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Appendix G(1):  Annual Report of Guardian of Estate under Rule 14, Section 8(b)

IN THE COURT OF COMMON PLEAS OF
ALLEGHENY COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
IN RE:   ESTATE OF
                                                             
Incapacitated Person
 )
)  No.
)
)


ANNUAL REPORT OF GUARDIAN OF ESTATE

I.  Principal Assets
A.
 Inventory total, or market value of principal as of date of last report.
                             
B.
 Principal Receipts (Income earned by and reinvested in principal or new assets acquired)
                             
C.
 Principal Disbursements (Assets redeemed, sold or transferred to income, includes income earned by assets acquired)
                             
D.
 Gains (Losses) of assets (assets that increased in value minus those that lost principal value)
                             
E. Increase/Decrease in market value of principal assets.                              
F. Principal Balance (A+E=F)                              

II. Income Assets
A.
 Income Balance as of date of last report (Value is 0 if this is first report)
                             
B.
 Income Receipts (income earned plus principal assets transferred for care of ward and estate)
                             
C.
 Income Disbursements (Amount paid for care and maintenance of person and estate of ward)
                             
D. Increase/Decrease in value of income assets                              
E. Income Balance (A+D=E)                              
F. Total value of estate (IF+IIE=IIF)                              

AS GUARDIAN OF THE ESTATE OF                                                    INCAPACITATED PERSON, I ACKNOWLEDGE THAT I SHALL FILE WITHIN SIXTY (60) DAYS OF THE DEATH OR THE ADJUDICATION OF CAPACITY OF                                                         A FINAL ACCOUNTING WITH THE ORPHANS' COURT DIVISION OF ALLEGHENY COUNTY, PENNSYLVANIA.

SIGNATURE OF GUARDIAN OF THE ESTATE:                                                           

Attached to this report shall be the following explanatory appendices:

  1. Appendix A shall set forth the nature and amount of each source of principal receipts providing the investment vehicle, account number, interest rate and amount of income yielded since the date of the last report. If a new investment was acquired, the date, amount, interest rate, expected annual yield and source of funds for the purchase of the new asset must be given.
  2. Appendix B shall set forth all principal assets redeemed, cashed in and/or transferred to principal for the purpose of providing for the care and maintenance of the ward. Also, if interest or dividend income earned by principal assets is transferred to an income account, then the amount and source of the funds transferred must be detailed.
  3. Appendix C shall set forth the gains and losses, if any, of each asset as well as which asset experienced a loss and in what amount.
  4. Appendix D shall set forth all sources of income used for the care and maintenance of the ward. Examples of such sources of income are Social Security, pension benefits, transfer from principal, interest earned by income accounts and any other asset received that is then held or spent for the ward's care and maintenance.
  5. Appendix E shall set forth a comprehensive annual summary of any and all expenditures made on behalf of the ward. These include personal care or nursing home room and board, medications, doctor and hospital bills, insurance premiums, clothing, utilities and property taxes, if the ward lives at home, and, (sic) professional fees. (Note: any attorney fees that are not paid with income assets must be approved by the Court before payment is made)

Received:                                                     

Approved:                                                   

Signature:                                                     

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