COURT OF COl\/[MON PLEAS OF ORPHANS’ COURT DIVISION To

IMPORTANT NOTICE CITATION WITH NOTICE A Petition has been filed With this Court to have you declared an Incapacitated Person. If` the Court finds you to be an lncapacitated Person, your rights Will be affected, including your right to manage money and property and to make decisions A copy of the Petition Which has been filed by is attached

You are hereby ordered to appear at a hearing to be held in Courtroom No. , , Pennsylvania on , 2 at _.m. to tell the Court why it should not find you to be an Incapacitated Person and appoint a Guardian to act on your behalf.

To be an Incapacitated Person means that you are not able to receive and effectively evaluate information and communicate decisions and that you are unable to manage your money and/or other property, or to make necessary decisions about Where you Will live, What medical care you Will get, or how your money Will be spent.

At the hearing, you have the right to appear, to be represented by an attorney, and to request a jury trial. If you do not have an attorney, you have the right to request the Court to appoint an attorney to represent you and to have the attorney’s fees paid for you if you cannot afford to pay them yourself. You also have the right to request that the Court order that an independent evaluation be conducted as to your alleged incapacity.

If the Court decides that you are an Incapacitated Person, the Court may appoint a Guardian for you, based on the nature of any condition or disability and your capacity to make and communicate decisions. The Guardian Will be of your person and/or your money and other property and Will have either limited or full powers to act for you.

Fomi' G~Ol Effective June 1,2019 Page l of 2 To:

If the Court finds you are totally incapacitated, your legal rights Will be affected and you Will not be able to make a contract or gift of your money or other property. If the Court finds that you are partially incapacitated, your legal rights vvill also be limited as directed by the Court.

If you do not appear at the hearing (either in person or by an attorney representing you), the Court will still hold the hearing in your absence and may appoint the Guardian requested By:

Orphans’ Court Clerk Form G~Ol Ef`fective June l, 2019 Page 2 of`2 COURT OF COMMON PLEAS COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION REPORT OF GUARDIAN OF THE ESTATE listate of: , an lncapacitated Person Name oflncapacitated Person

Case File No:

DATE COURT APPOINTED YOU AS GUARDIAN:

PART I. INTRODUCTION l. 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 Feriod"); or |: This is the Final Report for the period from to

EThe death of the lncapacitated Person.

Date of Deatli:

Name of Executor/Administrator: (the "Report Period") and is filed for the following reason:

E The Guardianship was terminated by a court order dated:

Transi"er of Guardianship to:

Date of court order approving transfer:

Forrn G-OZ Effective July l, 2018 p.lof9 PART II. INCOME l. List all sources of income received during the Report Period:

' Amount During Did the lncapacitated Person receive any of the following? Report Period

Alimony or Support

Dividends

Pension/Reriremem Beneiirs (for example 401(k), 403(b), ecc.) :| Yes m NO M,.W».~ .-m.

Trust Income l::| Yes |:l No

Wages |:| Yes |:| No

()ther \:|Yes l:___| No

Form G-02 Effective July l, 2018 p. 2 of9 PART III. ANNUAL EXPENSES l. List all payments made for the care and maintenance of the Incapacitated Person during the Report Period.

Expense To Whom Was lt Paid?

Total for Report Period

Auto Insurance

Forrn G~OZ Effective July l, 2018 p.30f9 2.

Does the lncapacitated Person have a credit card(S)? |:| Yes |::| No lfyes, has it been used during this report period? |:| Yes l:| No What is the current balance on the credit card(s)‘?

PART IV. COMPARING INCOME AND EXPENSES l.

Total Income (Part lI, Question l TOTAL): 2. Unspent Income from Previous Year (Part IV, Question 5 from Last Year's Report): 3. Add lines l and 2 together to calculate this year's TOTAL INCOME: 4.

Total Expense (Part III, Question l TOTAL): . Subtract line 4 from line 3.

If.` amount is positive, enter it here to show UNSPENT lNCOl\/IE, otherwise enter $0: Subtract line 4 from line 3.

If amount is negative, enter it here to show PRlNCIPAL SPENT, otherwise enter $O: ls line 6, PRINC.IPAL SPENT, greater than $0? |:|Yes |:|No lt" yes, was a court order obtained? |:Yes - Date of Court Order: :|No - Explain why court approval was not obtained:

PART V. ASSETS l.

