IN THE COURT OF COMMON PLEAS OF MONTGOMERY COUNTY, PENNSYLVANIA ORPHANS’ COURT DIVISION IN RE: , an incapacitated person FILE NO.______________ GUARDIAN OF THE ESTATE INITIAL/ANNUAL/ FINAL REPORT [20 Pa. C.S.A. 5521(C)] FROM TO _____________ Limited Plenary Guardian of the Estate of my ward, named above. 1. I am the , which was I was appointed Guardian by Order of the Court dated ____was not modified by Court Order(s) dated . 2. Is the incapacitated person still living? ______________ If no, answer the following: (a) Date of Death? (b) Place of Death? (c) Name of Administrator or Executor? (d) Date Guardian of the Person filed the last Annual Report? PLEASE ANSWER THE FOLLOWING QUESTIONS WHETHER THE INCAPACITATED PERSON IS LIVING OR DECEASED. 3. My initial Inventory was filed on _______________ and listed a total estate value of $___________________. The Inventory listed a total monthly income of $__________________ comprised of the following:_____________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 4. At the beginning date of this reporting period, my initial balance on hand was $_________________. 1 American LegalNet, Inc. www.FormsWorkflow.com 5. During this reporting period, the following reflects all sources of income (other than social security) received by me for my ward: (Add additional pages if needed) Date Received Source of Income Amount 1. 2. 3. 4. 5. 6. Total 6. During this reporting period, the following reflects all payments I have made for my ward: (Add additional pages if needed) Date To Whom Paid Reason for Payment Amount 1. 2. 3. 4. 5. 6. Total 7. The present principal assets of my ward are: Description of Asset Present Value 1. 2. 3. 4. 5. 6. Total 2 American LegalNet, Inc. www.FormsWorkflow.com 8. The present amount and sources of income for my ward are: Source of Income Amount of Income (Indicate whether monthly, quarterly, annually) 1. 2. 3. 4. 5. 6. 9. The regular monthly expenses of my ward which I pay are: To Whom Paid Amount 1. 2. 3. 4. 5. 6. 10. I have / have not (circle one) petitioned the Court for permission to invade principal to meet the needs of my ward. (If applicable) The following expenses of my ward have been paid from principal: To Whom Paid Purpose Amount 1. 2. 3. 4. 5. 6. 3 American LegalNet, Inc. www.FormsWorkflow.com 11. I have / have not (circle one) paid myself compensation for services I rendered as guardian. The amount I paid myself totaled $_____________________ and was calculated at the following rate: $______________ per week / month (circle one). 12. Circle the correct response and complete, if appropriate. There will be no need for extraordinary expenditures on behalf of my ward in the next twelve (12) months. or There will be a need for extraordinary expenditures on behalf of my ward in the next twelve (12) months because: 13. Circle the correct response and complete, if appropriate. A. B. C. My ward receives monthly social security benefits directly. I am the designated payee to receive my wards’ social security benefits. The designated payee of my wards’ social security benefits is: __________________________________________________ whose address is: __________________________________________________ __________________________________________________ __________________________________________________ and is / is not (circle one) related to my ward as __________________________________________________ __________________________________________________ _________________________________(insert relationship). 14. Please note any concerns about the incapacitated person’s physical or mental well being or the finances that the Court should know. _____________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 4 American LegalNet, Inc. www.FormsWorkflow.com 15. I _____ am ______ am not guardian of the incapacitated person’s person. If yes, my report is attached. I certify under the penalties of perjury that the information contained in this report is true and correct to the best of my knowledge, information and belief. Date: ___________ ______________________________________ Signature of the (Co-)Guardian of the Estate Name: _______________________________ Address: _____________________________ _____________________________________ Date: ___________ Telephone # Home: ______________ Work: ______________ ______________________________________ Signature of the (Co-)Guardian of the Estate Name: _______________________________ Address: _____________________________ _____________________________________ Telephone # Home: ______________ Work: ______________ 5 American LegalNet, Inc. www.FormsWorkflow.com