Pa. Code tit. 204, pt. II, ch. 29, subch. B, app A

Current through Register Vol. 54, No. 45, November 9, 2024

Appendix A

IN THE MATTER OF	:	IN THE COURT OF COMMON PLEAS OF
_____________________	:	COUNTY, PENNSYLVANIA
(name)	ORPHANS' COURT DIVISION
An Alleged Incompetent	:	No.	19

PETITION FOR APPOINTMENT OF GUARDIAN

The petition of ______________________________________Superintendent of ______________________________________ , respectfully represents:

1. Your Petitioner has custody of the alleged incompetent at ______ .

2. The alleged incompetent was admitted to the aforesaid institution on

_______________________________________________________.

3. The alleged incompetent is domiciled at_______________________ _______________________________________________________.

4. The alleged incompetent is_____ years of age, having been born on_____ .

5. The alleged incompetent's military status is:____

_______________________________________________________

___________________________________________________.

6. The alleged incompetent's marital status is_____________________

_______________________________________________________

_______________________________________________________.

7. Those persons, if any, who are the alleged incompetent's next of kin and their relationship to same, of whom your Petitioner has knowledge are as follows:

_______________________________________________________

_______________________________________________________.

8. No other Court within this Commonwealth of which Petitioner has knowledge has appointed a guardian for the alleged incompetent.

9. The alleged incompetent has income consisting of:

(a) Money due from _____________________________________________in the amount of $__________ per __________ .

(b) Money due from ________________________________________ ___________in the amount of $ __________ per _________ .

______________________________________________________________________

10. The alleged incompetent has assets, real and personal, of which the Petitioner is aware, in the amount of $ __________ consisting of:

(a) _______________________held by the Guardian Officer of _________________in the amount of $ __________________ as of ___________.

(b) "Vecchione Refund" monies in the amount of $ ____________ , title to which is in dispute.

_________________.

11. The alleged incompetent has debts outstanding in the amount of $ _______, as of _________________________, consisting of:

(a) $ ___________owing to the Commonwealth of Pennsylvania as payment for care and maintenance received from the period______________

19 _____ to _____ , _______ , in accordance with 50 P. S. §§ 4501 and 4504 and regulations promulgated thereunder.

(b) $ __________ owing to the Commonwealth of Pennsylvania as payment for care and maintenance rendered between July 11, 1974, and April 4, 1975, which relates to the "Vecchione Refund," title to which is in dispute.

_________________.

12. The alleged incompetent is incapable of handling _________________

financial affairs for the reasons set forth in the attached Affidavit and Competency Report, prepared by_______________________________________________

______________, marked as Exhibit A and made a part hereof.

13. _______________________________________________________ , Guardian Officer at the aforesaid institution, and his/her successors in office, having no interest adverse to the alleged incompetent, has agreed to act as Guardian if this Honorable Court shall so appoint. The consent of the proposed Guardian to so act is attached hereto and made a part hereof as Exhibit B.

14. If appointed as Guardian,____________________________________ is required to act in compliance with regulations promulgated under Court Order in 5 Pennsylvania Bulletin 931 et seq. (April 19, 1975).

15. In light of these provisions and in furtherance of Paragraph 7 of the aforesaid regulations, Petitioner requests preference be given to a bank, trust company or other individual willing to accept appointment as Guardian.

Wherefore, the Petitioner prays that a citation be issued directing

___ , and those persons, if any, listed in paragraph 7 of this Petition, to show cause, if any there be, why _________________________________________________ should not be declared an incompetent and a Guardian of the estate appointed, and why distribution of assets and income as payment of debts listed in paragraph 11 should not be made. Petitioner further prays that a guardian ad litem be appointed to act for the alleged incompetent regarding such hearing.

BY: _______________________________________________________

COMMONWEALTH OF PENNSYLVANIA	:
ss
COUNTY OF	:

__________________, Petitioner in this matter, being duly sworn according to law, do depose and state that I am ___________ of __________________________________________and that the facts set forth in the foregoing Petition are true and correct to the best of my knowledge, information and belief.

_______________________________________________________

Sworn to and Subscribed

Before me this____________

day of_________________ 19 _________

_____________________________________________

EXHIBIT "A"

COMPETENCY REPORT AFFIDAVIT

COMMONWEALTH OF PENNSYLVANIA	:
ss
COUNTY OF	:

I, ______________________________________ , being duly sworn according to law, depose and say that I am a____________________________________________ in the Commonwealth of Pennsylvania employed at________________________________________________ , and I have examined the patient,_________________ , an alleged incompetent, with care and diligence and based upon said examination and observations am of the opinion that said patient is incompetent to manage his/her own affairs for the reasons set forth in the attached Competency Report, and that the facts and opinions contained therein are true and correct to the best of my knowledge, information and belief.