2.

What was the value of the assets reported on the lnventory?

List any additional assets received during the Report Period (for example: gifts, inheritance, burial account, lawsuit recovery, etc.) TOTAL 0 F`orm G~OZ Ef`fective July l, 2018 3- Where are _a__ll the assets deposited or held at the end of the Report Period?

L-isi:_<)f` f TYP@@‘“d l TOTAL 0 4. Does the incapacitated person own a house/condo/co-op? |::] Yes - Answer Questions a - e |:|No a. b.

C.

Address of property:

Does the incapacitated Person live in the house/condo/co-op? |:| Yes |:| NO lf` purchased during the Report Period, what was the purchase price? . If real property was sold during the Report Period, what was the sale price?

Was a court order obtained if property was purchased or sold?

E Yes - Date of Court Order: |::| No - Explain why court approval was not obtained:

5. List any assets transferred to a third party such as a spouse or child.

Form G-02 Effective July l, 20l8 p. 5 of9 PART VI. GUARDIAN'S COMPENSATION l . Did the Guardian receive compensation during the Report Period? |:|ves - Compieie the table below |:|No _ skip to Quesrion 3

2. Was the compensation approved by the court? |:] Yes - Date of Court Order: [] No ~ Explain why court approval was not obtained:

3. l-Iave you maintained a log of your activities as guardian? |:|Yes - Attach a copy :|No PART VII. ATTORNEY'S FEES l. Were attorney's fees paid during the Report Period? |:| Yes - Complete the table below |:]No - Skip to Part Vlll

U$W}

PART VI[I. REPRESENTATIVE PAYEE la. Social Security Administration (SSA) Benefits |::|The Incapacitated Person does not receive SSA benefits |:|The Guardian acts as the representative payee - attach a copy of the report provided to the SSA during this Report Period. [|The Guardian is not the representative payee for SSA benefits. The payee is

Form G-02 Effective July l, 2018 p. 6 of9 lb. Veterans Adrninistration (VA) Benefits |:1 The lncapacitated Person does not receive VA benefits |:| The Guardian acts as the representative payee - attach a copy of the report provided to the VA during this Report Period. |::| The Guardian is not the representative payee for VA benefits The payee is

`PART IX. SURETY INFORMATION 1. Was a surety bond required?

1:1 YGS “ l“ What amount m - and then answer Questions a - b, |:| No - The court waived a surety bond, skip to Question 2. a. ls the Surety bond still in effect?

Yes |:1 No - Provide an explanation as to why not.

bn ls the value of the estate at the end of the Report Period greater than the amount reported at the end of the prior report period? |:| Yes |::| No lf yes, has the amount of the surety bond been increased'? |: Yes. To what amount: |:No 2. lf you are a professional guardian, agency or an attorney serving as guardian, do you have rofessional/guardian liability insurance that covers theft?

Yes - Answer Question a and b.

13 No ~ skip to Pari X.

E N/A a. Are the coverage limits greater than the assets (Part V, Question 3)? |:| Yes |:|No b. Describe the deductible and any exclusions

Form G-02 Effective July 1, 2018 p. 7 of9 PART X. GUARDIAN INFORMATION 1. lf yes provide the following information:

During this Report Period, did any guardian participate in guardianship training? |:] Yes |:] No

Wms.z

During this Report Period, have anyjudgments been filed against any guardian, or has any guardian filed for bankruptcy protection? :|Yes - Please describe\:| No Guardian Name Descr:'p.u`on

. During this Report Period, was any guardian charged with or convicted of a crime?

EYes - Please describel:lNO Guardian Name Descriptc`ori

4. ls there any reason any guardian cannot continue to serve as guardian? l::|Yes - Please describe|:|l\lo Guardian Nrtme Desc.riprr'nn

PART XI. SUMMARY

If this is the first annual report, state the value of the assets reported on the lnventory. ` (Use amount from Part V, Question l of this Report.) (principal)

lf this is not the first annual report, state the Total Assets (principal) from the prior Report. - (U se TOTAL amount from Part V, Question 3 of prior Report.)

What was the total income received during the Report Period? ' (Use the amount from Part lV, Question 3 of this Report.)

What is the total amount of Expenses paid during the Report Period? ' (Use the amount from Part lll, Question l ofthi`s Report,)

What are the Total Assets remaining at the end of the Report Period? ' (Use the amount from Part V, Question 3 of this Annual Report.)

