COURT OF COMMON PLEAS COUNTY, PENNSYLVANIAORPHANS' COURT DIVISIONGUARDIAN'S INVENTORY FOR AN INCAPACITATED PERSON Estate of: , an Incapacitated PersonName of Incapacitated PersonCase File No: DATE COURT APPOINTED YOU AS GUARDIAN: PART I: INTRODUCTIONInventory type: 250 Initial 250 AmendedPART II: ASSETS (PRINCIPAL)1. List all bank accounts, real estate, burial accounts, and other personal property below. If the property is owned by both the incapacitated person and others, indicate in the last column the name of the co-owner. AssetValueName of Co-Owner(s) TOTAL Page 1 of 8 American LegalNet, Inc. www.FormsWorkFlow.com Is any property (specifically bank accounts or real estate) co-owned by the Incapacitated Person and the guardian?2.YesNoIf yes:On what date was the property acquired?a.b.On what date was the guardian's name added?c.The guardian is:an individual having access or control over the accountan owner of the account 250 250 250 250 Does the Incapacitated Person have a homeowners insurance policy for real property?3.If yes:Carrier:a.b.Coverage period: 250Yes(Copy of policy to be provided upon request)250No Does the Incapacitated Person have an automobile insurance policy?4.If yes:Carrier:a.b.Coverage period: 250Yes(Copy of policy to be provided upon request)250No Does the Incapacitated Person have a safe deposit box?5.Yes, in sole nameYes, in joint name(s). List the name(s) of joint owner(s): If yes:Location of safe deposit box:a.b.Are there plans to inventory the contents?NoYesNo 250 250 250 250 250 Page 2 of 8 American LegalNet, Inc. www.FormsWorkFlow.com PART III: ANNUAL INCOMEList all sources of income for the Incapacitated Person:1. Does the Incapacitated Person receive any of the following as income?Specify AmountAlimony or SupportYesNo 250 250 Annuity PaymentsYesNo 250 250 DividendsYesNo 250 250 Interest IncomeYesNo 250 250 IRA DistributionsYesNo 250 250 Long Term Care Insurance BenefitsYesNo 250 250 Pension/Retirement Benefits (for example: 401(k), 403(b), etc.)YesNo 250 250 Public AssistanceYesNo 250 250 Rental Property IncomeYesNo 250 250 Royalties (including from mineral and land rights)YesNo 250 250 Social Security Benefits (Retirement, Disability, SSI)YesNo 250 250 Tax RefundYesNo 250 250 Trust IncomeYesNo 250 250 Veterans Benefits (disability/pension/aid and attendance)YesNo 250 250 WagesYesNo 250 250 Workers' Compensation BenefitsYesNo 250 250 OtherYesNo 250 250 TOTAL Page 3 of 8 American LegalNet, Inc. www.FormsWorkFlow.com PART IV: LIABILITIES/DEBTS1.List all debts the Incapacitated Person owes, including mortgages, loans, credit card debt, etc.Liabilities/DebtsLenderValueTOTAL DEBTS: PART V: GUARDIAN COVERAGE Was a surety bond required by the decree appointing you as guardian?250Yes(Please attach a copy of the bond)250NoAre you a professional guardianship agency or an attorney serving as a guardian? YesNoIf yes, do you have professional liability coverage? 250 250 250 Yes(Please attach a copy of the insurance policy) 250 NoIf no, explain: Page 4 of 8 American LegalNet, Inc. www.FormsWorkFlow.com If yes: List the name of the responsible family member:What services does the Incapacitated Person require?250Services from local Area Agency on Aging250Private Companion/Assistance Service Assistance from family membersNumber of days per week: Number of hours per week: Will compensation be provided?YesNoIf yes, indicate compensation amount: 250Yes250No250N/A - The Incapacitated Person is already in a supervised residential setting. PART VI: PERSONAL CARE PLAN1.Can the Incapacitated Person remain in current residence with assistance, or in the home of a ve 2.Will the Incapacitated Person be moved into a supervised residential setting?If yes:a.Indicate the type of supervised residential setting: Domiciliary Care Personal CareBoarding Home / Group HomeAssisted Living Facility Other: 250 250 250 250 250Yes250No250N/A - The Incapacitated Person is already in a supervised residential setting. Nursing Home 250 Describe the steps that are being taken to move the Incapacitated Person into a supervised residential setting.b. Page 5 of 8 American LegalNet, Inc. www.FormsWorkFlow.com PART VII: FINANCIAL PLANComplete the following table using initial inventory or most recent amended inventory.1.Total Annual Incomea.b.Annualestimated expenses Net Income(a minus b) Total assets (principal) (Part III, Question 1)(Part II, Question 1) d. c. Is the net income listed above sufficient to care for the needs of the Incapacitated Person?250Yes250No, but assets (principal) are available if a court order approves expenditures250No, and assets (principal) are not availableIndicate any applications for government benefits that have been submitted: Application TypeDate of SubmissionSocial Security Disability Insurance (SSDI)Supplemental Security Income (SSI)Social Security Retirement Benefits Veterans Benefits Medical assistance, long term careMedical assistance, Home WaiverOther (Explain: ) Describe all real estate included in the estate and how it will be maintained or sold:4. Page 6 of 8 American LegalNet, Inc. www.FormsWorkFlow.com Prior to the appointment of a guardian, has an agent under a Power of Attorney been serving?5. 250Yes250No If yes, has an accounting ever been requested or filed with the Orphans' Court?250Yes250NoIf yes, was the agent the same person as the guardian?250Yes250No PART VIII: MEDICAL INFORMATION1.2. Is a "no-code" (Do Not Resuscitate) provision in place for the incapacitated person?250Yes250NoWhen still capacitated, did the Incapacitated Person execute a durable power of attorney for health care orsome other health care directive (including, but not limited to, a POLST, a living will, or a mental health carepower of attorney)?250Yes250No If yes, identify the authorized agent for making health care decisions:3.Are you aware of any will or trust executed by the Incapacitated Person, or any funeral or burial wishes of the Incapacitated Person?250Yes250No If yes, please explain:Has a burial account been established for the Incapacitated Person? 250 250 YesNoIf yes, what is the value of the burial account? Page 7 of 8 American LegalNet, Inc. www.FormsWorkFlow.com 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. 2474904 relative to unsworn falsification to authorities. DateSignature of Guardian of the EstateName of Guardian of the Estate (type or print)AddressCity, State, ZipHome Phone NumberOffice Phone NumberCell Phone NumberEmailDateSignature of Co-Guardian of the Estate (if applicable)Name of Co-Guardian of the Estate (type or print)AddressCity, State, ZipHome Phone NumberOffice Phone NumberCell Phone Number Page 8 of 8 Email American LegalNet, Inc. www.FormsWorkFlow.com