IN THE COURT OF COMMON PLEAS OF MONTGOMERY COUNTY, PENNSYLVANIA ORPHANS’ COURT DIVISION IN RE: , an incapacitated person FILE NO. _____________ GUARDIAN OF PERSON INITIAL/ANNUAL/ FINAL REPORT [20 Pa. C.S.A. 5521(C)] FROM 1. I am the Limited TO _____________ Plenary Guardian of the Person of my ward, named above. 2. I was appointed Guardian by Order of the Court dated was not modified by Court Order(s) dated , which was . 3. 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? 4. If the incapacitated person is still living, answer the following questions: (a) Date Guardian of the Person filed the last Annual Report? (b) Current address of the incapacitated person (c) Current age Date of birth of incapacitated person (d) The incapacitated person’s residence is: Ward’s own residence My home/apartment Nursing Home Relative’s Home Hospital or Medical Facility Boarding Home ______ Other ________________________________________________ (e) The incapacitated person has been living there since If moved within the past year, state from where and the reason for the change 1 American LegalNet, Inc. www.FormsWorkflow.com (f) I rate his/her living arrangement as: Excellent Average Below Average Explain: __________________________________________________________ __________________________________________________________________ (g) I believe he/she is: content with the living situation unhappy with the living situation unaware of the living situation 5. Physical health (a) Current physical condition of the incapacitated person is: Excellent Good Fair Poor (b) His/her major physical health problems are as follows: ________________________ ________________________________________________________________________ ________________________________________________________________________ (c) During the past year, his/her physical condition has: remained about the same. improved. Explain:___________________________________________ worsened. Explain: __________________________________________ Date (d) During the past year, he/she received the following medical treatment (include checkups and dental work): Ailment Type of treatment Doctor’s name ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 6. Mental Health (a) The incapacitated person’s condition is: excellent good poor (b) His/her major mental health problems are as follows: __________________________ ________________________________________________________________________ ________________________________________________________________________ _________________________ _____ (c) During the past year, his/her mental condition has: remained about the same. 2 American LegalNet, Inc. www.FormsWorkflow.com improved. Explain worsened. Explain (d) During the past year, treatment or evaluation by a psychiatrist, psychologist or social worker was _____ was not provided. Such mental health services are briefly described as: _____________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 7. Social Activities / Services (a) His/her current social condition is: _____ excellent _____ good _____ fair _____ poor (b) During the past year, his/her social condition has: _____ remained about the same. _____ improved. Explain._______________________________________________ _____ worsened. Explain._______________________________________________ (c) During the past year he/she has participated in the following activities: _____ recreational______________________________________________________ _____ educational______________________________________________________ _____ social __________________________________________________________ _____ occupational ____________________________________________________ _____ no activities available. _____ he/she refuses to participate in any activities. _____ he/she is unable to participate in any activities. 8. Visitation (a) During the past year, I visited him/her as follows:_____________________________ _____________________________________________________________________ (b) The average amount of time I spent on each visit was _________________________. (c) The last time I visited was on __________. date 9. During the last year I have performed the following activities on behalf the incapacitated person:________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 3 American LegalNet, Inc. www.FormsWorkflow.com 10. I believe he/she has the following unmet needs:____________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 11. The guardianship _____ should _____ should not be continued without modification because: ______________________________________________________________________________ _______________________________________________________________________ 12. Please note any concerns about the incapacitated person’s physical or mental well being or the finances that the Court should know. _____________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 13. I _____ am ______ am not guardian of the incapacitated person’s estate. 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 Person Name: _______________________________ Address: _____________________________ _____________________________________ Date: ___________ Telephone # Home: ______________ Work: ______________ ______________________________________ Signature of the (Co-)Guardian of the Person Name: _______________________________ Address: _____________________________ _____________________________________ Telephone # Home: ______________ Work: ______________ 4 American LegalNet, Inc. www.FormsWorkflow.com