What is the Unspent Income at the end of the Report Period?

6' (Use the amount from Part lV, Question 5 of this Report.)

Form G-02 Effective July l, 2018 p.80f9 l 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 Effective June l, 2019, l further acknowledge the Notice of Filing must be served within 10 days of the filing of this report pursuant to Pa. O.C. Rule 14.8(b).

Date _ Sighar‘ure oquara’r'an afthe Eslate

Name oquarch'ah ofth Esrate (type or priht)

A ddress

Cr'ly, Srafe, Zr`p

Home Phohe Number

O]j‘ice Phohe Number

Ceh' Phone Number

Emai`i

Date Sr`ghature ofCr)-Guardr'an ofthe Estate

Name QfCo-Gtrardiah ofrhe Estare (type cr print)

Address

Ci`ty, Srate, Zi'p

Home Phone Number

Ojjrce Phohe Number

Emai'l Form G-02 Effective luly 1, 2018 p. 9 of9 COURT OF COMMON PLEAS COUNTY, PENNSYLVANIA ORPHANS‘ COURT DlVlSlON REPORT ()F GUARDIAN OF THE PERSON Estate of: , an lncapacitated Person Name oflhcapacirated Person

Case File No:

DATE COURT APP()INTED YOU AS GUARDIAN:

PART I. INTRODUCTlON 1. Name(s) of Guardian(s):

2, ls this a limited Guardianship? |:|Yes !:|No 3. Report Period |:| This is the Report for the period from to (the "Report Period"); or

i:| This is the Final Report for the period from to (the "Report Period") and is filed for the following reason:

[| The deem errhe incapacitated Pereen.

Date of Death: 7 Name of Executor/Administrator:

|:| The Guardianship was terminated by a court order dated:

|:| Transfer of Guardianship to: Date of court order approving transfer:

IF_THrs rs A FINAL REPORT, oNLY .crjMPLETE PART;;s_ o_1 ANI) v. ` Forrn G~03 Effective July 1, 2018 p.10f6 PART II. l’ERSONAL INFORMATION ABOUT THE INCAPACITATED PERSON l. lncapacitated Person's date of birth: f / 2. lncapacitated Person's Current Residence:

3. Residence of the lncapacitated Person E lncapacitated Person's home ( :| with part-time home health care aide or |:| 24/7 assistance) i:| Your home Relative's home Relative's Name: ` Relationship:

Domiciliary Care Facility Name:

Personal Care Boarding llome Facility Name: is this a Memory Support Facility? |:| Yes |:| NO |:| Assisted Living Facility Facility Name: ls this a l\/lemory Support Facility? |:| Yes |::| No

Nursing Home Facility Facil ity Name:

ls this a l\/lemory Support Facility? |:| Yes |:| No m Other: 4. The lncapacitated Person has been in the residence noted in question 3 since:

5. Has the lncapacitated Person moved during the Report Period? |:| Yes |:| No lfyes, date ofmove:

lfyes, please provide: Reason for move:

Previous residence/address

Form G-03 Effective ]u.ly 1, 2018 p. 2 of6 PART III. MEDICAL INFORMATION 1. luist the medical professionals who have seen the lncapacitated Person durin h Report sm-qg Period'

Medical Doctor

Dentist

Eye Doctor

Ear Doctor

Psychoiogist or Psychiatrist

Physical Therapist

Occupational Therapist

Social Worker

Geriatric Caseworker

()ther

2. The major medical or psychiatric problems of the lncapacitated Person are as follows:

3. l)escribe any social, medical, psychological and support services the lncapacitated Person is receiving:

4. lelas the lncapacitated Person been hospitalized during the Report Period? |:| Yes N o lf yes, date(s) of hospitalization:

5. Has the lncapacitated Person received a mental health assessment during the Report Period? m Yes m No lfyes, date(s) of evaluation:

Form G-03 Effective July l, 2018 p. 3 of6 PART IV. GUARDIAN'S OPINION l. Should the guardianship be: |::i Continued |:| Continued with modifications :| Terminated 2. Provide the reasons for your opinion. List specific recommended modifications

3. Have you filed a petition for modification or termination? |:| Yes ij No PART V. INF()RMATION ABOUT THE GUARDIAN l. On average, how often did you visit the lncapacitated Person during the Report Period?

