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Here is the text we could read:

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 $

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?

On what date was the property acquired?

________________________

On what date was the guardian's name added?

________________________

an individual having access or control over the account

an owner of the account

¨ ¨

The guardian is:

3.

Does the Incapacitated Person have a homeowners insurance policy for real property?
¨
No¨

Yes(Copy of policy to be provided upon request)

If yes:
a.

b.

c.

Yes

No

¨ ¨

Location of safe deposit box:

_______________________________________

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:

If yes:

a. Carrier:
b. Coverage period:

5.

Does the Incapacitated Person have a safe deposit box?

    List the name(s) of joint owner(s):

¨ Yes, in sole name
¨ Yes, in joint name(s).
¨ No

If yes:
a.

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

Long Term Care Insurance Benefits

Pension/Retirement Benefits (for example: 401(k), 403(b), etc.)

¨

Yes

¨

No

Alimony or Support

Annuity Payments

Dividends

Interest Income

IRA Distributions

Public Assistance

Rental Property Income

Royalties (including from mineral and land rights)

Social Security Benefits (Retirement, Disability, SSI)

Tax Refund

Trust Income

Wages

Other

Worker's Compensation Benefits

¨

Yes

¨

No

¨

Yes

¨

No

¨

Yes

¨

No

¨

Yes

¨

No

¨

Yes

¨

No

¨

Yes

¨

No

¨

Yes

¨

No

¨

Yes

¨

No

¨

Yes

¨

No

¨

Yes

¨

No

¨

Yes

¨

No

¨

Yes

¨

No

¨

Yes

¨

No

¨

Yes

¨

No

¨

Yes

¨

No

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

TOTAL $

Veterans Benefits (disability/pension/aid and attendance)

¨

Yes

¨

No

Form G-05 (Effective January 1, 2023)

Page 3 of 9

$ $ $ $ $ $ $ $

TOTAL DEBTS:

PART IV: LIABILITIES / DEBTS

1.

List all debts the Incapacitated Person owes, including mortgages, loans, credit card debt, etc.

Liabilities/Debts

Lender

Value

If no, explain: ________________________________________________________

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?

If yes, do you have professional liability coverage? 
¨ Yes  (Please attach a copy of the insurance policy) 
¨ No

Yes

No

¨ ¨

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:

______________________________________________________

If yes, indicate compensation amount: 

$

Yes

No

¨¨

Number of days per week: __________

Number of hours per week: __________

b. What services does the Incapacitated Person require?

Services from local Area Agency on Aging

Private Companion/Assistance Service

¨ ¨

¨

Assistance from family members

Will compensation be provided?

2.

Will the Incapacitated Person be moved into a supervised residential setting?

N/A - The Incapacitated Person is already in a supervised residential setting

Yes¨
No¨
¨

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?

__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

Application Type

Date of Submission

1.

Complete the following table using initial inventory or most recent amended inventory.

d.

Total assets (principal)
(Part II, Question 1)

$

$ $

$

a.

Total Annual Income
(Part III, Question 1)

b. Annual

estimated expenses

c.

Net Income
(a minus b)

PART VII:  FINANCIAL PLAN

2.

Is the net income listed above sufficient to care for the needs of the Incapacitated Person?

No, but assets (principal) are available if a court order approves expenditures

No, and assets (principal) are not available

3.

ndicate any applications for government benefits that have been submitted:

Yes¨

¨

¨ I

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?

If yes, has an accounting ever been requested or filed with the Orphans' Court?

If yes, was the agent the same person as the guardian?

PART VIII:  MEDICAL INFORMATION

Is a "no-code" (Do Not Resuscitate) provision in place for the incapacitated person?
¨ Yes
¨ No

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)?

If yes, identify the authorized agent for making health care decisions:
_____________________________________________________________________________

Yes

No

¨ ¨

Yes

No

¨ ¨

Yes

No

¨ ¨

1.

