IN THE COURT OF COMMON PLEAS OF 
ALLEGHENY COUNTY, PENNSYLVANIA

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

AND NOW, this           day of                    ,            , a hearing in this case having been held on *                     ,           , and it appearing to the Court that *                                       was served with a Notice of this 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 Plenary Guardian.

3. That based on the partial incapacity of *                                  , to receive and evaluate information effectively, and to make or communicate decisions, a Plenary Guardian of the Person and a Plenary 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 hereby is adjudged a totally incapacitated person.

                                           is appointed Permanent Plenary Guardian of the Person of *                                         and                                      is appointed Permanent Plenary Guardian of the Estate of  *                                .

The Permanent Plenary Guardian of the Person shall have authority to consent to the general care, maintenance and custody of *                                       without exception.

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

The Permanent Plenary Guardian of the Estate shall have the authority to marshal all of *                            's income and assets, pay *his/her bills and manage *his/her financial affairs as fully as *                            could do so *himself/herself if *he/she had not been adjudged incapacitated.

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 the Guardian of the Person and Estate shall be filed within              days and annually thereafter in a form approved by the Orphans' Court Divisions.

Within sixty (60) days of the death of the incapacitated person or an adjudication of capacity and modification of existing orders, the Guardian of the Estate shall file a final report with the Court in the form prescribed for accounts and shall cover the period from the date of the appointment of the Guardian of the Estate to the date of death of the incapacitated person or the adjudication of capacity.

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 review or terminate the adjudication of incapacity and guardianship herein established.

If *                                          was not present at this 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 such 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.