Alle. Cnty. Pa. XIV app C
IN THE COURT OF COMMON PLEAS OF ALLEGHENY COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION
IN RE: | ) |
) | |
) No. | |
*3______________________________ | ) |
an alleged incapacitated person | ) |
ORDER OF COURT DETERMINING PARTIAL INCAPACITY AND APPOINTING
PERMANENT LIMITED GUARDIAN OF PERSON AND ESTATE
AND NOW, this _____ day of ___________________ , a hearing in this case having been held on * __________________________ , and it appearing to the Court that _____________________ , was served with a Citation and Notice of the hearing on _________________________ , 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:
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 3 Sections marked by asterisk (*) must be completed by counsel before Court presentation.
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 a Limited Guardian of the Estate are required on a permanent basis.
NOW, THEREFORE, based on the clear and convincing evidence supporting the foregoing findings, it is ORDERED, ADJUDGED and DECREED that * _____________________ be and is hereby adjudged a partially incapacitated person.
* _____________________________ is appointed Limited Permanent Guardian of the Person of * __________________________ and _______________________ is appointed
Limited Permanent Guardian of the Estate of * _________________________________.
The Limited Guardian of the Person shall have full authority to consent to the general care, maintenance and custody of * _________________________ , except as follows: ______________________________________
The Limited Guardian of the Person shall assure that * _____________________ receives appropriate services and shall assist *him/her in developing self reliance and independence.
The Limited Guardian of the Estate shall have the authority to marshall 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.
An Inventory must be filed within ninety (90) days. A report by the Guardian of the Person and Estate shall be filed within _____ days and annually thereafter.
Within sixty (60) days of the death of the incapacitated person or an adjudication of capacity and modification of existing orders, the guardian of the estate shall file a final accounting.
A Surety Bond in the amount of shall be presented for approval by the Guardian of the Estate within five (5) days of the date of this Order.
* __________________________ , an incapacitated person, has the right to appeal this Order of Court by filing exceptions with the Clerk of the Orphans' Court Division within ten (10) 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 this 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 and marked 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.
Alle. Cnty. Pa. XIV app C