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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1162 EX(11-96)
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
POWERS THOMAS 0
6603 SPRING FORD TERRACE
HARRISBURG, PA 17111
n______ fold
ESTATE INFORMATION: SSN: 163-58-2694
FILE NUMBER: 2100-0425
DECEDENT NAME: POWERS RICHARD 0
DATE OF PAYMENT: 11/08/2007
POSTMARK DATE: 11/08/2007
COUNTY: CUMBERLAND
DATE OF DEATH: 06/14/2007
NO. CD 008928
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 I $2,183.27
I
I
I
I
I
I
I
I
TOTAL AMOUNT PAID:
$2,183.27
REMARKS: RECEIPT TO ATTORNEY
CHECK# 117
SEAL
INITIALS: AJW
RECEIVED BY:
REGISTER OF WILLS
GLENDA FARNER STRASBAUGH
REGISTER OF WILLS
CHARLES E. SHIELDS, III
ATTORNEY-AT-LAW
6 CWUSER ROAD
Corner ofTrindk and Clouser Roads
MECHANICSBURG, PA 17055
GEORGE M. HOUCK
(1912-1991)
TELEPHONE (717) 766-0209
FAX (717) 795-7473
November 2, 2007
Register of Wills
Cumberland County Court House
1 Court Square
Carlisle,PA 17013
Re: Estate of Richard D. Powers
Dear Register of Wills:
Please find enclosed for filing 2 copies of the Inheritance Tax Return for the Richard D.
Powers Estate as well as Check No. 117, in the amount of $2,183.27 for the Inheritance Tax due
and Check No. 118, in the amount of $15.00 for the filing fee.
Thank you for your kind attention to this matter.
Very truly yours,
~
Charles E. Shields, III
Attorney-At-Law
CES/mjj
Enclosures
,. ~.
,.. J
~.c
.-J
15056051047
REV-1500 EX (06-05)
PA Department of Revenue '*
Bureau of Individual Taxes .
PO BOX 280601
Harrisbur ,PA 17128-0601
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death
OFFICIAL USE ONLY
County Code Year
File Number
INHERITANCE TAX RETURN
RESIDENT DECEDENT
Date of Birth
Decedent's Last Name Suffix
Decedent's First Name
MI
(If Applicable) Enter Surviving Spouse's Information Below
Spouse's Last Name Suffix
Spouse's First Name
MI
Spouse's Social Security Number
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
_ 1. Original Return --<::)
2. Supplemental Return
c:::::>
3. Remainder Return (date of death
prior to 12-13-82)
5. Federal Estate Tax Return Required
t::)
4. Limited Estate
(:)
t::)
<=:) 4a. Future Interest Compromise (date of
death after 12-12-82)
_ 7. Decedent Maintained a .l.iving Trust ~ 8. Total Number of Safe Deposit Boxes
(Attach Copy ofTrust) (~MiVWDSJ
t::) 10. Spousal Poverty Credit (date of death t::) 11. Election to tax under Sec. 9113(A)
between 12-31-91 and 1-1-95) (Attach Sch. 0)
CORRESPONDENT - THIS SECTION MUST BE COMPLETED. ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED TO:
Name Da time Telephone Number
6. Decedent Died Testate
(Attach Copy of Will)
9. Litigation Proceeds Received
<:::)
;_'.1
Correspondent's e-mail address:
beameres (i)..ep;)Col'1et
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge and belief,
it is true, correct and complete. Declaration of preparer other than the personal representative is based on all information of which preparer has any knowledge.
DATE
II
/7111
SIGNAT
DATE
1// 'j) 7-
ADDRESS e W A-ll.lES E. :5 ILl$'
" CJDUser nt/., 1J1~(!),4nit:.5:bu~ 1111 /1",S-
P ASE USE ORIGINAL FORM ONLY
Side 1
L
15056051047
15056051047
--I
.-.I
15056052048
REV-1500 EX
Decedent's Social Security Number
8. Total Gross Assets (total Lines 1-7). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 8.
S 8 ;;.. ~~9 1-
Decedent's Name: ~ 1 CH /rILl> ]). foWEtlS
RECAPITULATION
1. Real estate (Schedule A). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .' 1.
2. Stocks and Bonds (Schedule B) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 2.
3. Closely Held Corporation, Partnership or Sole-Proprietorship (Schedule C) .. . .. 3.
4. Mortgages & Notes Receivable (Schedule D) . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 4.
5. Cash, Bank Deposits & Miscellaneous Personal Property (Schedule E) . . . . . . .. 5.
6. Jointly Owned Property (Schedule F) ~ Separate Billing Requested . . . . . .. 6.
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G) ~ Separate Billing Requested.. . . . . ., 7.
