Pennsylvania Code › Title 204 - JUDICIAL SYSTEM GENERAL PROVISIONS › Part II - GENERAL ADMINISTRATION › Chapter 29 - MISCELLANEOUS PROVISIONS › Subchapter B - ALLEGED INCOMPETENT SPECIAL MASTERS › Appendix A

Current through Register Vol. 54, No. 28, July 13, 2024
IN THE MATTER OF
:
IN THE COURT OF COMMON
PLEAS OF
_____________________
:
COUNTY, PENNSYLVANIA
(name)
ORPHANS' COURT DIVISION
An Alleged Incompetent
:
No.
19
PETITION FOR APPOINTMENT OF GUARDIAN
The petition of
					 ______________________________________Superintendent of
					 ______________________________________ , respectfully represents:
1. Your Petitioner has custody of the alleged incompetent
					 at ______ .
2. The alleged incompetent was admitted to the aforesaid
					 institution on
_______________________________________________________.
3. The alleged incompetent is domiciled
					 at_______________________
					 _______________________________________________________.
4. The alleged incompetent is_____ years of age, having
					 been born on_____ .
5. The alleged incompetent's military status is:____
_______________________________________________________
___________________________________________________.
6. The alleged incompetent's marital status
					 is_____________________
_______________________________________________________
_______________________________________________________.
7. Those persons, if any, who are the alleged incompetent's
					 next of kin and their relationship to same, of whom your Petitioner has
					 knowledge are as follows:
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________.
8. No other Court within this Commonwealth of which
					 Petitioner has knowledge has appointed a guardian for the alleged
					 incompetent.
9. The alleged incompetent has income consisting of:
(a) Money due from
					 _____________________________________________in the amount of $__________ per
					 __________ .
(b) Money due from ________________________________________
					 ___________in the amount of $ __________ per _________ .
______________________________________________________________________
______________________________________________________________________
10. The alleged incompetent has assets, real and personal,
					 of which the Petitioner is aware, in the amount of $ __________ consisting
					 of:
(a) _______________________held by the Guardian Officer of
					 _________________in the amount of $ __________________ as of
					 ___________.
(b) "Vecchione Refund" monies in the amount of $
					 ____________ , title to which is in dispute.
(c)
					 _______________________________________________________
_________________.
11. The alleged incompetent has debts outstanding in the
					 amount of $ _______, as of _________________________, consisting of:
(a) $ ___________owing to the Commonwealth of Pennsylvania
					 as payment for care and maintenance received from the
					 period______________
19 _____ to _____ , _______ , in accordance with
					 50
					 P. S. §§
											4501 and
					 4504 and regulations
					 promulgated thereunder.
(b) $ __________ owing to the Commonwealth of Pennsylvania
					 as payment for care and maintenance rendered between July 11, 1974, and April
					 4, 1975, which relates to the "Vecchione Refund," title to which is in
					 dispute.
(c)
					 _______________________________________________________
_________________.
12. The alleged incompetent is incapable of handling
					 _________________
financial affairs for the reasons set forth in the attached
					 Affidavit and Competency Report, prepared
					 by_______________________________________________
______________, marked as Exhibit A and made a part
					 hereof.
13. _______________________________________________________
					 , Guardian Officer at the aforesaid institution, and his/her successors in
					 office, having no interest adverse to the alleged incompetent, has agreed to
					 act as Guardian if this Honorable Court shall so appoint. The consent of the
					 proposed Guardian to so act is attached hereto and made a part hereof as
					 Exhibit B.
14. If appointed as
					 Guardian,____________________________________ is required to act in compliance
					 with regulations promulgated under Court Order in 5
Pennsylvania
					 Bulletin
931
et seq.
(April 19, 1975).
15. In light of these provisions and in furtherance of
					 Paragraph 7 of the aforesaid regulations, Petitioner requests preference be
					 given to a bank, trust company or other individual willing to accept
					 appointment as Guardian.
Wherefore,
the Petitioner prays that a
					 citation be issued directing
___ , and those persons, if any, listed in paragraph 7 of
					 this Petition, to show cause, if any there be, why
					 _________________________________________________ should not be declared an
					 incompetent and a Guardian of the estate appointed, and why distribution of
					 assets and income as payment of debts listed in paragraph 11 should not be
					 made. Petitioner further prays that a guardian ad litem be appointed to act for
					 the alleged incompetent regarding such hearing.
BY:
					 _______________________________________________________
COMMONWEALTH OF PENNSYLVANIA
:
ss
COUNTY OF
:
__________________, Petitioner in this matter, being duly
					 sworn according to law, do depose and state that I am ___________ of
					 __________________________________________and that the facts set forth in the
					 foregoing Petition are true and correct to the best of my knowledge,
					 information and belief.
_______________________________________________________
Sworn to and Subscribed
Before me this____________
day of_________________ 19 _________
_____________________________________________
EXHIBIT "A"
COMPETENCY REPORT AFFIDAVIT
COMMONWEALTH OF PENNSYLVANIA
:
ss
COUNTY OF
:
I, ______________________________________ , being duly
					 sworn according to law, depose and say that I am
					 a____________________________________________ in the Commonwealth of
					 Pennsylvania employed at________________________________________________ , and
					 I have examined the patient,_________________ , an alleged incompetent, with
					 care and diligence and based upon said examination and observations am of the
					 opinion that said patient is incompetent to manage his/her own affairs for the
					 reasons set forth in the attached Competency Report, and that the facts and
					 opinions contained therein are true and correct to the best of my knowledge,
					 information and belief.
