Court Opinion

ID: 9340431
Source: CourtListenerOpinion
Date Created: 2022-12-16 21:11:47.548081+00
Date Added: 2024-06-11T17:15:22.109270
License: Public Domain

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

                          REPORT OF GUARDIAN OF THE PERSON

Estate of: _________________________________________________________, an Incapacitated Person
                                 Name of Incapacitated Person

                                        Case File No: _____________________

DATE COURT APPOINTED YOU AS GUARDIAN: _____________________________________________________

PART I. INTRODUCTION
  1. Name(s) of Guardian(s):

  2. Is this a limited Guardianship? ¨ Yes       ¨ No
  3. Report Period
     ¨ This is the Report for the period from ______________ to ______________ (the "Report Period"); or

     ¨ This is the Final Report for the period from ______________ to ______________ (the "Report Period")
        and is filed for the following reason:

        ¨ The death of the Incapacitated Person.
            Date of Death:   __________________________________________
            Name of Executor/Administrator: ___________________________________________________

        ¨ The Guardian was discharged by a court order dated:        __________________________

        ¨ Order for Adjudication of Capacity dated:         __________________________

        ¨ Limited Duration Order Expired, dated: __________________________

        ¨ Transfer of Guardianship to: _________________________________________________________
            Date of court order approving transfer: ________________________________________________

                  IF THIS IS A FINAL REPORT, ONLY COMPLETE PARTS I AND V.

Form G-03 (Effective January 1, 2023)                                                              Page 1 of 7
PART II. PERSONAL INFORMATION ABOUT THE INCAPACITATED PERSON

  1. Incapacitated Person's date of birth: _____/_____/_____

  2. Incapacitated Person's Current Residence:
     __________________________________________________________________________________________________
     __________________________________________________________________________________________________
     __________________________________________________________________________________________________

  3. Nature of Residence of the Incapacitated Person (Select One)

     ¨ Incapacitated Person's home ( ¨ with part-time home health care aide or ¨ 24/7 assistance)

     ¨ Your home

     ¨ Relative's home
          Relative's Name: ________________________________ Relationship: _________________________

     ¨ Domiciliary Care
          Facility Name: _______________________________________________
          Is this a Memory Support Facility?      ¨ Yes ¨ No

     ¨ Personal Care Boarding Home
          Facility Name: _______________________________________________
          Is this a Memory Support Facility?      ¨ Yes ¨ No

     ¨ Group Home
          Facility Name: _______________________________________________
          Is this a Memory Support Facility?      ¨ Yes ¨ No

     ¨ Assisted Living Facility
          Facility Name: _______________________________________________
          Is this a Memory Support Facility?      ¨ Yes ¨ No

     ¨ Nursing Home Facility
          Facility Name: _______________________________________________
          Is this a Memory Support Facility?      ¨ Yes ¨ No

      ¨ Other: ___________________________________________________________

  4. The Incapacitated Person has been in the residence noted in question 3 since: _______________________

Form G-03 (Effective January 1, 2023)                                                                     Page 2 of 7
  5. Has the Incapacitated Person moved during the Report Period?
     ¨ Yes
     ¨ No
     If yes, date of move: ______________________
     If yes, please provide:
        Reason for move: ______________________________________________________________________
        Previous residence/address: ______________________________________________________________

PART III. MEDICAL INFORMATION
  1. List the medical professionals who have seen the Incapacitated Person during the Report Period:

                                                                             Name

      Medical Doctor

      Dentist

      Eye Doctor

      Ear Doctor

      Psychologist or Psychiatrist

      Physical Therapist

      Occupational Therapist

      Social Worker

      Geriatric Caseworker

      Other

  2. The major medical or psychiatric problems of the Incapacitated Person are as follows:
     _______________________________________________________________________________________
     _______________________________________________________________________________________
     _______________________________________________________________________________________

  3. Describe any social, medical, psychological and support services the Incapacitated Person is receiving:
     _______________________________________________________________________________________
     _______________________________________________________________________________________
     _______________________________________________________________________________________

Form G-03 (Effective January 1, 2023)                                                                      Page 3 of 7
  4. Has the Incapacitated Person been hospitalized during the Report Period?

     ¨ Yes
     ¨ No
     If yes, date(s) of hospitalization: _________________________

  5. Has the Incapacitated Person received a mental health assessment during the Report Period?
     ¨ Yes
     ¨ No
     If yes, date(s) of evaluation: _________________________

PART IV. GUARDIAN'S OPINION
  1. Should the guardianship be:

     ¨ Continued
     ¨ Continued with modifications
     ¨ Discharged
  2. Provide the reasons for your opinion. List specific recommended modifications.
     _______________________________________________________________________________________
     _______________________________________________________________________________________

  3. Have you filed a petition for modification or termination?
     ¨ Yes
     ¨ No
PART V. INFORMATION ABOUT THE GUARDIAN
  1. On average, how often did you visit the Incapacitated Person during the Report Period?

     ¨ I live with the Incapacitated Person
     ¨ None
     ¨ Quarterly
     ¨ Monthly
     ¨ Weekly
     ¨ Daily

Form G-03 (Effective January 1, 2023)                                                             Page 4 of 7
  2. What is the average length of a visit?
     ¨ Less than 15 minutes
     ¨ Between 15 minutes and 1 hour
     ¨ Between 1 and 2 hours
     ¨ More than 2 hours
     ¨ Not applicable
  3. Have you maintained a log of your activities as guardian?
     ¨ Yes - Attach a copy
     ¨ No
  4. During this Report Period, did any guardian participate in guardianship training?

     ¨ Yes
     ¨ No
     If yes, provide the following information:
           Guardian Name              Dates of Training             Provider             Training Description
                                    Starting     Ending

  5. During this Report Period, was any guardian charged with or convicted of a crime?
     ¨ Yes - Please describe          ¨ No
     Guardian Name             Description
     ___________________       ________________________________________________________________
     ___________________       ________________________________________________________________

  6. During this Report Period, was a Protection from Abuse Order or Protection from Sexual Violence or
     Intimidation Order entered against any guardian?

     ¨ Yes - Please describe          ¨ No
     Guardian Name             Description
     ___________________       ________________________________________________________________
     ___________________       ________________________________________________________________

Form G-03 (Effective January 1, 2023)                                                                     Page 5 of 7
  7. Is there any reason any guardian cannot continue to serve as guardian?

     ¨ Yes - Please describe          ¨ No
     Guardian Name             Description
     ___________________       ________________________________________________________________
     ___________________       ________________________________________________________________

  8. Did the Guardian receive compensation during the Report Period?
     ¨ Yes - Complete the table below        ¨ No
            Amount                       Guardian Name                    Is Amount Based on          If Hourly,
                                                                     Hourly, Monthly or Annual Fee?   # of Hours

  9. Was the compensation approved by the court?
     ¨ Yes - Date of Court Order:
     ¨ No - Explain why court approval was not obtained:
        __________________________________________________________________________________
        __________________________________________________________________________________
        __________________________________________________________________________________

Form G-03 (Effective January 1, 2023)                                                                  Page 6 of 7
   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 Person

                                                        Name of Guardian of the Person (type or print)

                                                        Address

                                                        City, State, Zip

                                                        Home Phone Number

                                                        Office Phone Number

                                                        Cell Phone Number

                                                        Email

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

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

                                                        Address

                                                        City, State, Zip

                                                        Home Phone Number

                                                        Office Phone Number

                                                        Cell Phone Number

                                                        Email

Form G-03 ( Effective January 1, 2023)                                                                        Page 7 of 7