Court Opinion

ID: 9340430
Source: CourtListenerOpinion
Date Created: 2022-12-16 21:11:46.484203+00
Date Added: 2024-06-11T17:15:23.086684
License: Public Domain

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: _____________________________________________________

PART I: INTRODUCTION
   Inventory type:
   ¨ Initial
   ¨ Amended
PART II: ASSETS (PRINCIPAL)
  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 $ 0.00

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

  4. Does the Incapacitated Person have an automobile insurance policy?
     ¨ Yes(Copy of policy to be provided upon request)
     ¨ No
             If yes:
                a. Carrier:
                b. Coverage period:

  5. Does the Incapacitated Person have a safe deposit box?
     ¨ Yes, in sole name
     ¨ Yes, in joint name(s). List the name(s) of joint owner(s):
     ¨ No
             If yes:
                a.   Location of safe deposit box: _______________________________________
                b.   Are there plans to inventory the contents?
                     ¨ Yes
                     ¨ No

Form G-05 (Effective January 1, 2023)                                                                       Page 2 of 9
PART III: ANNUAL INCOME
  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   $ 0.00

Form G-05 (Effective January 1, 2023)                                                            Page 3 of 9
PART IV: LIABILITIES / DEBTS
  1. List all debts the Incapacitated Person owes, including mortgages, loans, credit card debt, etc.

                        Liabilities/Debts                                       Lender                      Value

                                                                                                        $

                                                                                                        $

                                                                                                        $

                                                                                                        $

                                                                                                        $

                                                                                                        $

                                                                                                        $

                                                                                   TOTAL DEBTS: $ 0.00

PART V: GUARDIAN COVERAGE
  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?
     ¨ Yes
     ¨ No
             If yes, do you have professional liability coverage?
             ¨ Yes (Please attach a copy of the insurance policy)
             ¨ No
                     If no, explain: ________________________________________________________

Form G-05 (Effective January 1, 2023)                                                                        Page 4 of 9
PART VI: PERSONAL CARE PLAN
  1. Can the Incapacitated Person remain in his or her current residence with assistance, or in the home of a relative?
     ¨ Yes
     ¨ No
     ¨ N/A - The Incapacitated Person is already in a supervised residential setting

             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
                               Number of days per week: __________
                               Number of hours per week: __________
                     ¨ Assistance from family members
                               Will compensation be provided?
                               ¨ Yes
                               ¨ No
                                    If yes, indicate compensation amount:     $

  2. Will the Incapacitated Person be moved into a supervised residential setting?
     ¨ Yes
     ¨ No
     ¨ N/A - The Incapacitated Person is already in a supervised residential setting
             If yes:
                a.   Indicate the type of supervised residential setting:
                     ¨ Domiciliary Care
                     ¨ Personal Care
                     ¨ Boarding Home / Group Home
                     ¨ Assisted Living Facility
                     ¨ Nursing Home
                     ¨ Other
               b.    Describe the steps that are being taken to move the Incapacitated Person into a supervised
                     residential setting.
                     __________________________________________________________________________
                     __________________________________________________________________________
                     __________________________________________________________________________
                     __________________________________________________________________________

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

PART VII: FINANCIAL PLAN
  1. Complete the following table using initial inventory or most recent amended inventory.

  a. Total Annual Income                                        d. Total assets (principal)
     (Part III, Question 1)       $ 0.00                           (Part II, Question 1)      $ 0.00
  b. Annual
     estimated expenses           $
  c. Net Income
     (a minus b)                  $ 0.00

  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 (Explain:                                                      )

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

  5. Prior to the appointment of a guardian, has an agent under a Power of Attorney been serving?
     ¨ Yes
     ¨ No
            If yes, has an accounting ever been requested or filed with the Orphans' Court?
            ¨ Yes
            ¨ No
           If yes, was the agent the same person as the guardian?
           ¨ Yes
           ¨ No
PART VIII: MEDICAL INFORMATION
  1. Is a "no-code" (Do Not Resuscitate) provision in place for the incapacitated person?
     ¨ Yes
     ¨ No
  2. 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)?
     ¨ Yes
     ¨ No
           If yes, identify the authorized agent for making health care decisions:
           _____________________________________________________________________________

Form G-05 (Effective January 1, 2023)                                                                         Page 7 of 9
  3. Are you aware of any will or trust executed by the Incapacitated Person, or any funeral or burial wishes of
     the Incapacitated Person?
     ¨ Yes
     ¨ No
           If yes, please explain:
           _______________________________________________________________________________
           _______________________________________________________________________________
           _______________________________________________________________________________
           _______________________________________________________________________________
           Has a burial account been established for the Incapacitated Person?
           ¨ Yes
           ¨ No
              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

                                                          Email

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