Alle. Cnty. Pa. XIV app D
IN THE COURT OF COMMON PLEAS OF ALLEGHENY COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
IN RE: | ) |
) | |
) No. | |
*4 _______________ | ) |
an alleged incapacitated person | ) |
ORDER OF COURT DETERMINING INCAPACITY AND APPOINTING
PERMANENT PLENARY GUARDIAN OF PERSON AND/OR 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 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.
_________________
4 3Sections marked by asterisk (*) must be completed by counsel before Court presentation.
2. That there are insufficient supports available to assist * ____________________________ in overcoming such limitations and that there exists no less restrictive mechanism for decision making that the appointment of a 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 Plenary 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 hereby is adjudged a totally incapacitated person. * _________________________ is appointed Permanent Plenary Guardian of the Person of * _____________________ and * __________________ is appointed Permanent Plenary Guardian of the Estate of * _____________________.
The Permanent Plenary Guardian of the Person shall have full authority to consent to the general care, maintenance and custody of * _______________________ without exception.
The Permanent Plenary 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 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.
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 in a form approved by the Orphans' Court Divisions.
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 the hearing on the adjudication of *his/her incapacity and 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.
Alle. Cnty. Pa. XIV app D