COURT OF COMMON PLEAS _____________ COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION
GUARDIAN'S INVENTORY FOR AN INCAPACITATED PERSON
Estate of: _________________________________________________________, an Incapacitated Person Name of Incapacitated Person
Case File No: _____________________
DATE COURT APPOINTED YOU AS GUARDIAN: _____________________________________________________
PART I: INTRODUCTION Inventory type: ¨ Initial ¨ Amended PART II: ASSETS (PRINCIPAL) 1. List all bank accounts, real estate, burial accounts, and other personal property below. If the property is owned by both the incapacitated person and others, indicate in the last column the name of the co-owner.
Asset Value Name of Co-Owner(s)
$ $ $ $ $ $ $ $ $ $ $ $ TOTAL $ 0.00
Form G-05 (Effective January 1, 2023) Page 1 of 9 2. Is any property (specifically bank accounts or real estate) co-owned by the Incapacitated Person and the guardian? ¨ Yes ¨ No If yes: a. On what date was the property acquired? ________________________ b. On what date was the guardian's name added? ________________________ c. The guardian is: ¨ an individual having access or control over the account ¨ an owner of the account 3. Does the Incapacitated Person have a homeowners insurance policy for real property? ¨ Yes(Copy of policy to be provided upon request) ¨ No If yes: a. Carrier: b. Coverage period:
4. Does the Incapacitated Person have an automobile insurance policy? ¨ Yes(Copy of policy to be provided upon request) ¨ No If yes: a. Carrier: b. Coverage period:
5. Does the Incapacitated Person have a safe deposit box? ¨ Yes, in sole name ¨ Yes, in joint name(s). List the name(s) of joint owner(s): ¨ No If yes: a. Location of safe deposit box: _______________________________________ b. Are there plans to inventory the contents? ¨ Yes ¨ No
Form G-05 (Effective January 1, 2023) Page 2 of 9 PART III: ANNUAL INCOME 1. List all sources of income for the Incapacitated Person:
Does the Incapacitated Person receive any of the following as income? Specify Amount
Alimony or Support ¨ Yes ¨ No $
Annuity Payments ¨ Yes ¨ No $
Dividends ¨ Yes ¨ No $
Interest Income ¨ Yes ¨ No $
IRA Distributions ¨ Yes ¨ No $
Long Term Care Insurance Benefits ¨ Yes ¨ No $
Pension/Retirement Benefits (for example: 401(k), 403(b), etc.) ¨ Yes ¨ No $
Public Assistance ¨ Yes ¨ No $
Rental Property Income ¨ Yes ¨ No $
Royalties (including from mineral and land rights) ¨ Yes ¨ No $
Social Security Benefits (Retirement, Disability, SSI) ¨ Yes ¨ No $
Tax Refund ¨ Yes ¨ No $
Trust Income ¨ Yes ¨ No $
Veterans Benefits (disability/pension/aid and attendance) ¨ Yes ¨ No $
Wages ¨ Yes ¨ No $
Worker's Compensation Benefits ¨ Yes ¨ No $
Other ¨ Yes ¨ No $
TOTAL $ 0.00
Form G-05 (Effective January 1, 2023) Page 3 of 9 PART IV: LIABILITIES / DEBTS 1. List all debts the Incapacitated Person owes, including mortgages, loans, credit card debt, etc.
Liabilities/Debts Lender Value
$
TOTAL DEBTS: $ 0.00
PART V: GUARDIAN COVERAGE 1. Was a surety bond required by the decree appointing you as guardian? ¨ Yes (Please attach a copy of the bond) ¨ No 2. Are you a professional guardianship agency or an attorney serving as a guardian? ¨ Yes ¨ No If yes, do you have professional liability coverage? ¨ Yes (Please attach a copy of the insurance policy) ¨ No If no, explain: ________________________________________________________
Form G-05 (Effective January 1, 2023) Page 4 of 9 PART VI: PERSONAL CARE PLAN 1. Can the Incapacitated Person remain in his or her current residence with assistance, or in the home of a relative? ¨ Yes ¨ No ¨ N/A - The Incapacitated Person is already in a supervised residential setting
If yes: a. List the name of the responsible family member: ______________________________________________________ b. What services does the Incapacitated Person require? ¨ Services from local Area Agency on Aging ¨ Private Companion/Assistance Service Number of days per week: __________ Number of hours per week: __________ ¨ Assistance from family members Will compensation be provided? ¨ Yes ¨ No If yes, indicate compensation amount: $
2. Will the Incapacitated Person be moved into a supervised residential setting? ¨ Yes ¨ No ¨ N/A - The Incapacitated Person is already in a supervised residential setting If yes: a. Indicate the type of supervised residential setting: ¨ Domiciliary Care ¨ Personal Care ¨ Boarding Home / Group Home ¨ Assisted Living Facility ¨ Nursing Home ¨ Other b. Describe the steps that are being taken to move the Incapacitated Person into a supervised residential setting. __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________
Form G-05 (Effective January 1, 2023) Page 5 of 9 3. What is the current address of the Incapacitated Person? __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________
PART VII: FINANCIAL PLAN 1. Complete the following table using initial inventory or most recent amended inventory.