11. Total Deductions (total Lines 9 & 10).................... ............... 11.
.3~57 /
3" ~7 I '"
I fJI CJ.' {;
I {g. 7S7.,,7
If 371 ~ ~ 7
18'/93.;K1
t)O
/8' 1'13.8''1
9. Funeral Expenses & Administrative Costs (Schedule H). . . . . . . . . . . . . . . . . . . .. 9.
10 Debts of Decedent, Mortgage Liabilities, & Liens (Schedule !). . . . . . . . . . . . . . . . 10.
12. Net Value of Estate (Line 8 minus Line 11) . .. . . . ., . .. . . . . . . . . . . . . . . . . . . . 12.
13. Charitable and Governmental Bequests/See 9113 Trusts for which
an election to tax has not been made (Schedule J) . . . . . . . . . . . . . . . . . . . ... . . . 13.
14. Net Value Subject to Tax (Line 12 minus Line 13) .. . . . . . . . . . . . . . . . . . . . . . . 14.
TAX COMPUTATION. SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate, or
transfers under Sec. 9116
(a)(1.2) X .OD-
16. Amount of Line 14 taxable
at lineal rate X.O ~
17 . Amount of Line 14 taxable
at sibling rate X .12
18. Amount of Line 14 taxable
at collateral rate X .15
17.
. ()O
.00
J.. /'6 '3. 2. 1
.00
15.
. f) {)
/11'l3.??
16.
. () 0
18.
19. TAX DUE. . ., . . . . . ., . . . . . . . . . .. . . . . .
................19.
)..{f3.;l.1
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
c::::>
Side 2
L
15056052048
15056052048
-1
REV,1500 EX Page 3
File Number
Decedent's Complete Address:
DECEDENT'S NAME
~ / ~ H AI( ~ ]) .
fJ () w Jal~
STREET ADDRESS
/7/0
SflS'i' /{)()()./)
/t IJ,#J
CITY
I'/F/Y e U HI IJ ~LAN./)
STATE jJ A
ZIP
/7070
Tax Payments and Credits:
1. Tax Due (Page 2 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
B. Prior Payments
C. Discount
(1 )
,
:2/lr3,:17
o
o
-- ----_._---~....._-----------
o
Total Credits ( A + B + C ) (2)
o
3. InteresUPenalty if applicable
D. Interest
E. Penalty
()
- - __d. ____u.___ _________n__
o
(3) 0
(4) 0
r
(5) ':<,11'3,27
(5A) 0
(5B) 1;:(,./1'3,27
--------- Total Interest/Penalty ( 0 + E )
4. If Line 2 is greater than Line 1 + Line 3, enter the difference. This is the OVERPAYMENT.
Fill in oval on Page 2, Line 20 to request a refund.
5. If Line 1 + Line 3 is greater than Line 2, enter the difference. This is the TAX DUE.
A. Enter the interest on the tax due.
B. Enter the total of Line 5 + 5A. This is the BALANCE DUE.
Make Check Payable to: REGISTER OF WILLS, AGENT
PLEASE ANSWER THE FOllOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Yes No
a. retain the use or income of the property transferred;.......................................................................................... 0 ~
b. retain the right to designate who shall use the property transferred or its income; ............................................ 0 !Xl
c. retain a reversionary interest; or.......................................................................................................................... 0 ~
d. receive the promise for life of either payments, benefits or care? ...................................................................... 0 ~
2. If death occurred after December 12, 1982, did decedent transfer property within one year of death
without receiving adequate consideration? .............................................................................................................. 0 ~
3. Did decedent own an "in trust for" or payable upon death bank account or security at his or her death? .............. 0 IX]
4. Did decedent own an Individual Retirement Account, annuity, or other non-probate property which
contains a beneficiary designation? ........................................................................................................................ ~ 0
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse
is three (3) percent [72 P.S. S9116 (a) (1.1) (i)].
