[34 Pa.B. 2690]

[Continued from previous Web Page]

APPENDIX H

Preliminary Order Awarding a Citation for Emergency and Permanent Guardian Under Rule 14.2(a) and 14.6(a)

IN THE COURT OF COMMON PLEAS OF BEAVER COUNTY,
PENNSYLVANIA
ORPHANS' COURT DIVISION

IN RE:	:
	:	No. ______ of ______
_________________ , an Alleged Incapacitated Person	: :

PRELIMINARY ORDER OF COURT
(Emergency and Permanent Guardian)

AND NOW, this _____ day of ______ , 20 ____ , the foregoing Petition having been presented in Open Court, upon consideration thereof and on motion of ______ , counsel for Petitioner, IT IS HEREBY ORDERED AND DECREED that a Citation be awarded, directed to ______ . This Petition seeks to have ______ adjudged an Incapacitated Person and to have a Plenary/Limited Guardian of his/her Person and Estate appointed. The Citation shall be returnable and an emergency and permanent hearing on the Petition, and any answer thereto, shall be held on the following dates and times:

Emergency Guardianship	Permanent Guardianship
Return Date:	Return date:
Hearing Date:	Hearing Date:
Hearing Time:	Hearing Time:
Courtroom No.	Courtroom No.

The alleged Incapacitated Person shall be given notice of the hearing on appointment of an Emergency Guardian of his/her Person and Estate by serving him/her personally with the Citation, this Order of Court and a copy of the foregoing Petition prior to the time of such emergency hearing.

OR

The Court finds that service of notice of the hearing on appointment of an Emergency Guardian upon the alleged Incapacitated Person is not feasible under the circumstances and is, therefore, waived pursuant to 20 Pa.C.S.A. § 5513.

Any Answer or other response to the Petition shall be filed at the Office of the Register of Wills of Beaver County sitting as Clerk of the Orphans' Court, Beaver County Court House, Beaver, Pennsylvania 15009. Hearing shall be held in Court Room No. _____ , Beaver County Court House, Beaver, Pennsylvania.

The Court finds that strict compliance with 20 Pa.C.S.A. § 5511(e) and Rule 14.1 of the Beaver County Orphans' Court Division Rules (both relating to contents of the Petition) are not feasible under the circumstances and are waived for the purpose of the hearing on appointment of an Emergency Guardian of the alleged Incapacitated Person.

The Court further finds that strict compliance with 20 Pa.C.S.A. § 5511(a) (relating to notification concerning the right to counsel and the appointment of counsel for the alleged Incapacitated Person) are not feasible under the circumstances and are waived for the purpose of the hearing on appointment of an Emergency Guardian of the alleged Incapacitated Person.

At least twenty (20) days' written notice of the hearing on appointment of a Permanent Guardian shall be given to ______ , the alleged Incapacitated Person, by serving him/her personally with a copy of the Petition, the Citation and this Order of Court, together with an explanation of their contents. At least twenty (20) days' written notice of the petition and hearing on the appointment of a Permanent Guardian shall be given to the next of kin and other parties in interest in the petition, either personally or by registered or certified mail.

BY THE COURT:                       

_________________
J.  

APPENDIX I-1

Order Appointing Emergency Plenary Guardian Under Rule 14.6(d)

IN THE COURT OF COMMON PLEAS OF BEAVER COUNTY,
PENNSYLVANIA
ORPHANS' COURT DIVISION

IN RE:	:
	:	No. ______ of ______
_________________ , an Alleged Incapacitated Person	: :

ORDER OF COURT DETERMINING INCAPACITY
AND APPOINTING EMERGENCY PLENARY
GUARDIAN OF PERSON AND/OR ESTATE

AND NOW, this _____ day of _____ , 20 ____ , a hearing in this case having been held on ______ , 20 ____ , and it appearing to the Court that ______  was served with a Notice of this hearing on _____ , 20 ____ , and was present at the hearing (or) the Court finds that the physical or mental condition of  ______ would be harmed by his/her presence at the hearing, and further finds from the testimony as follows:

1.  That ______ suffers from ______ , a condition or disability which totally impairs his/her capacity to receive and evaluate information effectively and to make and communicate decisions concerning his/her management of financial affairs or to meet essential requirements for his/her physical health and safety.

2.  That there are insufficient supports available to assist ______  in overcoming such limitations and that there exists no less restrictive alternative mechanism for decision making than the appointment of an Emergency Plenary Guardian.

3.  That based on the total incapacity of ______ , to receive and evaluate information effectively and to make or communicate decisions, a Plenary Guardian of the Person and a Plenary Guardian of the Estate are required on an emergency basis.