1:| l live with the lncapacitated Person ij None ij Quarterly [:| Memhiy E Weekly |:] Dain 2. What is the average length ofa visit?

E Less than 15 minutes [:l Between 15 minutes and 1 hour 1:| Between l and 2 hours m More than 2 hours ij Not applicable 3. l~lave you maintained a log of your activities as guardian? m Yes - Attach a copy ENO Form G~03 Effective July 1, 2018 p.4of6 4. During this Report Period, did any guardian participate in guardianship training? |:1 Yes 1:1 No lf yes, provide the following information:

5. During this Report Period, was any guardian charged with or convicted of a crime? l:iYes - Please describe |:| No Guardian Name Descri'pn'on

During this Report Period, was a Protection from Abuse Order or Protection from Sexual Violence or lntimidation Order entered against any guardian?

EYes ~ Please describe l:! No Guardian Name Descrr`pfr'oh

7. ls there any reason any guardian cannot continue to serve as guardian? l:]Yes - Please describe |:] No Guardian Nrim€ Descri'prioh

Forni G-03 E'ffective .luly l, 2018 p. 5 of6 l 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 Effective June l, 2019, l further acknowledge the Notice ofFiling must be served within 10 days of the filing of this report pursuant to Pa. O.C. Rule 14.8(b).

Date Signature oquardi'an ofth Person

Name oquardiah ofthe Person (lype or pri'nr)

A dcfress

Ci`ly, State, Zr'p

Home Phohe Number

Oyj"rce Phohe Numher

Celf Phohe Number

Email

Date Sr`gharure of 610-Guardian erhe Person

Name ofCo-Guardiah ofrhe Person (lj/pe or priht)

Address

Cr'ly, Siafe, Zr.`p

Home Phone Numher O]jice Phohe Numher

Cell Phone Number

Emar`l Forni G~03 Effective July l, 2018 p. 6 of6 COURT ()F COl\/IMON PLEAS OF _ COUNTY, PENNSYLVANIA ORPHANS’ COURT DIVISION GUARDIAN’S INVENTORY F()R A MINOR Estate of _ _ } a_ l\/linor 1. Real Estate: (Location, by whom occupied and rental Estimated Value: terms, if applicable)

Sub-Tota[_for Rea[ Estate: 2. Personal Property: Estim ated Value:

3. Jointly Held Property: Estimated Value: (Setforrh real and personal property owned by the Mi`nor .!G!NTLY with any other person(s). Sra.ie whether held as tenants by the ehli`)'e!r`es,' ifrrot, whether the right of survivorship exis!s.)

J'oinfly Hr:ld Property

Form G-04 Effective July 1, 2018 Pag€ 1 Of2 Estate of _ } a Minor 4. Anticipated Assets: Estimated Value: (Ser forth properly ofany kind expected to be acquired hereafter. together with anticipated date ofacqnz'sr'tr'oh.)

Pmpeny Antr`cipated Date ofA cqur`sitr'on

Sub-Tomlfor Personal Estate: Attach Addirionar' Sheets if necessary TOTAL OF ITEMS 1, 2, 3, and 4: .............................. ` Commonwealth of Pennsylvania : : ss.

County of _ , says that the foregoing is a full, true and complete Guardian lnventory of the Estate of ` \ , a l\/[inor; and that all ofthe information set forth herein is true and correct to the best Of the Guardian’s knowledge and belief. l verify that the statements made in this ) lnventory are true and correct. l under- ) stand that false statements herein are ) made subject to the penalties of ) Pa.C.S. § 4904 relating to unsworn ) Guardian Signature falsification to authorities )

Attorney for Guardian:

Suprerne Court l.D. No.: Address:

Telephone:

Form G-04 Ef'fective July l, 2018 Pag@ 2 sz COURT OF COMMON PLEAS COUNTY, PENNSYLVANLA ORPHANS' COURT DlVlSlON

GUARDIAN‘S INVENTORY FOR AN INCAPACITATED PERSON Estate of: 7 7 7 , an lncapacitated Person Name offhcapacitatea’ Person

Case File No:

DATE COURT APPO[NTED YOU AS GUARDIAN:

PART I: INTRODUCTION lnventory type: PART ne AssETs (PRINCIPAL) I. luist all bank accounts, real estate, burial accounts, and other personal property below. If the property is owned by both the incapacitated person and others, indicate in the last column the name of the co-owner.

