COURT OF COMMON PLEAS COUNTY, PENNSYLVANIAORPHANS' COURT DIVISIONREPORT OF GUARDIAN OF THE ESTATEEstate of: , an Incapacitated PersonName of Incapacitated PersonCase File No: DATE COURT APPOINTED YOU AS GUARDIAN: PART I. INTRODUCTIONName(s) of Guardian(s):1. 2.250NoYes250Is this a limited Guardianship?3.Report PeriodThis is the Report for the period from to (the "Report Period"); or250This is the Final Report for the period from to (the "Report Period") and is filed for the following reason:250250The death of the Incapacitated Person.Date of Death: Name of Executor/Administrator: 250The Guardianship was terminated by a court order dated: 250Transfer of Guardianship to:Date of court order approving transfer: p.1 of 9 American LegalNet, Inc. www.FormsWorkFlow.com List all sources of income received during the Report Period:PART II. INCOME Did the Incapacitated Person receive any of the following?Amount DuringReport PeriodYesNo250250Alimony or SupportYesNo250250Annuity PaymentsYesNo250250DividendsYesNo250250Interest IncomeYesNo250250IRA DistributionsYesNo250250Long Term Care Insurance BenefitsYesNo250250Pension/Retirement Benefits (for example: 401(k), 403(b), etc.)YesNo250250Public AssistanceYesNo250250Rental Property IncomeYesNo250250Royalties (including from mineral and land rights)YesNo250250Social Security Benefits (Retirement, Disability, SSI)YesNo250250Tax RefundYesNo250250Trust IncomeYesNo250250Veterans Benefits (disability/pension/aid and attendance)YesNo250250WagesYesNo250250Worker's Compensation BenefitsYesNo250250OtherTOTAL 1.p.2 of 9 American LegalNet, Inc. www.FormsWorkFlow.com PART III. ANNUAL EXPENSES1.List all payments made for the care and maintenance of the Incapacitated Person during the Report Period. ExpenseTo Whom Was It Paid?Total forReport PeriodAuto InsuranceCable/Satellite/InternetChild/Spousal Support/AlimonyClothingCondo/Co-op AssessmentsDebt (incurred prior to your appointment)EntertainmentFees/Costs Paid to GuardianFoodGifts - Personal or CharitableHome Health Care/Personal AideHomeowners InsuranceHome/Property Maintenance & RepairIncome TaxesLife Insurance PremiumsMedical Insurance PremiumsMedical ExpensesMedicineMortgageNursing Home/Assisted Living/Institutionalized CarePersonal Expenses (including allowance)Phone/Cell PhoneReal Estate TaxesRentUtilitiesOtherTOTAL p.3 of 9 American LegalNet, Inc. www.FormsWorkFlow.com If yes, has it been used during this report period?NoYesNoYes2502502502502.Does the Incapacitated Person have a credit card(s)?What is the current balance on the credit card(s)? PART IV. COMPARING INCOME AND EXPENSES Total Income (Part II, Question 1 TOTAL):Unspent Income from Previous Year (Part IV, Question 5 from Last Year's Report):Add lines 1 and 2 together to calculate this year's TOTAL INCOME:Total Expense (Part III, Question 1 TOTAL): Subtract line 4 from line 3.If amount is positive, enter it here to show UNSPENT INCOME, otherwise enter $0:5. 6. Subtract line 4 from line 3.If amount is negative, enter it here to show PRINCIPAL SPENT, otherwise enter $0:Is line 6, PRINCIPAL SPENT, greater than $0? Yes - Date of Court Order: No - Explain why court approval was not obtained:2502507.YesNoIf yes, was a court order obtained?250250 PART V. ASSETS Description/SourceValue at the end ofReport Period What was the value of the assets reported on the Inventory?List any additional assets received during the Report Period (for example: gifts, inheritance, burial account,lawsuit recovery, etc.) TOTAL p.4 of 9 American LegalNet, Inc. www.FormsWorkFlow.com Yes - Date of Court Order: No - Explain why court approval was not obtained: 4. 