Northum. Cnty. Pa 14.10
The periodic account of the estate of an incapacitated person referred to in Rule NOC-14.4E shall be substantially in the following form:
In the matter of (Respondent), an alleged incapacitated person | : | IN THE COURT OF COMMON PLEAS OF NORTHUMBERLAND COUNTY, PA. |
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: | ||
: | ORPHANS' COURT DIVISION | |
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: | O.C. NO. |
PERIODIC ACCOUNT OF GUARDIAN OF THE ESTATE OF AN INCAPACITATED PERSON
Estate of___________________________
1. I, _________________, represent that I am the___________________ of the estate and submit the following as my account, which covers the period from________
(Date) to _____________.
(Date)
INCOME | |||
RECEIPTS | DISBURSEMENTS | ||
Balance on hand, from last account (or value of inventory, if first account) | |||
_______________ | $________ | _______________ | $________ |
_______________ | $________ | _______________ | $________ |
_______________ | $________ | _______________ | $________ |
_______________ | $________ | _______________ | $________ |
_______________ | $________ | _______________ | $________ |
_______________ | $________ | _______________ | $________ |
_______________ | $________ | _______________ | $________ |
Total | Total | ||
PRINCIPAL | |||
RECEIPTS | DISBURSEMENTS | ||
_______________ | $________ | _______________ | $________ |
_______________ | $________ | _______________ | $________ |
_______________ | $________ | _______________ | $________ |
_______________ | $________ | _______________ | $________ |
_______________ | $________ | _______________ | $________ |
_______________ | $________ | _______________ | $________ |
_______________ | $________ | _______________ | $________ |
Total | Total | ||
2. Receipts in the accounting period (total from column one) $_______
Subtract disbursements (total from column two) $_______
Balance on hand of principal and income (itemize below) $_______
3. Conversions of assets, and gains and losses have been as follows: (as determined from guardian's inventory valuation)
4. The balance of assets on hand are: _____________________
ITEMIZED ASSETS REMAINING AT END OF ACCOUNT PERIOD
____________________________ | $_________________ |
____________________________ | $_________________ |
____________________________ | $_________________ |
____________________________ | $_________________ |
____________________________ | $_________________ |
Total balance on hand |
5. I represent that the interested parties, addresses and their representatives as defined in 20 P.S. Sec 3503 are identical to those appearing on the initial petition, except as to the following: _______________________________________________________
6. Needs of the incapacitated person for which the guardian of the estate has provided since the last report are as follows:
7. I represent that the foregoing account contains a correct statement of all receipts and disbursements which have come to my knowledge.
8. I, therefore, request that the foregoing be allowed as my __________ annual account.
9. I certify that I have served a copy of this periodic account to all those persons in interest listed in the original petition, as may be amended in paragraph 5 of this account.
I attest that this account and petition has been examined by me and that its contents are true and correct to the best of my information, knowledge, and belief, and I present this information subject to the penalties of 18 Pa. C.S. Sec 4904 relating to unsworn falsification to authorities.
________________________
Date
________________________
Petitioner's Signature
________________________
Petitioner's Name (type or print)
________________________
Address
________________________
City, State, Zip Tele. Number
(Caption)
NOTICE
Enclosed herewith you will find a Periodic Account of Fiduciary in reference to the above-captioned matter. If you should have any questions in reference to this account, please contact the guardian. If you have any objections to the account, you are respectfully asked to prepare your objections, in writing, make reference to the incapacitated person and court docket number, and, within 30 days of receiving this notice, mail or deliver the objections to the following:
1. Orphans' Court Clerk
Northumberland County Courthouse
201 Market Street
Sunbury, PA 17801
2. Chambers of Judge __________________________
(Name of Judge who appointed the fiduciary)
3. ______________________ (fill in name and address of the fiduciary making the periodic account).
Not filing your objections within the 30 days does not preclude you from filing them at some future time including the time when the formal account or first and partial account is filed. If, however, you do have valid objections, it would be very helpful to address them now rather than at some future time.
____________________________
Guardian/Attorney for Guardian
Northum. Cnty. Pa 14.10