For dates of death on or after January 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is zero (0) percent
[72 PS. S9116 (a) (1.1) (ii)]. The statute does not exempt a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and
filing a tax return are still applicable even if the surviving spouse is the only beneficiary.
For dates of death on or after July 1, 2000:
The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an
adoptive parent, or a stepparent of the child is zero (0) percent [72 P.S. s9116(a)(1.2)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is four and one-half (4.5) percent, except as noted in
72 P.S. S9116(1.2) [72 PS. s9116(a)(1)].
The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is twelve (12) percent [72 P.S. s9116(a)(1.3)]. A sibling is defined, under
Section 9102, as an individual who has at least one parent in common with the decedent, whether by blood or adoption.
REV.'5'O EX .(,.97)
SCHEDULE G
COMMONWEALTH OF PENNSYLVANIA INTER-VIVOS TRANSFERS &
INHERITANCE TAX RETURN MISC. NON-PROBATE PROPERTY
RESIDENT DECEDENT
ESTATE OF
Po LU ei<S, ~ I CHIt~..D ]).
ITEM
'JUMBER
1.
FILE NUMBER
This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes
DESCRIPTION OF PROPERTY
INCLUDE THE NAME OF THE TRANSFEREE, THEIR RELATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER
ATTACH A CDPY OFTHE DEED FOR REAl ESTATE. .
%OF
DECD'S
INTEREST
TAXABLE VALUE
EXCLUSION
IIF APPliCABLE \
DATE OF DEATH
VALUE OF ASSET
'D~eEDeN-r W~ DiSABLED Rz.o#1tt Ble7N.
HIS Flfr/{~ /,t)/ll/AAt .:T. f1f)I#I:-'1lJ
f Il~ 'Pee ~e:1J HldI, INr€ S7Jf rEo /(J~
IiSrArE FleE J>>~r~ 7P CUM8~lAAJP
et)tll'l ry Nt), :11- f"l- /~f-"), R.ICHA-/lIJ 1>.
fDWer<.>, /!Jy 7J/E lkJV5 ~I= 7i{IS (2I1lJJff)N-
tV E A- /.. rJ./ , 1tJG" CII-/J1t: 1/6 re-/) til17/f A
p;eA C TIt) /I/,f-t.. SHA-ItE ~ H/S ~ f)
rA- rHa;.~ ES r,lf-7iP. (JEE /ff?,1f-(!.I{Ef)
-
10 SME'D. ~: 7l2ttE ANt) &rbecc.r
Cbl/18 ()t::" 7-'YL: tf/E 77n~/I/ 71) E:Sr~
1M! //l/!?YPt!/fJSLE 'S,PEC/~ /f~7:0S
7/l.U.!. T, "Eo 7~ Df: ')C-,fN F. GRA-Y BILL,
dr /Jpw J L~ 7761f tJF c/. fJA~ ])/&:rlT,I Df.
JJefJr: (<.EY" 61= 7NE' I/Q(EY8eA~tlF SABYA-L
tYlEl!SPS '77lH5T~.f) tJF Juf)(;/r" GUI DoS
~(Je( ~~I3~NSHIAI~ IT). fJGi7C. C/JttJ!.r
,4-flP/lDvAi.. -"If //lDrp~AtJtl: .sPct!./~
.lfs::D~ plt/si t()d J!f5771-,g, FbR
~eAlE~/r t/r ,l)E(!EiJEN7: TIWSr
A CMt/IJT tv~ /J1A/l/rA-/A'P /fT
CtJMJr1E/le~ ~A-AlK (Sa: YALu/fr;~JI/
LE rrt9( A rTACIIEtJ).
1JEc..EfJ aJ T ()ulflrt) Aft? P/l/J//t7l7Y.