a. Total Annual Income d. Total assets (principal) (Part III, Question 1) $ 0.00 (Part II, Question 1) $ 0.00 b. Annual estimated expenses $ c. Net Income (a minus b) $ 0.00
2. Is the net income listed above sufficient to care for the needs of the Incapacitated Person? ¨ Yes ¨ No, but assets (principal) are available if a court order approves expenditures ¨ No, and assets (principal) are not available
3. Indicate any applications for government benefits that have been submitted:
Application Type Date of Submission
Social Security Disability Insurance (SSDI) Supplemental Security Income (SSI) Social Security Retirement Benefits Veterans Benefits Medical assistance, Long term care Medical assistance, Home Waiver Other (Explain: )
Form G-05 (Effective January 1, 2023) Page 6 of 9 4. Describe all real estate included in the estate and how it will be maintained or sold: _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________
5.
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COURT OF COMMON PLEAS _____________ COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION
GUARDIAN'S INVENTORY FOR AN INCAPACITATED PERSON
Estate of: _________________________________________________________, an Incapacitated Person Name of Incapacitated Person
Case File No: _____________________
DATE COURT APPOINTED YOU AS GUARDIAN: _____________________________________________________
PART I: INTRODUCTION Inventory type: ¨ Initial ¨ Amended PART II: ASSETS (PRINCIPAL) 1. List all bank accounts, real estate, burial accounts, and other personal property below. If the property is owned by both the incapacitated person and others, indicate in the last column the name of the co-owner.
Asset Value Name of Co-Owner(s)
$ $ $ $ $ $ $ $ $ $ $ $ TOTAL $ 0.00
Form G-05 (Effective January 1, 2023) Page 1 of 9 2. Is any property (specifically bank accounts or real estate) co-owned by the Incapacitated Person and the guardian? ¨ Yes ¨ No If yes: a. On what date was the property acquired? ________________________ b. On what date was the guardian's name added? ________________________ c. The guardian is: ¨ an individual having access or control over the account ¨ an owner of the account 3. Does the Incapacitated Person have a homeowners insurance policy for real property? ¨ Yes(Copy of policy to be provided upon request) ¨ No If yes: a. Carrier: b. Coverage period:
4. Does the Incapacitated Person have an automobile insurance policy? ¨ Yes(Copy of policy to be provided upon request) ¨ No If yes: a. Carrier: b. Coverage period:
5. Does the Incapacitated Person have a safe deposit box? ¨ Yes, in sole name ¨ Yes, in joint name(s). List the name(s) of joint owner(s): ¨ No If yes: a. Location of safe deposit box: _______________________________________ b. Are there plans to inventory the contents? ¨ Yes ¨ No
Form G-05 (Effective January 1, 2023) Page 2 of 9 PART III: ANNUAL INCOME 1. List all sources of income for the Incapacitated Person:
Does the Incapacitated Person receive any of the following as income? Specify Amount
Alimony or Support ¨ Yes ¨ No $
Annuity Payments ¨ Yes ¨ No $
Dividends ¨ Yes ¨ No $
Interest Income ¨ Yes ¨ No $
IRA Distributions ¨ Yes ¨ No $
Long Term Care Insurance Benefits ¨ Yes ¨ No $
Pension/Retirement Benefits (for example: 401(k), 403(b), etc.) ¨ Yes ¨ No $
Public Assistance ¨ Yes ¨ No $
Rental Property Income ¨ Yes ¨ No $
Royalties (including from mineral and land rights) ¨ Yes ¨ No $
Social Security Benefits (Retirement, Disability, SSI) ¨ Yes ¨ No $
Tax Refund ¨ Yes ¨ No $
Trust Income ¨ Yes ¨ No $
Veterans Benefits (disability/pension/aid and attendance) ¨ Yes ¨ No $
Wages ¨ Yes ¨ No $
Worker's Compensation Benefits ¨ Yes ¨ No $
Other ¨ Yes ¨ No $
TOTAL $ 0.00
Form G-05 (Effective January 1, 2023) Page 3 of 9 PART IV: LIABILITIES / DEBTS 1. List all debts the Incapacitated Person owes, including mortgages, loans, credit card debt, etc.
