In Re: Order Rescinding and Replacing Pennsylvania Orphans' Court Forms G-02, G-03, and G-05
Date Filed2022-12-16
Docket929 Supreme Court Rules
JudgePer Curiam
Cited0 times
StatusPublished
Full Opinion (html_with_citations)
COURT OF COMMON PLEAS
_____________ COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
REPORT OF GUARDIAN OF THE PERSON
Estate of: _________________________________________________________, an Incapacitated Person
Name of Incapacitated Person
Case File No: _____________________
DATE COURT APPOINTED YOU AS GUARDIAN: _____________________________________________________
PART I. INTRODUCTION
1. Name(s) of Guardian(s):
2. Is this a limited Guardianship? ¨ Yes ¨ No
3. Report Period
¨ This is the Report for the period from ______________ to ______________ (the "Report Period"); or
¨ This is the Final Report for the period from ______________ to ______________ (the "Report Period")
and is filed for the following reason:
¨ The death of the Incapacitated Person.
Date of Death: __________________________________________
Name of Executor/Administrator: ___________________________________________________
¨ The Guardian was discharged by a court order dated: __________________________
¨ Order for Adjudication of Capacity dated: __________________________
¨ Limited Duration Order Expired, dated: __________________________
¨ Transfer of Guardianship to: _________________________________________________________
Date of court order approving transfer: ________________________________________________
IF THIS IS A FINAL REPORT, ONLY COMPLETE PARTS I AND V.
Form G-03 (Effective January 1, 2023) Page 1 of 7
PART II. PERSONAL INFORMATION ABOUT THE INCAPACITATED PERSON
1. Incapacitated Person's date of birth: _____/_____/_____
2. Incapacitated Person's Current Residence:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
3. Nature of Residence of the Incapacitated Person (Select One)
¨ Incapacitated Person's home ( ¨ with part-time home health care aide or ¨ 24/7 assistance)
¨ Your home
¨ Relative's home
Relative's Name: ________________________________ Relationship: _________________________
¨ Domiciliary Care
Facility Name: _______________________________________________
Is this a Memory Support Facility? ¨ Yes ¨ No
¨ Personal Care Boarding Home
Facility Name: _______________________________________________
Is this a Memory Support Facility? ¨ Yes ¨ No
¨ Group Home
Facility Name: _______________________________________________
Is this a Memory Support Facility? ¨ Yes ¨ No
¨ Assisted Living Facility
Facility Name: _______________________________________________
Is this a Memory Support Facility? ¨ Yes ¨ No
¨ Nursing Home Facility
Facility Name: _______________________________________________
Is this a Memory Support Facility? ¨ Yes ¨ No
¨ Other: ___________________________________________________________
4. The Incapacitated Person has been in the residence noted in question 3 since: _______________________
Form G-03 (Effective January 1, 2023) Page 2 of 7
5. Has the Incapacitated Person moved during the Report Period?
¨ Yes
¨ No
If yes, date of move: ______________________
If yes, please provide:
Reason for move: ______________________________________________________________________
Previous residence/address: ______________________________________________________________
PART III. MEDICAL INFORMATION
1. List the medical professionals who have seen the Incapacitated Person during the Report Period:
Name
Medical Doctor
Dentist
Eye Doctor
Ear Doctor
Psychologist or Psychiatrist
Physical Therapist
Occupational Therapist
Social Worker
Geriatric Caseworker
Other
2. The major medical or psychiatric problems of the Incapacitated Person are as follows:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
3. Describe any social, medical, psychological and support services the Incapacitated Person is receiving:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Form G-03 (Effective January 1, 2023) Page 3 of 7
4. Has the Incapacitated Person been hospitalized during the Report Period?
¨ Yes
¨ No
If yes, date(s) of hospitalization: _________________________
5. Has the Incapacitated Person received a mental health assessment during the Report Period?
¨ Yes
¨ No
If yes, date(s) of evaluation: _________________________
PART IV. GUARDIAN'S OPINION
1. Should the guardianship be:
¨ Continued
¨ Continued with modifications
¨ Discharged
2. Provide the reasons for your opinion. List specific recommended modifications.
_______________________________________________________________________________________
_______________________________________________________________________________________
3. Have you filed a petition for modification or termination?
¨ Yes
¨ No
PART V. INFORMATION ABOUT THE GUARDIAN
1. On average, how often did you visit the Incapacitated Person during the Report Period?
¨ I live with the Incapacitated Person
¨ None
¨ Quarterly
¨ Monthly
¨ Weekly
¨ Daily
Form G-03 (Effective January 1, 2023) Page 4 of 7
2. What is the average length of a visit?
¨ Less than 15 minutes
¨ Between 15 minutes and 1 hour
¨ Between 1 and 2 hours
¨ More than 2 hours
¨ Not applicable
3. Have you maintained a log of your activities as guardian?
¨ Yes - Attach a copy
¨ No
4. During this Report Period, did any guardian participate in guardianship training?
¨ Yes
¨ No
If yes, provide the following information:
Guardian Name Dates of Training Provider Training Description
Starting Ending
5. During this Report Period, was any guardian charged with or convicted of a crime?
¨ Yes - Please describe ¨ No
Guardian Name Description
___________________ ________________________________________________________________
___________________ ________________________________________________________________
6. During this Report Period, was a Protection from Abuse Order or Protection from Sexual Violence or
Intimidation Order entered against any guardian?
¨ Yes - Please describe ¨ No
Guardian Name Description
___________________ ________________________________________________________________
___________________ ________________________________________________________________
Form G-03 (Effective January 1, 2023) Page 5 of 7
7. Is there any reason any guardian cannot continue to serve as guardian?
¨ Yes - Please describe ¨ No
Guardian Name Description
___________________ ________________________________________________________________
___________________ ________________________________________________________________
8. Did the Guardian receive compensation during the Report Period?
¨ Yes - Complete the table below ¨ No
Amount Guardian Name Is Amount Based on If Hourly,
Hourly, Monthly or Annual Fee? # of Hours
9. Was the compensation approved by the court?
¨ Yes - Date of Court Order:
¨ No - Explain why court approval was not obtained:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Form G-03 (Effective January 1, 2023) Page 6 of 7
I verify that the foregoing information is correct to the best of my knowledge, information and belief; and that
this verification is subject to the penalties of 18 Pa.C.S. §4904 relative to unsworn falsification to authorities.
I further acknowledge the Notice of Filing must be served within 10 days of the filing of this report pursuant
to Pa.R.O.C.P. 14.8(b). Service shall be in accordance with Pa.R.O.C.P. 4.3.
Date Signature of Guardian of the Person
Name of Guardian of the Person (type or print)
Address
City, State, Zip
Home Phone Number
Office Phone Number
Cell Phone Number
Email
Date Signature of Co-Guardian of the Person (if applicable)
Name of Co-Guardian of the Person (type or print)
Address
City, State, Zip
Home Phone Number
Office Phone Number
Cell Phone Number
Email
Form G-03 ( Effective January 1, 2023) Page 7 of 7