NOW THEREFORE, based on the clear and convincing evidence supporting the foregoing findings, IT IS HEREBY ORDERED, ADJUDGED AND DECREED that ______  be and hereby is adjudged a totally Incapacitated Person.

______ is appointed Emergency Plenary Guardian of the Person of  ______ and ______ is appointed Emergency Plenary Guardian of the Estate of ______ .

The Emergency Plenary Guardian of the Person shall have authority to consent to the general care, maintenance and custody of ______ without exception.

The Emergency Plenary Guardian of the Person shall assure that ______  receives appropriate services and shall assist him/her in developing self-reliance and independence.

The Emergency Plenary Guardian of the Estate shall have the authority to marshal all of ______ 's income and assets, pay his/her bills and manage his/her financial affairs as fully as ______ could do so himself/herself if he/she had not been adjudged incapacitated.

If there is a safe deposit box in the name of the Incapacitated Person alone or in the names of the Incapacitated Person and another or others, said safe deposit box shall not be entered by the Guardian except in the presence of a representative of the financial institution where the box is located or in the presence of a representative of the Orphans' Court Division. The representative present at the time of entry shall make or cause to be made a record of the Incapacitated Person's property, and said record shall be filed with the Clerk of the Orphans' Court Division. None of the Incapacitated Person's property may be removed until after the aforesaid inventory is completed.

If the safe deposit box is jointly owned, five (5) days' notice of the proposed entry shall be given to the other owners by the Guardian.

The appointment of the Emergency Plenary Guardian of the Person and Estate shall remain in effect until further Order of Court.

NO BOND REQUIRED ON EMERGENCY PLENARY GUARDIAN APPOINTMENT.

______ , an Incapacitated Person, has the right to appeal this Order of Court by filing exceptions with the Clerk of the Orphans' Court Division within twenty (20) days of the date of this Order or by filing an appeal with the Prothonotary's Office of the Superior Court of Pennsylvania within thirty (30) days of the date of this Order or to petition this Court for a hearing to review or terminate the adjudication of incapacity and guardianship herein established.

If ______ was not present at the hearing on the adjudication of his/her incapacity and the appointment of a Guardian, then Petitioner shall serve upon, and read to ______ , the Statement of Rights attached to this Order of Court and marked as Exhibit A. Proof of service of the Statement of Rights shall be filed by the Guardian with the Clerk of the Orphans' Court within ten (10) days of the date of this Order.

BY THE COURT:                       

_________________
J.  

APPENDIX I-2

Order Appointing Emergency Limited Guardian Under Rule 14.6(d)

IN THE COURT OF COMMON PLEAS OF BEAVER COUNTY,
PENNSYLVANIA
ORPHANS' COURT DIVISION

IN RE:	:
	:	No. ______ of ______
_________________ , an Alleged Incapacitated Person	: :

ORDER OF COURT DETERMINING INCAPACITY
AND APPOINTING EMERGENCY LIMITED
GUARDIAN OF PERSON AND/OR ESTATE

AND NOW, this _____ day of ______ , 20 ____ , a hearing in this case having been held on ______ , 20 ____ , and it appearing to the Court that ______  was served with a Notice of this hearing on ______ , 20 ____ , and was present at the hearing (or) the Court finds that the physical or mental condition of  ______ would be harmed by his/her presence at the hearing and further finds from the testimony as follows:

1.  That ______ suffers from ______ , a condition or disability which partially impairs his/her capacity to receive and evaluate information effectively and to make and communicate decisions concerning his/her management of financial affairs or to meet essential requirements for his/her physical health and safety.

2.  That there are insufficient supports available to assist ______ in overcoming such limitations and that there exists no less restrictive alternative mechanism for decision making than the appointment of a Limited Guardian.

3.  That based on the partial incapacity of ______ to receive and evaluate information effectively and to make or communicate decisions, a Limited Guardian of the Person and Limited Guardian of the Estate are required on an emergency basis.

NOW THEREFORE, based on the clear and convincing evidence supporting the foregoing findings, IT IS HEREBY ORDERED, ADJUDGED AND DECREED that ______  be and hereby is adjudged a Partially Incapacitated Person.

______ is appointed Emergency Limited Guardian of the Person of ______ and ______ is appointed Emergency Limited Guardian of the Estate of ______ .

The Emergency Limited Guardian of the Person shall have authority to consent to the general care, maintenance and custody of ______ with the exception of: _________________ .

The Emergency Limited Guardian of the Person shall assure that ______  receives appropriate services and shall assist him/her in developing self-reliance and independence.

The Emergency Limited Guardian of the Estate shall have the authority to marshal all of ______ 's income and assets except that ______ , the Incapacitated Person, shall retain the following power and authority to act on his/her own behalf: _____________________________________ .