250Yes250No 5. List any assets transferred to a third party such as a spouse or child.Transferred To p.5 of 9 Asset Relationshipto IP Amount Order Date 250250 Does the Incapacitated Person live in the house/condo/co-op?If purchased during the Report Period, what was the purchase price?If real property was sold during the Report Period, what was the sale price?Was a court order obtained if property was purchased or sold? b.c.d.e. Does the incapacitated person own a house/condo/co-op?250Yes - Answer Questions a - e250Noa.Address of property: 3.Where are all the assets deposited or held at the end of theReport Period? List of Assets: Type and Location Co-OwnersValue at the end ofReport Period American LegalNet, Inc. www.FormsWorkFlow.com PART VII. ATTORNEY'S FEESWere attorney's fees paid during the Report Period?1.Yes - Complete the table belowNo - Skip to Part VIII250250PART VIII. REPRESENTATIVE PAYEESocial Security Administration (SSA) Benefits1a. The Incapacitated Person does not receive SSA benefits.The Guardian acts as the representative payee - attach a copy of the report provided to the SSA during Report Period.The Guardian is not the representative payee for SSA benefits. The payee is 250250250p.6 of 9 AmountName of CounselHourly Rate# of Hours Order Date or Reason Not Approved250Yes - Attach a copy250No3.Have you maintained a log of your activities as guardian?No - Explain why court approval was not obtained:250250Yes - Date of Court Order: 2.Was the compensation approved by the court? Amount Guardian Name Is Amount Based onHourly, Monthly or Annual Fee?1.Did the Guardian receive compensation during the Report Period?250Yes - Complete the table below250No - Skip to Question 3PART VI. GUARDIAN'S COMPENSATION American LegalNet, Inc. www.FormsWorkFlow.com b.Describe the deductible and any exclusions.YesNo 250 250 If you are a professional guardian, agency or an attorney serving as guardian, do you haveprofessional/guardian liability insurance that covers theft?250Yes - Answer Question a and b.250No - Skip to Part X.250N/AAre the coverage limits greater than the assets (Part V, Question 3)? Yes - Please describeNo 250 4.Is there any reason any guardian cannot continue to serve as guardian?p.7 of 9 YesNoIf yes, has the amount of the surety bond been increased?250Yes. To what amount:250No 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? b. YesNo - Provide an explanation as to why not. 250250a.Is the surety bond still in effect? No - The court waived a surety bond, skip to Question 2. The Guardian is not the representative payee for VA benefits. The payee is . 1.Was a surety bond required? 250250 Yes - In what amount - and then answer Questions a - b. The Incapacitated Person does not receive VA benefits.The Guardian acts as the representative payee - attach a copy of the report provided to the VA during this Report Period. 250 1b.Veterans Administration (VA) Benefits250250250 American LegalNet, Inc. www.FormsWorkFlow.com Guardian Name Description PART XI. SUMMARY If this is the first annual report, state the value of the assets reported on the Inventory.(Use amount from Part V, Question 1 of this Report.) (rincipal) If this is not the first annual report, state the Total Assets (principal) from the prior Report.(Use TOTAL amount from Part V, Question 3 of prior Report.) What was the total income received during the Report Period?(Use the amount from Part IV, Question 3 of this Report.)What is the total amount of Expenses paid during the Report Period?(Use the amount from Part III, Question 1 of this Report.)What are the Total Assets remaining at the end of the Report Period?(Use the amount from Part V, Question 3 of this Annual Report.)What is the Unspent Income at the end of the Report Period?(Use the amount from Part IV, Question 5 of this Report.) 1.2.3.4.5.6.p.8 of 9 .?3.During this Report Period, was any guardian charged with or convicted of a crime? Yes - Please describe Guardian NameDescription Yes - Please describe 250250250No 250250No DescriptionGuardian NameYes - Please describeNo250 During this Report Period, have any judgments been filed against any guardian, or has any guardian filed for bankruptcy protection?2. Guardian Name Dates of TrainingTraining Description StartingEnding ProviderIf yes, provide the following information: NoYes2502501.During this Report Period, did any guardian participate in guardianship training?PART X. GUARDIAN INFORMATION American LegalNet, Inc. www.Fo