2.

Yes¨
¨ No

Form G-05 (Effective January 1, 2023)

Page 7 of 9

_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

Has a burial account been established for the Incapacitated Person?

If yes, what is the value of the burial account?

$

Yes

No

¨¨

3. Are you aware of any will or trust executed by the Incapacitated Person, or any funeral or burial wishes of

If yes, please explain:

the Incapacitated Person?

Yes

No

¨ ¨

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

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

(Untitled)

This info page is part of the LIT Lab's Form Explorer project. It is not associated with the Pennsylvania state courts. To learn more about the project, check out our about page.

Downloads: You can download both the original form (last checked 2023-03) and the machine-processed form with normalized data fields.

About This Form:

Sourced from www.pacourts.us (2023-03)
Page(s): 9
Fields(s): 238
Average fields per page: 26
Reading Level: Grade 7
LIST Grouping(s): GO-00-00-00-00.

Use our Rate My PDF tool to learn more. Go beyond the above insights and learn more about this or any pdf form at RateMyPDF.com, includes: counts of difficult words used, passive voice decetion, and suggestions for how to make the form more usable.

Identified Data Fields:

We have done our best to automaticly identify and name form fields according to our naming conventions. When possible, we've used names tied to our question library. See e.g., user1_name. If we think we've found a match to a question in our library, it is highlighted in green. Novel names are auto generated. So, you will probably need to edit some of them if you're trying to stick to the convention.

Here are the fields we could identify.

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cb_pg_bx was CBPgBx1 (0.30 conf)
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pg_asset__1 was Pg1Asset1 (0.35 conf)
pg_value__1 was Pg1Value1 (0.35 conf)
pg_coowner__1 was Pg1Coowner1 (0.35 conf)
pg_asset__2 was Pg1Asset2 (0.35 conf)
pg_value__2 was Pg1Value2 (0.35 conf)
pg_coowner__2 was Pg1Coowner2 (0.35 conf)
pg_asset__3 was Pg1Asset3 (0.35 conf)
pg_value__3 was Pg1Value3 (0.35 conf)
pg_coowner__3 was Pg1Coowner3 (0.35 conf)
pg_asset__4 was Pg1Asset4 (0.35 conf)
pg_value__4 was Pg1Value4 (0.35 conf)
pg_coowner__4 was Pg1Coowner4 (0.35 conf)
pg_asset__5 was Pg1Asset5 (0.35 conf)
pg_value__5 was Pg1Value5 (0.35 conf)
pg_coowner__5 was Pg1Coowner5 (0.35 conf)
pg_asset__6 was Pg1Asset6 (0.35 conf)
pg_value__6 was Pg1Value6 (0.35 conf)
pg_coowner__6 was Pg1Coowner6 (0.35 conf)
pg_asset__7 was Pg1Asset7 (0.35 conf)
pg_value__7 was Pg1Value7 (0.35 conf)
pg_coowner__7 was Pg1Coowner7 (0.35 conf)
pg_asset__8 was Pg1Asset8 (0.35 conf)
pg_value__8 was Pg1Value8 (0.35 conf)
pg_coowner__8 was Pg1Coowner8 (0.35 conf)
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pg_coowner__9 was Pg1Coowner9 (0.35 conf)
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pg_value__10 was Pg1Value10 (0.35 conf)
pg_coowner__10 was Pg1Coowner10 (0.35 conf)
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pg_value__11 was Pg1Value11 (0.35 conf)
pg_coowner__11 was Pg1Coowner11 (0.35 conf)
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pg_coowner__12 was Pg1Coowner12 (0.35 conf)
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pg_acquired was Pg2Acquired (0.28 conf)
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pg_joint_name was Pg2JointName (0.34 conf)
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pg_describe__7 was Pg7Describe7 (0.35 conf)
pg_describe__8 was Pg7Describe8 (0.35 conf)
pg_describe__9 was Pg7Describe9 (0.35 conf)
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signature_guardian_estate was Signature of Guardian of the Estate1 (0.40 conf)
last_page_date__1 was LastPageDate1 (0.38 conf)
last_page_type_name_guardian was LastPageTypeOrPrintNameOfGuardianOftheEstate (0.44 conf)
last_page_address__1 was LastPageAddress (0.33 conf)
last_page_city_state_zip__1 was LastPageCityStateZip (0.38 conf)
last_page_home_phone_number__1 was LastPageHomePhoneNumber (0.43 conf)
last_page_office_phone_number__1 was LastPageOfficePhoneNumber (0.35 conf)
last_page_cell_phone_number__1 was LastPageCellPhoneNumber (0.32 conf)
last_page_email__1 was LastPageEmail (0.33 conf)
last_page_date__2 was LastPageDate2 (0.38 conf)
last_page_signature was LastPageSignatureCoGuardianofEstateifapplicable (0.40 conf)
last_page_name_guardian_estate was LastPageNameCoGuardianOfEstate (0.42 conf)
last_page_address__2 was LastPageAddress_2 (0.31 conf)
last_page_city_state_zip__2 was LastPageCity State Zip_2 (0.38 conf)
last_page_home_phone_number__2 was LastPageHome Phone Number_2 (0.47 conf)
last_page_office_phone_number__2 was LastPageOffice Phone Number_2 (0.35 conf)
last_page_cell_phone_number__2 was LastPageCell Phone Number_2 (0.36 conf)
last_page_email__2 was LastPageEmail_2 (0.37 conf)

