Alle. Cnty. Pa. XIV app E
IN THE COURT OF COMMON PLEAS OF ALLEGHENY COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
IN RE: | ) |
) | |
) No. | |
*5_____________________________________________ | ) |
an alleged incapacitated person | ) |
ORDER OF COURT DETERMINING INCAPACITY AND APPOINTING
EMERGENCY LIMITED 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 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.
__________________
5 Sections 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 alternative mechanism for decision making than the appointment of a Limited Guardian.
3. That based on the partial in capacity 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 a emergency 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 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.
The appointment of Emergency Limited Guardian of the Person and Estate shall remain in effect until further Order of Court.
NO BOND REQUIRED ON EMERGENCY LIMITED GUARDIAN APPOINTMENT.
The testimony from this hearing on the emergency adjudication of incapacity and guardianship herein established shall be preserved and perpetuated for the hearing on the permanent adjudication of incapacity and guardianship.
_________________________ , 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 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.
Alle. Cnty. Pa. XIV app E