Asset Value Name of Co-Owner(s)

Form G-05 Eff`ective July l, 2018 Page 1 of 8 guard ian? :| Yes m ~@ lf yes: a. On what date was the property acquired?

b. On what date was the guardian's name added?

c. The guardian is: [|an individual having access or control over the account man owner of the account 3. Does the lncapacitated Person have a homeowners insurance policy for real property? |:| Yes (Copy of policy to be provided upon request) l\lo If yes: a. Carrier:

b. Coverage period:

4. Does the lncapacitated Person have an automobile insurance policy?

1:| Yes (Copy of policy to be provided upon request) |:|No lf yes: a. Carrier:

b. Coverage period:

5. Does the lncapacitated Person have a safe deposit box? |:|No |:| Yes, in sole name

|:l Yes, in joint name(s). List the name(s) ofjoint owner(s): lf yes: a. Location of safe deposit box:

b. Are there plans to inventory the contents? |:lYes |:No Forrn G~O§ Effective July l, 2018 ls any property (specifically bank accounts or real estate) co»owned by the lncapacitated Person and the Page 2 of 8 PART III: ANNUAL INC()ME l. List all sources of income for the lncapacitated Person:

Does the lncapacitated Person receive any of the following as income?

Specify Amount

Alimony or Support

Pension/Retirement Benefits (for example

Form G~05 Effective July 1, 2018 Page 3 of 8 PART IV: LIABILITIESfDEBTS l. List all debts the lncapacitated Person owes, including mortgages loans, credit card debt, etc.

Liabilities/Debts Lender Value

2. Are you a professional guardianship agency or an attorney serving as a guardian? m Yes m No lf yes, do you have professional liability coverage? |:| Yes (Please attach a copy of the insurance policy) l:|l\lo lf no, explain:

Form G»05 Effective July 1, 2018 Page 4 of8 PART VI: PERSONAL CARE PLAN . Can the lncapacitated Person remain in his or her current residence with assistance, or in the home of a relative?

1:1 Yes |:| l\lo :| N/A - "l`he lncapacitated Person is already in a supervised residential setting If yes: a. List the name of the responsible family member:

b. What Services does the lncapacitated Person require? |:| Services from local Area Agency on Aging ['Private Cornpanion/Assistance Service Number of days per week: Number of hours per week: |::|Assistance from family members Will compensation be provided? |:| Yes |::| No lf yes, indicate compensation amount:

2. Will the lncapacitated Person be moved into a supervised residential setting? |:| Yes [:1 No N/A - The lncapacitated Person is already in a supervised residential setting. lf yes: a. lndicate the type of supervised residential setting: |:] Domicilial”y Care ij Personal Care |:| Boarding l~lome / Group Home |: Assisted Living Facility |::| Nursing Home |: Other: b. Describe the steps that are being taken to move the lncapacitated Person into a supervised residential setting.

Form G~05 Effective .luly l, 2018 Page 5 of8 PART VII: FINANCIAL PLAN 1. Complete the following table using initial inventory or most recent amended inventory. a. Total Annual income d. Total assets (principal) (PHF'I lll, QU@StiOn 1) 5 0-00 (Part ll, Question 1) 5 0-00 b. Annual estimated expenses c. Net Income (a minus b) 13 0.00 2. ls the net income listed above sufficient to care for the needs of the lncapacitated Person? l_:] Yes l:‘ No, but assets (principal) are available if a court order approves expenditures \:| l\lo, and assets (principal) are not available 3. lndicate any applications for government benefits that have been submitted:

Application Type Date of Submission

Social Security Disability lnsurance (SSDI) m

___-ek Social Security Retirement Benef.its

l\/Iedical assistance, long term care

Other

(Explain: )

4. Describe all real estate included in the estate and how it will be maintained or sold:

Form G-05 Effective .luly l, 2018 Page 6 of 8 5. Prior to the appointment of a guardian, has an agent under a Power of Attorney been serving? |:| Yes :| l\lo lf yes, has an accounting ever been requested or filed with the Orphans' Court? l:| Yes |:| No lf yes, was the agent the same person as the guardian? |:| Yes |:l l\lo PART VIII: MEDICAL INFORMATION 1. ls a "no-code" (Do Not Resuscitate) provision in place for the incapacitated person?