_______________________________________________________
Sworn to and Subscribed Before
me this___________________ day of ________________ , 19
					 ____.
EXHIBIT "B"
CONSENT OF PROPOSED GUARDIAN
I,_________________________ ,____________________________
					 of _______________________________, do hereby certify that I and my successors
					 in office are willing to act as Guardian for the estate of
					 ___________________________, an alleged incompetent, if the Court shall so
					 appoint.
Further, I do hereby certify that I am not a fiduciary of
					 any estate in which the alleged incompetent has an interest, nor have I any
					 interest adverse to the alleged incompetent.
The facts and opinions contained herein are true and
					 correct to the best of my knowledge, information, and belief.
_______________________________________________________
IN THE MATTER OF
:
IN THE COURT OF COMMON
PLEAS OF
__________________________
:
COUNTY, PENNSYLVANIA
(name)
ORPHANS' COURT DIVISION
An Alleged Incompetent
:
No. 19
PRELIMINARY ORDER OF COURT
AND NOW, this _____________ day of ____________ 19 ______ ,
					 upon consideration of the foregoing Petition, it is Ordered that a citation be
					 issued, directed to ___________________________________________________________
					 to show cause why __________________________________________should not be
					 adjudged an incomeptent, and a guardian of____________________________ estate
					 appointed; and why distribution of assets and income as payment of debts listed
					 in paragraph _______ of the within Petition should not be made.
_____________________________________________ is hereby
					 appointed Special Master for the purposes of conducting a hearing on said
					 Petition at the institutuion at
					 which_________________________________________________
__________________________________________resides, at a
					 time to be fixed by said Special Master, and to submit a Report and
					 Recommendation to this Court in a timely
					 fashion.___________________________________________ is hereby appointed by the
					 court to act as guardian ad litem for ________________________________the
					 alleged incompetent regarding this hearing.
At least twenty (20) days written notice of the hearing
					 shall be given ________to the alleged incompetent, by serving
					 ________________personally with the citation and a copy of the foregoing
					 Petition; and at least twenty (20) days written notice of the Petition and
					 hearing shall also be given to any next of kin listed in the Petition either
					 personally or by certified mail.
BY THE COURT:
_______________________________________________________
J.
IN THE MATTER OF
:
IN THE COURT OF COMMON
PLEAS OF
________________________
:
COUNTY, PENNSYLVANIA
(name)
ORPHANS' COURT DIVISION
An Alleged Incompetent
:
No.
19____
CITATION
TO:_____________________________________________
We command you to appear at a hearing in the Orphans' Court
					 of ____________, County, to be held at on____________ ,19 ______,at
					 _____________ .M., to show cause why you should not be adjudged an incompetent,
					 and a guardian appointed for your estate.
Citation Returnable the _____________ day of ____________,
					 19 _____.
WITNESSETH:
The Honorable______________________________________________
					 President Judge of said Court, sitting in the Orphans' Court this ___________
					 day of _________ ,19 _______ .
_______________________________________________________
CLERK OF THE ORPHANS' COURT DIVISION
IN THE MATTER OF
:
IN THE COURT OF COMMON
PLEAS OF
____________________
:
COUNTY, PENNSYLVANIA
(name)
ORPHANS' COURT DIVISION
An Alleged Incompetent
:
No.
19____
REPORT AND RECOMMENDATION OF THE SPECIAL MASTER AND
					 ORDER OF COURT
Upon hearing of the Petition and Citation for Appointment
					 of a guardian for __________________ , proof of notice of the said hearing to
					 _______________ next of kin having been filed, and ______________ appointed as
					 guardian
ad litem
,
the Special Master, appointed by this Honorable Court to
					 hear said Petition, finds that the said ______________________________ is so
					 mentally infirm that _________________ is likely to dissipate or lose
					 _______________________ estate and become the victim of designing persons; and
					 that the Court further finds that the entire real and personal estate of the
					 said _________________ should be handled by the Guardian designated
					 herein.
It Is Therefore Recommended that
______________________ _____________________________and his/her successors in
					 office be and are hereby authorized to receive, hold and dispose of the estate
					 of the said ________________________________ as the duly appointed guardian
					 under Court Decree, and to pay such debts as enumerated in said Petition, such
					 debts having been found to be proper and in accord with law.
The guardian, within three months after real or personal
					 estate of the incompetent comes into his possession, shall verify by oath and
					 file with the Clerk an inventory and appraisement of such personal estate, a
					 statement of such real estate, and a statement of any real or personal estate
					 which he expects to acquire thereafter.
____________________________________________________________
Special Master
DATE:______________
ORDER
IT IS ORDERED AND DECREED THAT the report and
					 recommendation of the Special Master be approved.
IT IS FURTHER ORDERED AND DECREED, that the Surety Bond
					 issued by
_______________Bond No.__________________________________
					 shall be sufficient as bond.
All costs and expenses of this hearing to be borne by the
					 Estate of the said
_____________________ , including a fee of
					 __________________________
to be paid the guardian ad litem.
BY THE COURT
____________________________________________________________
J.
DATE:_______________