1
3'1 S 7/./'
JDD~
-0-
TOTAL (Also enter on line 7, Recapitulation) $"'3'. 57/. Ic"
{If more snace IS neened. mSArt t=lrlditinnt=ll shp.p.ts ()f thp ~;::Imp ~17P'
Commerce
"Bank~
RICHARD D POWERS SPECIAL NEEDS TRUST
VIRGINIA D POWERS
THOMAS D POWERS
1710 SHERWOOD ROAD
NEW CUMBERLAND, PA 17070-1454
06/ I 5/07
0520030727
CY CLE-OO I 4
* * *CHECKING * * * NOW
ACCOUNT NUMBER 520030727
PREVIOUS STATEMENT BALANCE AS OF 05/15/07 ... .. .. 36,571.16
PLUS 0 DEPOSITS AND OTHER CREDITS. . . . . .
LESS 0 WITHDRA WLS AND OTHER DEBITS. . .
CURRENT STATEMENT BALANCE AS OF 06/15/07 . . . . . . .. 36,571. I 6
NUMBER OF DAYS IN THIS STATEMENT PERIOD 31
* * * ACCOUNT TRANSACTION * * *
DATE DESCRIPTION DEBITS
CREDITS
* * * BALANCE BY DATE * * *
06/15 36.571.16
PAYER FEDERAL IS NUMBER 23-2324730
Commerce Bank / Harrisburg, N.A.
P.O. Box 8599
100 Senate Avenue
Camp Hill, Pennsylvania 17001-8599
REV-1511 EX+ (12-99)
ESTATE OF
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS I
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
P()tJ)E~5" ,(ltlllfteD
])~
FILE NUMBER
2/-07-
ITEM
NUMBER
A.
Debts of decedent must be reported on Schedule I.
DESCRIPTION
1.
FUNERAL EXPENSES:
fteEPA 11>
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s) -r~t)AlK powElf!S
Social Security Number(s)/EIN Number of Personal Representative(s)
Street Address ~(, 03 517 ,../n1(;,,.d 7i1"f'ac.e.
City Htl. rr; sb Ll Y'j State ~ Zip 1 71/ 1
Year(s) Commission Paid:
2.
3.
C CL' ~ (i "d~e.s Me..e.h'nq$, Cd'IsulhJIOns
Attorney Fees h A r1 e5 E: ...:m,' e..- J as ill. fh r'~ iv ~u....t 11.,1.1'<<, resC!A.I'Gok
;;Ies I Pt-f!.f'. Tet. d.,'se + ~"re.sp
Family Exemption: (If decedent's address is not the same as claimant's, attach explanation) l.ul'~ "DPw ~
t'o.\lJ\ D; \.Jut J e.h..)
Claimant
Street Address
City
State _ Zip
4. Probate Fees
Relationship of Claimant to Decedent
5. Accountant's Fees
6. Tax Return Preparer's Fees
7.
~I
'P,
F; lil1d lie. -b 1(~"s~r Bf Lui\ \s
/(eim6/,1rsemtl1t Ie> {!I,lJr/es E. Slll'el&(~ JjJ. ~Y"
of'l7'c-/a/ /II/)h~fl/e~ de. ~II( i?r;skr "I a;///.s
Re/M~JI~ellt- ~ ChArleS E: Sh,'ejt:l.s IiL t:,r IJtw~UJp;es
C!.a.rti {,'uI /Ha//I'nf~" ;'J~sm?l'/ e~ USh;.J
AMOUNT
W~I/I~
;.
I J sroS'. 00
AJOT ItPPUC!lJ.t3lG
5l'J S. 00
'1J '?; ~O
~
t2-? ~O
(If more space is needed, insert additional sheets of the same size)
TOTAL (Also enter on line 9, Recapitulation) $ / 1/9 I CJ
,I (0 . CJ:)
RECEIPT FOR PAYMENT
-------------------
-------------------
GLENDA FARNER STRASBAUGH
Cumberland County - Orphans Court
One Courthouse Square
Carlisle, PA 17013-3387
Recetpt Date:
Rece~pt Time:
Recelpt No.:
10/24/2007
13:54:30
1034748
POWERS RICHARD
File Number:
Paid By Remarks:
2000-00425
CHARLES E SHIELDS III ESQ
JA
------------------------ Receipt Distribution ------------------------
Fee/Tax Description Payment Amount Payee Name
PHOTOCOPIES
Check# 1030
Total Received.........
