COURT OF COMMON PLEAS PHILADELPHIA COUNTY, PENNSYLVANIA ORPHANS’ COURT DIVISION O.C. NO. __________ OF __________ ESTATE OF ________________________________________, AN INCAPACITATED PERSON ANNUAL REPORT OF GUARDIAN OF THE ESTATE I ,______________________________________________________, was appointed (Name of Guardian) ______________________ guardian of the estate by Decree of ___________________ J., (Plenary or limited) dated _______________________, __ ____. This is my annual report for the period from _____________________, __ ____ to _______________________, __ ____ (the “Report Period”). I. SUMMARY A. Value of principal assets at the beginning of the Report Period? (See Inventory if first report, otherwise last report) $ ____________________ B. Total amount of income earned during the Report Period? C. $ ____________________ Total amount of all expenditures made for care and maintenance of the Incapacitated Person during the Report Period? $ ____________________ (1) (2) From principal From income $ _______________ $ _______________ D. Total amount spent for all other purposes during the Report Period? $ ____________________ E. Total amounts remaining at the end of the Report Period? (1) (2) (3) Principal Income Total (1 & 2) $ _____________ $ _____________ $ _____________ 2002 © American LegalNet, Inc. II. ADDITIONAL INFORMATION (If more space is needed, attach additional pages) A. Principal: (1) Total amount remaining at the end of the Report Period? $____________ (2) How is principal currently invested? (Please specify, i,e., real estates, certificates of deposits, restricted bank accounts, etc.): __________________________________________________ __________________________________________________ __________________________________________________ (3) Have there been any expenditures from principal during the Report Period? (check one) 9YES or 9 NO (4) Did you receive any principal assets during the Report Period which were not included in the Inventory or a prior report filed For the estate. (check one) 9 YES or 9 NO If you answered YES: (a) Did you receive Court approval prior to receiving additional principal? (check one) 9YES or 9 NO (b) State the sources and amounts of the additional principal you received: _____________________________ _____________________________ $ ____________ _____________________________ B. $ ____________ $ ____________ INCOME: (1) State sources and amounts of income received during the Report Period (i.e., Social Security, Pension, Rents, etc.): _________________________________________ $_____________ _________________________________________ $_____________ _________________________________________ $_____________ Total income received during Report Period $_____________ 2002 © American LegalNet, Inc. (2) How is income currently invested? (Please specify, restricted bank accounts, client care account, etc. ) ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ C. Specify what payments were made for the care and maintenance of the Incapacitated Person (i.e., clothing, nursing home, medicine, support, etc.) _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ D. Specify what other payments were made during the Report Period. (Do not include any items stated in response to question C above). _______________________________________________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ 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.A. 4904 relative to unsworn falsification to authorities. Date: ____________________ , 20 ____ Signature ______________________________ Name of Guardian (type or print) ______________________________ Address ______________________________ City, State, Zip ______________________________ Telephone Number ______________________________ 2002 © American LegalNet, Inc.