If there is a safe deposit box in the name of the Incapacitated Person alone or in the names of the Incapacitated Person and another or others, said safe deposit box shall not be entered by the Guardian except in the presence of a representative of the financial institution where the box is located or in the presence of a representative of the Orphans' Court Division. The representative present at the time of entry shall make or cause to be made a record of the Incapacitated Person's property, and said record shall be filed with the Clerk of the Orphans' Court Division. None of the Incapacitated Person's property may be removed until after the aforesaid inventory is completed.

If the safe deposit box is jointly owned, five (5) days' notice of the proposed entry shall be given to the other owners by the Guardian.

NO BOND REQUIRED ON EMERGENCY LIMITED GUARDIAN APPOINTMENT.

______ , an Incapacitated Person, has the right to appeal this Order of Court by filing exceptions with the Clerk of the Orphans' Court Division within twenty (20) days of the date of this Order or by filing an appeal with the Prothonotary's Office of the Superior Court of Pennsylvania within thirty (30) days of the date of this Order or to petition this Court for a hearing to review or terminate the adjudication of incapacity and guardianship herein established.

If ______ was not represent at the hearing on the adjudication of his/her incapacity and the appointment of a Guardian, then Petitioner shall serve upon, and read to ______ the Statement of Rights attached to this Order of Court and marked as Exhibit A. Proof of service of the Statement of Rights shall be filed by the Guardian with the Clerk of the Orphans' Court within ten (10) days of the date of this Order.

BY THE COURT:                       

_________________
J.  

APPENDIX J

Guardian of the Estate Annual Report

IN THE COURT OF COMMON PLEAS OF BEAVER COUNTY,
PENNSYLVANIA
ORPHANS' COURT DIVISION

IN RE:	:
	:	No. ______ of ______
_________________ , an Incapacitated Person	: :

GUARDIAN OF THE ESTATE ANNUAL REPORT

FROM ______ , 20 ____, to ______ , 20 ____ .

1.  I am the _____ Limited _____ Plenary Guardian of the Estate of my ward, named above. I was appointed Guardian by the Order of the Court dated ______ , 20 ____ , which was _____ was not _____ modified by Court Order(s) dated _________________ .

2.  If the Incapacitated Person still living? _____

      If no, answer the following:

      a.  Date of Death: ______

      b.  Place of Death: _________________

      c.  Name of Administrator or Executor: ______
         ___________________________

      d.  Date Guardian of the Estate filed the last Annual Report:
         ___________________________

PLEASE ANSWER THE FOLLOWING QUESTIONS WHETHER THE INCAPACITATED PERSON IS LIVING OR DECEASED:

3.  My initial inventory was filed on ______ , 20 ____ , and listed a total estate value of $ ______ . The inventory listed a total monthly income of $ ______ comprised of the following:

_____________________________________
_____________________________________
_____________________________________

   4.  At the beginning date of this reporting period, my initial balance on hand was $ ______ .

5.  During this reporting period, the following reflects all sources of income (other than social security) received by me for my ward:  (add additional pages, if needed)

	Date Received	Source of Income	Amount
(1)	______	_________________	$ ______
(2)	______	_________________	$ ______
(3)	______	_________________	$ ______
(4)	______	_________________	$ ______
(5)	______	_________________	$ ______
(6)	______	_________________	$ ______
		TOTAL:	$ ______

6.  During this reporting period, the following reflects all payments I have made for my ward:  (add additional pages, if needed)

	Date	To Whom Paid	Reason for Pmt.	Amount
(1)	______	_________________	______	$ ______
(2)	______	_________________	______	$ ______
(3)	______	_________________	______	$ ______
(4)	______	_________________	______	$ ______
(5)	______	_________________	______	$ ______
(6)	______	_________________	______	$ ______
		TOTAL:		$ ______

7.  The present principal assets of my ward are:

	Description of Asset	Present Value
(1)	_________________	$ ______
(2)	_________________	$ ______
(3)	_________________	$ ______
(4)	_________________	$ ______
(5)	_________________	$ ______
(6)	_________________	$ ______
	TOTAL:	$ ______

8.  The present amount and sources of income for my ward are:

	Sources of Income	Amount
(1)	_________________	$ ______
(2)	_________________	$ ______
(3)	_________________	$ ______
(4)	_________________	$ ______
(5)	_________________	$ ______
(6)	_________________	$ ______
	TOTAL:	$ ______

9.  The regular monthly expenses of my ward which I pay are:

	To Whom Paid	Amount
(1)	_________________	$ ______
(2)	_________________	$ ______
(3)	_________________	$ ______
(4)	_________________	$ ______
(5)	_________________	$ ______
(6)	_________________	$ ______
	TOTAL:	$ ______

10.  I have/have not (circle one) petitioned the Court for permission to invade principal to meet the needs of my ward.

(If applicable) The following expenses of my ward have not been paid from principal:

	To Whom Paid	Purpose	Amount
(1)	______	_________________	$ ______
(2)	______	_________________	$ ______
(3)	______	_________________	$ ______
(4)	______	_________________	$ ______
(5)	______	_________________	$ ______
(6)	______	_________________	$ ______
		TOTAL:	$ ______

11.  I have/have not (circle one) paid myself compensation for services I rendered as guardian.

The amount I paid myself totaled $ ______ and was calculated at the following rate:  $ ______ per week/month (circle one).