_______________________________________________________

Sworn to and Subscribed Before

me this___________________ day of ________________ , 19 ____.

EXHIBIT "B"

CONSENT OF PROPOSED GUARDIAN

I,_________________________ ,____________________________ of _______________________________, do hereby certify that I and my successors in office are willing to act as Guardian for the estate of ___________________________, an alleged incompetent, if the Court shall so appoint.

Further, I do hereby certify that I am not a fiduciary of any estate in which the alleged incompetent has an interest, nor have I any interest adverse to the alleged incompetent.

The facts and opinions contained herein are true and correct to the best of my knowledge, information, and belief.

_______________________________________________________

IN THE MATTER OF	:	IN THE COURT OF COMMON
PLEAS OF
__________________________	:	COUNTY, PENNSYLVANIA
(name)	ORPHANS' COURT DIVISION
An Alleged Incompetent	:	No. 19

PRELIMINARY ORDER OF COURT

AND NOW, this _____________ day of ____________ 19 ______ , upon consideration of the foregoing Petition, it is Ordered that a citation be issued, directed to ___________________________________________________________ to show cause why __________________________________________should not be adjudged an incomeptent, and a guardian of____________________________ estate appointed; and why distribution of assets and income as payment of debts listed in paragraph _______ of the within Petition should not be made.

_____________________________________________ is hereby appointed Special Master for the purposes of conducting a hearing on said Petition at the institutuion at which_________________________________________________

__________________________________________resides, at a time to be fixed by said Special Master, and to submit a Report and Recommendation to this Court in a timely fashion.___________________________________________ is hereby appointed by the court to act as guardian ad litem for ________________________________the alleged incompetent regarding this hearing.

At least twenty (20) days written notice of the hearing shall be given ________to the alleged incompetent, by serving ________________personally with the citation and a copy of the foregoing Petition; and at least twenty (20) days written notice of the Petition and hearing shall also be given to any next of kin listed in the Petition either personally or by certified mail.

BY THE COURT:

_______________________________________________________

IN THE MATTER OF	:	IN THE COURT OF COMMON
PLEAS OF
________________________	:	COUNTY, PENNSYLVANIA
(name)	ORPHANS' COURT DIVISION
An Alleged Incompetent	:	No.	19____

CITATION

TO:_____________________________________________

We command you to appear at a hearing in the Orphans' Court of ____________, County, to be held at on____________ ,19 ______,at _____________ .M., to show cause why you should not be adjudged an incompetent, and a guardian appointed for your estate.

Citation Returnable the _____________ day of ____________, 19 _____.

WITNESSETH:

The Honorable______________________________________________ President Judge of said Court, sitting in the Orphans' Court this ___________ day of _________ ,19 _______ .

_______________________________________________________

CLERK OF THE ORPHANS' COURT DIVISION

IN THE MATTER OF	:	IN THE COURT OF COMMON
PLEAS OF
____________________	:	COUNTY, PENNSYLVANIA
(name)	ORPHANS' COURT DIVISION
An Alleged Incompetent	:	No.	19____

REPORT AND RECOMMENDATION OF THE SPECIAL MASTER AND ORDER OF COURT

Upon hearing of the Petition and Citation for Appointment of a guardian for __________________ , proof of notice of the said hearing to _______________ next of kin having been filed, and ______________ appointed as guardian ad litem,

the Special Master, appointed by this Honorable Court to hear said Petition, finds that the said ______________________________ is so mentally infirm that _________________ is likely to dissipate or lose _______________________ estate and become the victim of designing persons; and that the Court further finds that the entire real and personal estate of the said _________________ should be handled by the Guardian designated herein.

It Is Therefore Recommended that ______________________ _____________________________and his/her successors in office be and are hereby authorized to receive, hold and dispose of the estate of the said ________________________________ as the duly appointed guardian under Court Decree, and to pay such debts as enumerated in said Petition, such debts having been found to be proper and in accord with law.

The guardian, within three months after real or personal estate of the incompetent comes into his possession, shall verify by oath and file with the Clerk an inventory and appraisement of such personal estate, a statement of such real estate, and a statement of any real or personal estate which he expects to acquire thereafter.

____________________________________________________________

Special Master

DATE:______________

ORDER

IT IS ORDERED AND DECREED THAT the report and recommendation of the Special Master be approved.

IT IS FURTHER ORDERED AND DECREED, that the Surety Bond issued by

_______________Bond No.__________________________________ shall be sufficient as bond.

All costs and expenses of this hearing to be borne by the Estate of the said

_____________________ , including a fee of __________________________

to be paid the guardian ad litem.

BY THE COURT

____________________________________________________________

DATE:_______________

Pa. Code tit. 204, pt. II, ch. 29, subch. B, app A