Yes \:| l\lo When still capacitated, did the lncapacitated Person execute a durable power of attorney for health care or some other health care directive (including, but not limited to, a POLST, a living will, or a mental health care power of attorney)?

Yes :|l\lo lf yes, identify the authorized agent for making health care decisions:

3. Are you aware of any will or trust executed by the lncapacitated Person, or any funeral or burial wishes of the lncapacitated Person? |::| Yes |:| Ne lfyes, please explain:

Has a burial account been established for the lncapacitated Person? |:| Yes |:| No lfyes, what is the value of the burial account?

Form G-05 Effective July 1, 2018 Page 7 of8 l 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 Effective June 1, 2019, l further acknowledge the Notice of Filing must be served within 10 days of the filing ofthis report pursuant to Pa. O.C. Rule 14.8(b).

Date Signarnre oquara’i`an of the Estate

Nome of Guardian ofthe Estafe (type or prfht)

Address

Cr`ly, State, Zi`]:)

Home Phohe Numher

O]j?ce Phone Number

Cell Phohe Nn.mber

Emar.`l

page Sighature ofCo-Guardian ofthe Esrare (ifapplicable)

Name of Co-Guardz`ah ofthe Estote (rype or priht)

Address

Cily, State, Zr`p

Home Phone Nurnber

Ojj‘ice Phorie Number

Cell Phone Number

Email Form G-05 Ef`fective July 1, 2018 Page 8 of 8 INSTRUCTIONS FOR SUBMITTING AN EXPERT REPORT To establish incapacity, the petitioner must present testimony from an individual qualified by training and experience in evaluating persons with incapacities of the type alleged by the petitioner. As an accommodation to such expert witnesses, the court may accept a complete and legible expert report in accordance with the attached form in lieu of expert testimony, whether in person or by deposition, unless otherwise required by rule or order of court.

Forrn G-06 Effective June l, 2019 COURT OF COl\/ll\/ION PLEAS OF COUNTY PENNSYLVANIA ORPHANS’ COURT DIVISION EXPERT REPORT

An Afleged lncapacitated Person (AIP) No.

PART I: PROFESSIONAL BACKGR()UND (You may attach your curriculum vitae, ifit provides an- swers to Questions 1 through 5. Please answer those questions not covered by curriculum vitae.) l . Name: Title:

2. Professional Address:

3. Complete education information:

Name of institution Type of Degree Received Date Completed

Undergraduate

Graduate

`Post-Grad uate

4. Do you have any active professional licenses? |:1 Yes l::l No lf yes, indicate in what state or states you are licensed as well as the date(s) issued.

List any board certifications:

5. An lncapacitated Person is legally defined as: An adult whose ability to receive and evaluate information effectively and communicate decisions in any way is impaired to such a significant extent that he/she is partially or totally unable to manage his/her financial resources or to meet essential requirements for histl her physical health and safety.

Do you have experience evaluating whether or not an individual is incapacitated? |:| Yes |:| No lf yes, indicate the basis of your experience:

Forrn G~06 Effective June 1, 2019 p. 1 of5 PART II: ALLEGED INCAPACITATED PERSON (AIP) 6. a. lafave you treated, assessed, or evaluated the AlP?

EYes |::|No b. lndicate the date(s) and location of any treatment, assessment, or evaluation you have provided or made over the last two (2) years:

c. lf 6a. is yes, what tests have you or others administered, e.g., mini mental status exam (l\/ll\/ISE), l\/Iontreal Cognitive Assessment (l\/IOCA), St. Louis University Mental Status Exam (SLUMS), etc.?

List dates administered and the score. (Attach test results notjust the Score.)

7. What is the present condition of the AIP? List all known medical and psychiatric diagnoses and current symptoms (You may attach a list from your records.)

l)iagnosis Svmptoms/Manifestations

8. List all known medications including over-the-counter, that the AlP is taking. For each known medication, indicate, if known, the prescribing physician and the diagnosis for which the medication was prescribed or the reason for taking. (You may attach a list from your records)

Medication Diagnosis/Reason Taken Prescribing Physician

Form G-06 Effective June l, 2019 p. 2 of5 9. lndicate the AlP’s ability to perform the following functions:

Needs Somc Tota]l Not Assessed Unimpairecl Help . y or Not Enough . . lmpaired , (Explam ln #10 ) llthl'mE\flOn