Liabilities/Debts Lender Value
$
TOTAL DEBTS: $ 0.00
PART V: GUARDIAN COVERAGE 1. Was a surety bond required by the decree appointing you as guardian? ¨ Yes (Please attach a copy of the bond) ¨ No 2. Are you a professional guardianship agency or an attorney serving as a guardian? ¨ Yes ¨ No If yes, do you have professional liability coverage? ¨ Yes (Please attach a copy of the insurance policy) ¨ No If no, explain: ________________________________________________________
Form G-05 (Effective January 1, 2023) Page 4 of 9 PART VI: PERSONAL CARE PLAN 1. Can the Incapacitated Person remain in his or her current residence with assistance, or in the home of a relative? ¨ Yes ¨ No ¨ N/A - The Incapacitated Person is already in a supervised residential setting
If yes: a. List the name of the responsible family member: ______________________________________________________ b. What services does the Incapacitated Person require? ¨ Services from local Area Agency on Aging ¨ Private Companion/Assistance Service Number of days per week: __________ Number of hours per week: __________ ¨ Assistance from family members Will compensation be provided? ¨ Yes ¨ No If yes, indicate compensation amount: $
2. Will the Incapacitated Person be moved into a supervised residential setting? ¨ Yes ¨ No ¨ N/A - The Incapacitated Person is already in a supervised residential setting If yes: a. Indicate the type of supervised residential setting: ¨ Domiciliary Care ¨ Personal Care ¨ Boarding Home / Group Home ¨ Assisted Living Facility ¨ Nursing Home ¨ Other b. Describe the steps that are being taken to move the Incapacitated Person into a supervised residential setting. __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________
Form G-05 (Effective January 1, 2023) Page 5 of 9 3. What is the current address of the Incapacitated Person? __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________
PART VII: FINANCIAL PLAN 1. Complete the following table using initial inventory or most recent amended inventory.
a. Total Annual Income d. Total assets (principal) (Part III, Question 1) $ 0.00 (Part II, Question 1) $ 0.00 b. Annual estimated expenses $ c. Net Income (a minus b) $ 0.00
2. Is the net income listed above sufficient to care for the needs of the Incapacitated Person? ¨ Yes ¨ No, but assets (principal) are available if a court order approves expenditures ¨ No, and assets (principal) are not available
3. Indicate any applications for government benefits that have been submitted:
Application Type Date of Submission
Social Security Disability Insurance (SSDI) Supplemental Security Income (SSI) Social Security Retirement Benefits Veterans Benefits Medical assistance, Long term care Medical assistance, Home Waiver Other (Explain: )
Form G-05 (Effective January 1, 2023) Page 6 of 9 4. Describe all real estate included in the estate and how it will be maintained or sold: _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________
5. Prior to the appointment of a guardian, has an agent under a Power of Attorney been serving? ¨ Yes ¨ No If yes, has an accounting ever been requested or filed with the Orphans' Court? ¨ Yes ¨ No If yes, was the agent the same person as the guardian? ¨ Yes ¨ No PART VIII: MEDICAL INFORMATION 1. Is a "no-code" (Do Not Resuscitate) provision in place for the incapacitated person? ¨ Yes ¨ No 2. When still capacitated, did the Incapacitated Person execute a durable power of attorney for health care or some other health care directive (including, but not limited to, a POLST, a living will, or a mental health care power of attorney)? ¨ Yes ¨ No If yes, identify the authorized agent for making health care decisions: _____________________________________________________________________________
Form G-05 (Effective January 1, 2023) Page 7 of 9 3. Are you aware of any will or trust executed by the Incapacitated Person, or any funeral or burial wishes of the Incapacitated Person? ¨ Yes ¨ No If yes, please explain: _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ Has a burial account been established for the Incapacitated Person? ¨ Yes ¨ No If yes, what is the value of the burial account? $
Form G-05 (Effective January 1, 2023) Page 8 of 9 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. §4904 relative to unsworn falsification to authorities.
I further acknowledge the Notice of Filing must be served within 10 days of the filing of this report pursuant to Pa.R.O.C.P. 14.8(b). Service shall be in accordance with Pa.R.O.C.P. 4.3.
Date Signature of Guardian of the Estate
Name of Guardian of the Estate (type or print)
Address
City, State, Zip
Home Phone Number
Office Phone Number
Cell Phone Number
Email
Date Signature of Co-Guardian of the Estate (if applicable)
Name of Co-Guardian of the Estate (type or print)
Form G-05 (Effective January 1, 2023) Page 9 of 9