COURT OF COMMON PLEAS _____________ COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION

REPORT OF GUARDIAN OF THE ESTATE

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: ________________________________________________

Form G-02 (Effective January 1, 2023) Page 1 of 10 PART II. INCOME 1. List all sources of income received during the Report Period:

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

Alimony or Support ¨ Yes ¨ No $

Annuity Payments ¨ Yes ¨ No $

Dividends ¨ Yes ¨ No $

Interest Income ¨ Yes ¨ No $

IRA Distributions ¨ Yes ¨ No $

Long Term Care Insurance Benefits ¨ Yes ¨ No $

Pension/Retirement Benefits (for example: 401(k), 403(b), etc.) ¨ Yes ¨ No $

Public Assistance ¨ Yes ¨ No $

Rental Property Income ¨ Yes ¨ No $

Royalties (including from mineral and land rights) ¨ Yes ¨ No $

Social Security Benefits (Retirement, Disability, SSI) ¨ Yes ¨ No $

Tax Refund ¨ Yes ¨ No $

Trust Income ¨ Yes ¨ No $

Veterans Benefits (disability/pension/aid and attendance) ¨ Yes ¨ No $

Wages ¨ Yes ¨ No $

Worker's Compensation Benefits ¨ Yes ¨ No $

Other ¨ Yes ¨ No $

TOTAL $ 0.00

Form G-02 (Effective January 1, 2023) Page 2 of 10 PART III. ANNUAL EXPENSES 1. List all payments made for the care and maintenance of the Incapacitated Person during the Report Period.

Total for Expense To Whom Was It Paid? Report Period Auto Insurance $ Cable/Satellite/Internet $ Child/Spousal Support/Alimony $ Clothing $ Condo/Co-op Assessments $ Debt (incurred prior to your appointment) $ Entertainment $ Fees/Costs Paid to Guardian $ Food $ Gifts - Personal or Charitable $ Home Health Care/Personal Aide $ Homeowners Insurance $ Home/Property Maintenance & Repair $ Income Taxes $ Life Insurance Premiums $ Medical Insurance Premiums $ Medical Expenses $ Medicine $ Mortgage $ Nursing Home/Assisted Living/Institutionalized $ Care Personal Expenses (including allowance) $ Phone/Cell Phone $ Real Estate Taxes $ Rent $ Utilities $ Other $ TOTAL $ 0.00

Form G-02 (Effective January 1, 2023) Page 3 of 10 2. Does the Incapacitated Person have a credit card(s)? ¨ Yes ¨ No If yes, has it been used during this report period? ¨ Yes ¨ No What is the current balance on the credit card(s)? $ PART IV. COMPARING INCOME AND EXPENSES 1. Total Income (Part II, Question 1 TOTAL): $ 0.00 2. Unspent Income from Previous Year (Part IV, Question 5 from Last Year's Report): $ 3. Add lines 1 and 2 together to calculate this year's TOTAL INCOME: $ 0.00 4. Total Expense (Part III, Question 1 TOTAL): $ 0.00 5. Subtract line 4 from line 3. If amount is positive, enter it here to show UNSPENT INCOME, otherwise enter $0: $ 0.00 6. Subtract line 4 from line 3. If amount is negative, enter it here to show PRINCIPAL SPENT, otherwise enter $0: $ 0.00 7. Is line 6, PRINCIPAL SPENT, greater than $0? ¨ Yes ¨ No If yes, was a court order obtained? ¨ Yes - Date of Court Order: ¨ No - Explain why court approval was not obtained: __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ PART V. ASSETS 1. What was the value of the assets reported on the Inventory? $ 2. List any additional assets received during the Report Period? (for example: gifts, inheritance, burial account, lawsuit recovery, etc.) Any currently held asset not previously reported must be reported regardless of when the asset was obtained. Value at the end of Description/Source Report Period $ $ $ $ TOTAL $ 0.00

Form G-02 (Effective January 1, 2023) Page 4 of 10 3. Where are all the assets deposited or held at the end of the Report Period? Value at the end of List of Assets: Type and Location Co-Owners Report Period $ $ $ $ $ $ TOTAL $ 0.00

4. Does the incapacitated person own a house/condo/co-op? (If yes, please make sure the property is listed under assets.) ¨ Yes - Answer Questions a - e ¨ No a. Address of property: ___________________________________________________________________ b. Does the Incapacitated Person live in the house/condo/co-op? ¨ Yes ¨ No c. If purchased during the Report Period, what was the purchase price? $ d. If real property was sold during the Report Period, what was the sale price? $ e. Was a court order obtained if property was purchased or sold? ¨ 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.