12.  Circle the correct response and complete, if applicable.

There will be no need for extraordinary expenditures on behalf of my ward in the next twelve (12) months.

There will be a need for extraordinary expenditures on behalf of my ward in the next twelve (12) months because:

_______________________________________________
_______________________________________________ .

13.  Circle the correct response and complete, if appropriate.

a.  My ward receives monthly social security benefits.

b.  I am the designated payee to receive my ward's social security benefits.

c.  The designated payee of my ward's social security benefits is:
    _________________ , whose address is
    ___________________________
    and is/is not (circle one) related to my ward as ______
    _________________ (insert relationship).

14.  Please note any concerns about the Incapacitated Person's physical or mental well being or the finances that the Court should know.

_______________________________________________
_______________________________________________

15.  I am _____ /am not _____ Guardian of the Incapacitated Person's person. If yes, my report is attached.

I certify under penalties of perjury that the information contained in this report is true and correct to the best of my knowledge, information and belief.

Date: ______       _________________
                                                   Signature of Guardian of the Estate

Name:     _________________

Address:  _________________

                _________________

Phone:  Home-- _________________

             Work-- _________________

APPENDIX K

Guardian of the Person Annual Report

IN THE COURT OF COMMON PLEAS OF BEAVER COUNTY,
PENNSYLVANIA
ORPHANS' COURT DIVISION

IN RE:	:
	:	No. ______ of ______
_________________ , an Incapacitated Person	: :

GUARDIAN OF THE PERSON ANNUAL REPORT

1.  Current address of the Incapacitated Person:

_______________________________________________

_______________________________________________

2.  Describe the type of placement and living arrangements of the Incapacitated Person, e.g., private residence, personal care of nursing home, institution, hospital, etc.

_______________________________________________

_______________________________________________

3.  Briefly describe the Incapacitated Person's medical care and any social, psychological or other support services he/she receives.

_______________________________________________

_______________________________________________

4.   As Guardian of the Person, do you think the guardianship of the Person should continue, be terminated or
modified? _________________

Reason:

_______________________________________________

_______________________________________________

5.  Number and length of times you have visited the Incapacitated Person since your appointment or last report.

Date	Duration
_________________	_________________
_________________	_________________
_________________	_________________
_________________	_________________
_________________	_________________
_________________	_________________
_________________	_________________

Date:  ______      _________________
                                                Guardian's signature

Guardian's address:      _________________

                                       _________________

Daytime Telephone No. ______

RECEIVED:  ______

APPROVED:  ______

SIGNATURE:  _________________

APPENDIX L

Final Report of the Guardian of the Person Under Rule 14, Section 8(e)

IN THE COURT OF COMMON PLEAS OF BEAVER COUNTY,
PENNSYLVANIA
ORPHANS' COURT DIVISION

IN RE:	:
	:	No. ______ of ______
_________________ , an Alleged Incapacitated Person	: :

FINAL REPORT OF THE GUARDIAN OF THE PERSON

1.  Reason for this Final Report is:  _________________

    The Incapacitated Person died on _________________ .

    The adjudication of capacity has been entered by Decree of this Court dated _________________ .

2.  If the Incapacitated Person died, the cause of death was: _________________.

3.  The address of the Incapacitated Person as of the date of death or adjudication of capacity: ______
_______________________________________________ .

4.  Describe the type of facility and living arrangements that the Incapacitated Person was placed as of the date of death or adjudication of capacity:

     A.  Private home                                    ______
     B.  Personal Care of Nursing Home         ______
     C.  Hospital                                           ______
     D.  Institution                                        ______

5.  Number and length of times you visited the Incapacitated Person from the date of the last report to the date of death or adjudication of capacity:

Date	Duration
_________________	_________________
_________________	_________________
_________________	_________________
_________________	_________________
_________________	_________________
_________________	_________________
_________________	_________________

Date:  ______      _________________
                                                Guardian's signature

Guardian's address:      _________________
                                        _________________
Daytime Telephone No.  _________________

RECEIVED:  ______

ACCEPTED:  ______

SIGNATURE:  _________________

[Pa.B. Doc. No. 04-898. Filed for public inspection May 21, 2004, 9:00 a.m.]

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