We've done our best to group similar variables togther to avoid overwhelming the user.

Suggested Screen 0:

pg_county
pg_estate
pg_case
p_date_guardian
cb_pg_bx
cb_pg_box
pg_asset__1
pg_value__1
pg_coowner__1
pg_asset__2
pg_value__2
pg_coowner__2
pg_asset__3
pg_value__3
pg_coowner__3
pg_asset__4
pg_value__4
pg_coowner__4
pg_asset__5
pg_value__5
pg_coowner__5
pg_asset__6
pg_value__6
pg_coowner__6
pg_asset__7
pg_value__7
pg_coowner__7
pg_asset__8
pg_value__8
pg_coowner__8
pg_asset__9
pg_value__9
pg_coowner__9
pg_asset__10
pg_value__10
pg_coowner__10
pg_asset__11
pg_value__11
pg_coowner__11
pg_asset__12
pg_value__12
pg_coowner__12
pg_total_value
cb_pg_q__1
cb_pg_q_n__1
pg_acquired
pg_q_name_added
cb_pg_q_cind
cb_pg_q_cowner
cb_pg_q_yes__1
cb_pg_q__2
pg_q_carrier__1
pg_q_coverage_period__1
cb_pg_q_yes__2
cb_pg_q__3
pg_q_carrier__2
pg_q_coverage_period__2
cb_pg_q_yes__3
cb_pg_q_b_yes__1
pg_joint_name
cb_pg_q_b__1
pg_location_safe
cb_pg_q_b_yes__2
cb_pg_q_b__2
cb_pg_row__1
cb_pg_row_n__1
pg_amount__1
cb_pg_row__2
cb_pg_row_n__2
pg_amount__2
cb_pg_row__3
cb_pg_row_n__3
pg_amount__3
cb_pg_row__4
cb_pg_row_n__4
pg_amount__4
cb_pg_row__5
cb_pg_row_n__5
pg_amount__5
cb_pg_row__6
cb_pg_row_n__6
pg_amount__6
cb_pg_row__7
cb_pg_row_n__7
pg_amount__7
cb_pg_row__8
cb_pg_row_n__8
pg_amount__8
cb_pg_row__9
cb_pg_row_n__9
pg_amount__9
cb_pg_row__10
cb_pg_row_n__10
pg_amount__10
cb_pg_row__11
cb_pg_row_n__11
pg_amount__11
cb_pg_row__12
cb_pg_row_n__12
pg_amount__12
cb_pg_row__13
cb_pg_row_n__13
pg_amount__13
cb_pg_row__14
cb_pg_row_n__14
pg_amount__14
cb_pg_row__15
cb_pg_row_n__15
pg_amount__15
cb_pg_row__16
cb_pg_row_n__16
pg_amount__16
cb_pg_row__17
cb_pg_row_n__17
pg_amount__17
pg_total_amount
pg_liabilities_debts_row__1
pg_lender_row__1
pg_value_row__1
pg_liabilities_debts_row__2
pg_lender_row__2
pg_value_row__2
pg_liabilities_debts_row__3
pg_lender_row__3
pg_value_row__3
pg_liabilities_debts_row__4
pg_lender_row__4
pg_value_row__4
pg_liabilities_debts_row__5
pg_lender_row__5