Asset Transferred To Relationship Amount Order Explanation to IP Date $ $ $ $ $ $

Form G-02 (Effective January 1, 2023) Page 5 of 10 PART VI. GUARDIAN'S COMPENSATION

1. Did the Guardian receive compensation during the Report Period? ¨ Yes - Complete the table below ¨ No - Skip to Question 3

Amount Guardian Name Is Amount Based on If Hourly, Hourly, Monthly or Annual Fee? # of Hours $ $ $ $ $ $ $ $ $

2. Was the compensation approved by the court? ¨ Yes - Date of Court Order: ¨ No - Explain why court approval was not obtained: __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ 3. Have you maintained a log of your activities as guardian? ¨ Yes - Attach a copy ¨ No

PART VII. ATTORNEY'S FEES 1. Were attorney's fees paid during the Report Period? ¨ Yes - Complete the table below ¨ No - Skip to Part VIII

Amount Name of Counsel Hourly Rate # of Hours Order Date or Reason Not Approved $ $ $ $ $ $

Form G-02 (Effective January 1, 2023) Page 6 of 10 PART VIII. REPRESENTATIVE PAYEE 1a. Social Security Administration (SSA) Benefits ¨ The Incapacitated Person does not receive SSA benefits. ¨ The Guardian acts as the representative payee. If you were required to provide a report to the SSA during this Report Period, please attach a copy. ¨ The Guardian is not the representative payee for SSA benefits. The payee is _______________________.

1b. Veterans Administration (VA) Benefits ¨ The Incapacitated Person does not receive VA benefits. ¨ The Guardian acts as the fiduciary. If you were required to provide a report to the VA during this Report Period, please attach a copy. ¨ The Guardian is not the fiduciary for VA benefits. The fiduciary is _______________________. PART IX. SURETY INFORMATION 1. Was a surety bond required? ¨ Yes - In what amount $ - and then answer Questions a - b. ¨ No - The court waived a surety bond, skip to Question 2. a. Is the surety bond still in effect? ¨ Yes ¨ No - Provide an explanation as to why not. __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________

b. Is 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 If yes, has the amount of the surety bond been increased? ¨ Yes. To what amount: $ ¨ No

Form G-02 (Effective January 1, 2023) Page 7 of 10 2. If you are a professional guardian, agency or an attorney serving as guardian, do you have professional/guardian liability insurance that covers theft? ¨ Yes - Answer Question a and b. ¨ No - Skip to Part X. ¨ N/A a. Are the coverage limits greater than the assets (Part V, Question 3 TOTAL)? ¨ Yes ¨ No b. Describe the deductible and any exclusions. __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ PART X. GUARDIAN INFORMATION 1. 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

2. During this Report Period, have any judgments been filed against any guardian, or has any guardian filed for bankruptcy protection? ¨ Yes - Please describe ¨ No Guardian Name Description ___________________ ________________________________________________________________ ___________________ ________________________________________________________________

3. During this Report Period, was any guardian charged with or convicted of a crime? ¨ Yes - Please describe ¨ No Guardian Name Description ___________________ ________________________________________________________________ ___________________ ________________________________________________________________

Form G-02 (Effective January 1, 2023) Page 8 of 10 4. Is there any reason any guardian cannot continue to serve as guardian? Guardian Name Description ___________________ ________________________________________________________________ ___________________ ________________________________________________________________

PART XI. SUMMARY

1. If this is the first annual report, state the value of the assets reported on the Inventory. $ 0.00 (Use amount from Part V, Question 1 of this Report.) (principal)

2. If this is not the first annual report, state the Total Assets (principal) from the prior Report. $ 0.00 (Use TOTAL amount from Part V, Question 3 of prior Report.)

3. What was the total income received during the Report Period? $ 0.00 (Use the amount from Part IV, Question 3 of this Report.)

4. What is the total amount of Expenses paid during the Report Period? $ 0.00 (Use the amount from Part III, Question 1 of this Report.)

5. What are the Total Assets remaining at the end of the Report Period? $ 0.00 (Use the amount from Part V, Question 3 of this Annual Report.)

6. What is the Unspent Income at the end of the Report Period? $ 0.00 (Use the amount from Part IV, Question 5 of this Report.)

Form G-02 (Effective January 1, 2023) Page 9 of 10 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 Estate

Name of Guardian of the Estate (type or print)

Address

City, State, Zip

Home Phone Number

Office Phone Number

Cell Phone Number

Email

Date Signature of Co-Guardian of the Estate (if applicable)

Name of Co-Guardian of the Estate (type or print)

Address

City, State, Zip

Home Phone Number

Office Phone Number

Cell Phone Number

Email

Form G-02 (Effective January 1, 2023) Page 10 of 10