### 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 9Is any property (specifically bank accounts or real estate) co-owned by the Incapacitated Person and the guardian? 2. Yes No If yes: On what date was the property acquired? a. 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: Does the Incapacitated Person have a homeowners insurance policy for real property? 3. Yes(Copy of policy to be provided upon request) No 

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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. 

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

###  ̈ Y es, in sole name 

###  ̈ Y es, in joint name(s) . 

###  ̈ No Yes



###  ̈ b. Are there plans to inventory the contents? _______________________________________ Location of safe deposit box: a. If yes: 

###  ̈ No

Form G-05 (Effective January 1, 2023 ) Page 2 of 9 List the name(s) of joint owner(s):List all sources of income for the Incapacitated Person: 1. Does the Incapacitated Person receive any of the following as income? Specify Amount Y es No 

###  ̈  ̈ $ Alimony or Support Y es No 

###  ̈  ̈ $ Annuity Payments Y es No 

###  ̈  ̈ $ Dividends Y es No 

###  ̈  ̈ $ Interest Income Y es No 

###  ̈  ̈ $ IRA Distributions Y es No 

###  ̈  ̈ $ Long T erm Care Insurance Benefits Yes No 

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

###  ̈  ̈ $ Public Assistance Y es No 

###  ̈  ̈ $ Rental Property Income Y es No 

###  ̈  ̈ $ Royalties (including from mineral and land rights) Y es No 

###  ̈  ̈ $ Social Security Benefits (Retirement, Disability, SSI) Y es No 

###  ̈  ̈ $ T ax Refund Yes No 

###  ̈  ̈ $ T rust Income Yes No 

###  ̈  ̈ $ V eterans Benefits (disability/pension/aid and attendance) Yes No 

###  ̈  ̈ $ Wages Yes No 

###  ̈  ̈ $ W orker's Compensation Benefits Yes No 

###  ̈  ̈ $ Other TOTAL $ PART III: ANNUAL INCOME

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

TOTAL DEBTS: List all debts the Incapacitated Person owes, including mortgages, loans, credit card debt, etc. 1. PART IV: LIABILITIES / DEBTS

PART V: GUARDIAN COVERAGE
Yes No If yes, do you have professional liability coverage? 

###  ̈ Y es (Please attach a copy of the insurance policy) 

###  ̈ No If no, explain:
________________________________________________________ 

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

###  ̈ Y es (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 : List the name of the responsible family member: a. 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 9What is the current address of the Incapacitated Person? 3.

__________________________________________________________________________

__________________________________________________________________________

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

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

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

###  ̈ No, and assets (principal) are not available 

###  ̈ Indicate any applications for government benefits that have been submitted: 3. Application Type Date of Submission Social Security Disability Insurance (SSDI) Supplemental Security Income (SSI) Social Security Retirement Benefits V eteransBenefits Medical assistance, Long term care Medical assistance, Home Waiver Other

Form G-05 (EffectiveJanuary 1, 2023 ) Page 6 of 9 (Explain: )4. Describe all real estate included in the estate and how it will be maintained or sold:

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_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

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_______________________________________________________________________________________

_______________________________________________________________________________________

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

###  ̈ 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 9Yes

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? $ 

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