COURT OF COMMON PLEAS COUNTY, PENNSYLVANIAORPHANS' COURT DIVISIONREPORT OF GUARDIAN OF THE PERSONEstate of: , an Incapacitated PersonName of Incapacitated PersonCase File No: DATE COURT APPOINTED YOU AS GUARDIAN: PART I. INTRODUCTION The death of the Incapacitated Person.Date of Death: Name of Executor/Administrator: Transfer of Guardianship to: Date of court order approving transfer: 250The Guardianship was terminated by a court order dated: IF THIS IS A FINAL REPORT, ONLY COMPLETE PARTS I AND V. p.1 of 6 Name(s) of Guardian(s): Is this a limited Guardianship?YesoReport Period This is the Report for the period from to (the "ReportPeriod");and is filed for the following reason: American LegalNet, Inc. www.FormsWorkFlow.com Incapacitated Person's date of birth: //1.PART II. PERSONAL INFORMATION ABOUT THE INCAPACITATED PERSONIncapacitated Person's Current Residence:2. Residence of the Incapacitated Person3. 250 Incapacitated Person's home( 250with part-time home health care aide or 250 24/7 assistance) 250Your home250Relative's homeRelative's Name: Relationship: 250Domiciliary CareFacility Name: Personal Care Boarding HomeFacility Name: Is this a Memory Support Facility?250Yes250 No250Assisted Living FacilityFacility Name: Is this a Memory Support Facility?250Yes250 No250Nursing Home Facility Facility Name: Is this a Memory Support Facility?Other: The Incapacitated Person has been in the residence noted in question 3 since: 4.5.Has the Incapacitated Person moved during the Report Period?YesNo 250 250 If yes, date of move: If yes, please provide:Reason for move: Previous residence/address: p.2 of 6 American LegalNet, Inc. www.FormsWorkFlow.com The major medical or psychiatric problems of the Incapacitated Person are as follows:Describe any social, medical, psychological and support services the Incapacitated Person is receiving:Has the Incapacitated Person been hospitalized during the Report Period? PART III. MEDICAL INFORMATION1.List the medical professionals who have seen the Incapacitated Person during the Report Period: DentistEye DoctorEar DoctorPsychologist or PsychiatristPhysical TherapistOccupational TherapistSocial WorkerGeriatric CaseworkerOther YesNoIf yes, date(s) of hospitalization: 5.Has the Incapacitated Person received a mental health assessment during the Report Period? YesNo 250 250 If yes, date(s) of evaluation: p.3 of 6 Name American LegalNet, Inc. www.FormsWorkFlow.com 1.Should the guardianship be:ContinuedContinued with modificationsTerminated 250 250 250 PART IV. GUARDIAN'S OPINION2.Provide the reasons for your opinion. List specific recommended modifications.3.Have you filed a petition for modification or termination?YesNo 250 250 1.On average, how often did you visit the Incapacitated Person during the Report Period?NoneQuarterlyMonthlyWeeklyDaily 250 250 250 250 250 I live with the Incapacitated PersonPART V. INFORMATION ABOUT THE GUARDIAN 250 2.What is the average length of a visit?Less than 15 minutesBetween 15 minutes and 1 hourBetween 1 and 2 hoursMore than 2 hoursNot applicable 250 250 250 250 250 Have you maintained a log of your activities as guardian?3.Yes - Attach a copyNo 250 250 p.4 of 6 American LegalNet, Inc. www.FormsWorkFlow.com 4.During this Report Period, did any guardian participate in guardianship training?YesNoIf yes, provide the following information: Training DescriptionProviderDates of TrainingGuardian Name 250 250 During this Report Period, was any guardian charged with or convicted of a crime?5. During this Report Period, was a Protection from Abuse Order or Protection from Sexual Violence or Intimidation Order entered against any guardian?6.7.Is there any reason any guardian cannot continue to serve as guardian? p.5 of 6 250No Description 250Yes - Please describeGuardian Name 250NoDescription 250No 250Yes - Please describeGuardian Name 250Yes - Please describeGuardian Name Starting EndingDescription American LegalNet, Inc. www.FormsWorkFlow.com Signature of Guardian of the PersonDateName of Guardian of the Person (type or print)AddressCity, State, ZipHome Phone NumberOffice Phone NumberCell Phone Number p.6 of 6 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. EmailDate Cell Phone Number Address Phone Number Phone Number Email Signature of Guardian of the Person American LegalNet, Inc. www.FormsWorkFlow.com