 

 ̈

 ̈

 ̈

 ̈

 ̈

$

2.

 ̈ Yes

 ̈ No

 ̈ N/A - The Incapacitated Person is already in a supervised residential setting

Will the Incapacitated Person be moved into a supervised residential setting?

 ̈ Domiciliary Care

 ̈ Personal Care

 ̈ Boarding Home / Group Home

 ̈ Assisted Living Facility

 ̈ Nursing Home

 ̈ Other

If yes:

a. Indicate the type of supervised residential setting:

Describe the steps that are being taken to move the Incapacitated Person into a supervised

residential setting.

b.

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

Form G-05 (Effective January 1, 2023) Page 5 of 9
3. What is the current address of the Incapacitated Person?

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

1. Complete the following table using initial inventory or most recent amended inventory.

Total Annual Income

(Part III, Question 1)

a.

b. Annual

estimated expenses

$

$

Net Income

(a minus b) $

Total assets (principal)

(Part II, Question 1)

d.

$

c.

PART VII: FINANCIAL PLAN

2. Is the net income listed above sufficient to care for the needs of the Incapacitated Person?

 ̈ Yes

 ̈ No, but assets (principal) are available if a court order approves expenditures

 ̈ No, and assets (principal) are not available

3. Indicate any applications for government benefits that have been submitted:

Application Type Date of Submission

Social Security Disability Insurance (SSDI)

Supplemental Security Income (SSI)

Social Security Retirement Benefits

Veterans Benefits

Medical assistance, Long term care

Medical assistance, Home Waiver

Other

Form G-05 (Effective January 1, 2023) Page 6 of 9

 (Explain: )
4. Describe all real estate included in the estate and how it will be maintained or sold:

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

No

Yes

If yes, was the agent the same person as the guardian?

No

Yes

If yes, has an accounting ever been requested or filed with the Orphans' Court?

No

Yes

 ̈

 ̈

 ̈

 ̈

 ̈

 ̈

5. Prior to the appointment of a guardian, has an agent under a Power of Attorney been serving?

PART VIII: MEDICAL INFORMATION

1. Is a "no-code" (Do Not Resuscitate) provision in place for the incapacitated person?

 ̈ Yes

 ̈ No

2.

 ̈ Yes

 ̈ No

If yes, identify the authorized agent for making health care decisions:

_____________________________________________________________________________

When still capacitated, did the Incapacitated Person execute a durable power of attorney for health care or

some other health care directive (including, but not limited to, a POLST, a living will, or a mental health care

power of attorney)?

Form G-05 (Effective January 1, 2023) Page 7 of 9
Yes

No

If yes, please explain:

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

 ̈

 ̈

3. Are you aware of any will or trust executed by the Incapacitated Person, or any funeral or burial wishes of

the Incapacitated Person?

Has a burial account been established for the Incapacitated Person?

No

Yes

If yes, what is the value of the burial account? $

 ̈

 ̈

Form G-05 (Effective January 1, 2023) Page 8 of 9
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.

I further acknowledge the Notice of Filing must be served within 10 days of the filing of this report pursuant 

to Pa.R.O.C.P. 14.8(b). Service shall be in accordance with Pa.R.O.C.P. 4.3.

Date Signature of Guardian of the Estate

Name of Guardian of the Estate (type or print)

Address

City, State, Zip

Home Phone Number

Office Phone Number

Cell Phone Number

Email

Date Signature of Co-Guardian of the Estate (if applicable)

Name of Co-Guardian of the Estate (type or print)

Address

City, State, Zip

Home Phone Number

Office Phone Number

Cell Phone Number

Form G-05 (Effective January 1, 2023) Page 9 of 9

Email