Receiving and evaluating information effectively |:l

Communicating decisions

Ability to give informed consent

Sliort-term memory

Long»term memory

Activities of daily living

l\/Ianaging finances (including paying bills, making deposits, withdrawals and working with financial institutions)

l\/lanaging health care (including following doctor’s orders and managing/taking medications)

Providing for physical safety

Responding to emergency situations

Ability to resist scams

E.EEE |j l:lEEEEE EEEE E |IEEEEE EEEE E EEEl:ll:lE EEE E lj E|IEl:l

10. .For any response in Question 9 where the AlP “needs some help,” please describe the type and extent of assistance needed

l l. What recommendations have you made or would you make concerning services necessary to meet the essential requirements for the AlP’s physical health and safety?

Form G-06 Effective lune 1, 2019 p. 3 of5 12. What recommendations have you made or would you make concerning management of the All”s finances?

13. As indicated in Question 5, an lncapacitated Person is legally defined as: An adult whose ability to receive and evaluate information effectively and communicate decisions in any way is impaired to such a significant extent that he/she is partially or totally unable to manage his/her financial resources otto meet essential requirements for his/her physical health and safety. ln your expert opinion, within a reasonable degree of professional certainty and based on your knowledge, skills, experience, and education, is the AlP incapacitated? |:Yes, totally impaired |:| Yes, partially impaired |:| No 14. ln our opinion, the most appropriate, least restrictive living situation for the AlP is (check one): l ii`he AIP can be left alone without supervision |::|Home (|:|with part-time home health aide or |:1 24/ 7 assistance) |:llndependent living facility (room and board provided, emergency services readily available) Assisted living facility (room and board provided, assistance with some activities of daily living) 1:18ecure facility (Alzheimer’s/Mental Health for safety and basic needs) |:|Skilled nursing facility 15. lf your responses in Question 9 indicated that the AlP is totally impaired or “needs some help”, do you expect the AlP’s abilities in the next 6 months to (Check best estimate): :|Stay the same 1:|lmprove |:iDecline Please explain:

PART III: GUARDIANSHIP AND SERVICES 16. Are you aware of any circumstances medical or otherwise, that create a need for the appointment of an emergency guardian for the AlP‘? |:|Yes |::1 No lfyes, indicate reasons:

Form G-06 Effective June l, 2019 p. 4 of 5 17. The AlP is required to be at the hearing, absent circumstances that could cause harm to the AIP. Putting aside whether the court proceeding may be moderately upsetting to, confusing to or not understood by the AIP, do you believe that the AlP’s presence at the hearing would cause harm to the AIP’s physical or mental condition?

1:1Yes 1:|1\10 lndicate reason for response:

18. Please provide any additional information that could assist the court in determining incapacity.

l 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

Date Sz'ghamre

Name (n)pe or print)

Ada'ress

Ci'ty, Stare, Zz`p

Telephone

Ema.il Form G~06 Effective .lune 1, 2019 p. 5 of5 COURT OF COMl\/ION PLEAS OF COUNTY, PENNSYLVANIA ORPHANS’ COURT DIVISION

NOTICE OF PILING ESTATE/GUARDIANSH]P OF , AN INCAPACITATED P.ERSON , GUARDlAN No. l certify that on l filed the following documents: E lnventory |:| Amended lnventory |: Annual Report - Guardian of the Person |:| Annual Report - Guardian of the Estate :[ Final Report A copy of this Notice of Filing is being served on the following person(s) designated by court order and in the following manner:

l::| By mail |:| By fax \:| By personal delivery [| By e-mail ifrequested

2. :| By mail l:| By fax |:| By personal delivery |___| By emaili'frequested 3. |:1 By mail |:i By tax |:] By personal delivery |:| By emailifrequested 4.

1:| By mail \:l By'fax |:| By personal delivery |:| By email if requested Fctm G_t)'/ affective Jtme i, 2019 Pas€ l Of 2 Submitted by:

Date Sigriarure

Name @)rint or rype)

A address

Ci'ty, State, Zr'p

Telephone

Emaii

Instructions for Document Access lf you are one of the individuals noted above to whom this notice of filing was sent, you may access and view the documents filed by presenting this notice of filing along with proper identification to the Clerk of the Orphans’ Court in the county listed on the previous page.

Fctm G~o'/ affective lime 1, 2019 Pase 2 01°2