ORDER OF COURT DETERMINING PARTIAL INCAPACITY
AND APPOINTING LIMITED PERMANENT
GUARDIAN OF PERSON AND/OR ESTATE

AND NOW, this          day of                ,          , a hearing in this case having been held *                                 and it appearing to the Court that *                                       was served with a Citation and Notice of the hearing on                    ,             , and was present at the hearing (or) the Court finds that the physical or mental condition of *                                   would be harmed by *his/her presence at the hearing, and further finds from the testimony:

1.That *                                  suffers from *                              , a condition or disability which partially impairs his/her capacity to receive and evaluate information effectively and to make and communicate decisions concerning *his/her management of financial affairs or to meet essential requirements to *his/her physical health and safety.

2. That there are insufficient supports available to assist *                                in overcoming such limitations and that there exists no less restrictive alternative mechanism for decision making than the appointment of a Limited Guardian.

3. That based on the partial incapacity of *                                  to receive and evaluate information and to make or communicate decisions, a Limited Guardian of the Person and a Limited Guardian of the Estate are required on a permanent basis.

NOW, THEREFORE, based on the clear and convincing evidence supporting the foregoing findings, it is ORDERED, ADJUDGED and DECREED that *                                       be and is hereby adjudged a partially incapacitated person.                                             is appointed Limited Permanent Guardian of the Person of  *                                           and                                          is appointed Limited Permanent Guardian of the Estate of *                                         .

The Limited Guardian of the Person shall have full authority to consent to the general care, maintenance and custody of *                                       with the exception of:                                                                                                                                 .

The Limited Guardian of the Person shall assure that *                                   receives appropriate services and shall assist *him/her in developing self-reliance and independence.

The Limited Guardian of the Estate shall have the authority to marshal all of *                            's income and assets except that, *                                   , the incapacitated person, shall retain the following power and authority to act on *his/her own behalf:
                                                                                                                                .

If there is a safe deposit box in the name of the incapacitated person alone or in the names of the incapacitated person and another or others, said safe deposit box shall not be entered by the Guardian except in the presence of a representative of the financial institution where the box is located or in the presence of a representative of the Orphans' Court Division.  The representative present at the time of entry shall make, or cause to be made, a record of the incapacitated person's property, and said record shall be filed with the Clerk of the Orphans' Court Division.  None of the incapacitated person's property may be removed until after the aforesaid inventory is completed.

If the safe deposit box is jointly owned, five (5) days notice of the proposed entry shall be given to the other owners by the Guardian.

An Inventory must be filed within ninety (90) days. A report by each Guardian of the Person and Estate shall be filed within          days and annually thereafter in a from approved by the Orphans' Court Divisions.

A Surety Bond in the amount of                          shall be presented for approval by the Guardian of the Estate within five (5) days of the date of this Order. 

*                                                      , an incapacitated person, has the right to appeal this Order of Court by filing exceptions with the Clerk of the Orphans' Court Division within twenty (20) days of the date of this Order or by filing an appeal with the Prothonotary's Office of the Superior Court of Pennsylvania within thirty (30) days of the date of this Order or to petition this Court for a hearing to review or terminate the adjudication of incapacity and guardianship herein established.  

If *                                          was not present at the hearing on the adjudication of *his/her incapacity and the appointment of a guardian, then Petitioner shall serve upon, and read to *                                      , the Statement of Rights attached to this Order of Court and marked as Exhibit A.  Proof of service of the Statement of Rights shall be filed by the Guardian with the Clerk of the Orphans' Court within ten (10) days of the date of this Order.

PER CURIAM:

                                                         J.