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