pg_value_row__5
pg_liabilities_debts_row__6
pg_lender_row__6
pg_value_row__6
pg_liabilities_debts_row__7
pg_lender_row__7
pg_value_row__7
pg_value_tota_l_debts
cb_pg_prt_q
cb_pg_prt_q_n__1
cb_pg_prt_q_n__2
pg_lastitem
cb_pg_part_q__1
cb_pg_part_q_n__1
cb_pg_part_q_na
pg_responsible_fam_member
cb_pg_part_q_yb__1
cb_pg_part_q_yb__2
pg_daysweek
pg_hoursperweek
cb_pg_part_q_yb__3
cb_pg_comp_yes
cb_pg_comp
pg_comp_amt
cb_pg_part_qq_yes
cb_pg_part_qq
cb_pg_part_qq_na
cb_pg_q_ya__1
cb_pg_q_ya__2
cb_pg_q_ya__3
cb_pg_q_ya__4
cb_pg_q_ya__5
cb_pg_q_ya__6
pg_q_bline__1
pg_q_bline__2
pg_q_bline__3
pg_q_bline__4
pg_current_add__1
pg_current_add__2
pg_current_add__3
pg_part__1
pg_part_b
pg_part_c
pg_part__2
cb_pg_q__4
cb_pg_q_n__2
cb_pg_q_n__3
pg_ssdi
pg_ssi
pg_retirement_bene
pg_veterans_benefits
medical_assistance_long_term_care
medical_assistance_home_waiver
pg_govt_benefits
pg
pg_describe__1
pg_describe__2
pg_describe__3
pg_describe__4
pg_describe__5
pg_describe__6
pg_describe__7
pg_describe__8
pg_describe__9
pg_describe__10
pg_describe__11
pg_describe__12
pg_describe__13
pg_describe__14
pg_describe__15
cb_pg_q__5
cb_pg_q_n__4
cb_pg_q__6
cb_pg_q_n__5
cb_pg_q__7
cb_pg_q_n__6
cb_pg_part_q__2
cb_pg_part_q_n__2
cb_pg_part_q__3
cb_pg_part_q_n__3
pg_auth_agent
cb_pg_q__8
cb_pg_q_n__7
pg_explain__1
pg_explain__2
pg_explain__3
pg_explain__4
cb_pg_q__9
cb_pg_q_b_n
pg_value__13
signature_guardian_estate
last_page_date__1
last_page_type_name_guardian
last_page_address__1
last_page_city_state_zip__1
last_page_home_phone_number__1
last_page_office_phone_number__1
last_page_cell_phone_number__1
last_page_email__1
last_page_date__2
last_page_signature
last_page_name_guardian_estate
last_page_address__2
last_page_city_state_zip__2
last_page_home_phone_number__2
last_page_office_phone_number__2
last_page_cell_phone_number__2
last_page_email__2

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The Legal Innovation & Technology Lab's Form Explorer ^Beta @ Suffolk Law School Last updated 2023-04-02