Northum. Cnty. Pa 14.9
The periodic report of guardian of the person of an incapacitated person referred to in Rule NOC-14.2A and Rule NOC-14.4D 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 REPORT OF GUARDIAN OF THE PERSON OF AN INCAPACITATED PERSON
In the matter of____________, a legally incapacitated person.
1. I, _____________, am the guardian of the above named adult and my annual report is as follows:
2. Present age of the adult: _____ D.O.B.: ________
3. Living arrangements:
a. Current address of the adult: _________________
b. The adult's current residence is:
_____ own home/apartment _____ guardian's home/apartment
_____ nursing home _____ hospital or medical facility
_____ foster/boarding home _____ relative's home________________ relationship
_____ other: __________________________________
c. The adult has been in the present residence since
______________.
If moved within past year, state change(s) and reason(s) for change:
d. I rate the adult's living arrangements as: ______ Exc. ______ Avg. ______ Below Avg. (Explain)
_________________________________
e. I believe the adult is ______ content with the living situation.
I believe the adult is ______ unhappy with the living situation.
f. ______ I recommend a more suitable living arrangement for the adult as follows:_____________________
4. Physical Health:
a. The adult's current physical condition is:
____ Exc. ____ Good ____ Fair ____ Poor
b. The adult's major physical health problems are as
follows: _____________________________ ______________________.
c. During the past year, the adult's physical condition has:
____ remained about the same.
____ improved. (Explain) ______________________________
____ worsened. (Explain) ___________________________
d. During the past year, the adult received the following medical treatment (include check-ups and dental work):
Date Ailment Treatment Dr.'s Name
_____________________________
_____________________________
_____________________________
5. Mental Health:
a. The adult's condition is: ____ Exc. ____ Good ____ Poor
b. The adult's major mental health problems are as follows: __________________________ .
c. During the past year, the adult's mental condition has
_____ remained about the same.
_____ improved. (Explain)________________
_____ worsened. (Explain) _______________
d. During the past year, treatment or evaluation by a psychiatrist, psychologist, or social worker_________was ________was provided. Such mental health services are briefly described as follows:
6. Social Activities/Services:
a. The adult's current social condition is:
____ Exc. ____ Good ____ Fair ____ Poor
b. During the past year, the adult's social condition has: _____ remained about the same.
_____ improved. (Explain) ___________________
_____ worsened. (Explain) ___________________
c. During the past year, the adult has participated in the following activities:
____ recreational__________________________
____ educational __________________________
____ social ______________________________
____ occupational _________________________
____ no activities available.
____ refused to participate in any activities.
____ was unable to participate in any activities.
7. List of visits:
a. During the past year, I visited the adult as follows:
_______________________________________
b. The average amount of time I spent on each visit was:
_______________________________________
c. The last time I visited with the adult was on (date)
_______________________________________
8. Activities:
During the past year, I performed the following activities on behalf of the adult: _______________________________
9. I believe the adult has the following unmet needs:
10. The guardianship ____ should ____ should not be continued without modification because: _____________________________
11. I ____ do _____ do not have possession or control of the adult's estate, if yes, my accounting is attached.
12. 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: _____________________
13. I certify that I have served a copy of this periodic report on all those parties in interest listed in the original petition, as may be amended in paragraph of this report.
I attest that the above information is 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 xn 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. Orphans1 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 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 14.9