17.00
CUMBERLAND COUNTY GENERAL FUN
$17.00
$17.00
REV-1512 EX+ (12-03)
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES, & LIENS
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
po WE R S I J< IC.H A-R])
:J::>.
FILE NUMBER
;LI- 07
Report debts incurred by the decedent prior to death which remained unpaid as of the date of death, including unreimbursed medical expenses.
ITEM
NUMBER DESCRIPTION
1. 1<tf'COUPtnI:IJT OttJED 10 /JEff OF Pu f3J../C tJ.J~
( SF E C/)1lIU:5 jJ ~AI./J tNcE A"/ T/ff!H 51)
VALUE AT DATE
OF DEATH
f6
I ~J 757.&7
TOTAL (Also enter on line 10, Recapitulation) $ I {, I 7 s 7. "7
(If more space is needed, insert additional sheets of the same size)
~--..;,;...
I ) f J ~'\
tljlli-{&;!t
CHARLES E. SHIELDS, III
ATTORNEY-AT-LAW
6 CLOUSER ROAD
Corner ofTrindle and Clouser Roads
MECHANICSBURG. PA 17055
EORGE M. HOUCK
(1912-1991)
TELEPHONE (717) 766-0209
FAX (717) 795-7473
October 16,2007
Ms. Jem1ifer Hartman
Commonwealth of Pennsylvania
Department of Public Welfare
Estate Recovery Program
PO Box 8486
Harrisburg, P A 17105
RE: Richard D. Powers, deceased, late of
1710 Sherwood Road, New Cumberland, P A 17070
Date of Death: 6/14/07
SSN: 163-58-2694
Dear Ms. Hartman:
Please find enclosed Check No. 116 in the amount of $16,757.67. I am also enclosing
your letter and Statement of Claim Summary dated October 5, 2007 for your ready reference and
convenience. As I understand it, this is a final billing and the Check represents payment in full.
If I am in enol', please advise at your earliest convenience.
Thank you for your kind attention to this matter.
Very truly yours,
~f~
Charles E. Shields, III
Attorney-At-Law
CES/mjj
Enclosure
cc: Thomas Powers
CHARLES E. SHIELDS, III
A TTORNEY-AT-LA W
6 CWUSER ROAD
Corner ofTrindIe and Clouser Roads
MECHANlCSBURG, PA 17055
GEORGE M. HOUCK
(1912-1991)
TELEPHONE (717) 766-0209
FAX (717) 795-7473
~
~
--
Ms. Jennifer Hartman
Commonwealth of Pennsylvania
Department of Public Welfare
Estate Recovery Program
PO Box 8486
Harrisburg, P A 17105
RE: Richard D. Powers, deceased, late of
1710 Sherwood Road, New Cumberland, PA 17070
Date of Death: 6/14/07
SSN: 163-58-2694
Dear Ms. Hartman:
Please find enclosed Check No. 116 in the amountof$16,757.67. I am also enclosing
your letter and Statement of Claim Summary dated October 5,2007 for your ready reference and
convenience. As I understand it, this is a final billing and the Check represents payment in full.
If I am in error, please advise at your earliest convenience.
Thank you for your kind attention to this matter.
Very truly yours,
~~~
Charles E. Shields, III
Attorney-At-Law
CES/mjj
Enclosure
...
~
-~~~~- -'
cc: Thomas Powers
RICHARD D. POWERS
SPECIAL NEEDS TRUST ACCOUNT
60-184/313
520030727
DATE \ 0 ~ Il.c - 0 "7
116
Commerce
tI'Bank / Harrisburg, N.A.
4700 JONESTOWN RD.
HARRlSBURG, PA 17109
'"Il./' /p l-
*'
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
BUREAU OF FINANCIAL OPERATIONS
DIVISION OF THIRD PARTY LIABILITY
CASUALTY UNIT
P.O.BOX 8486
HARRISBURG, PA 17105-8486
October 24, 2007
CHARLES E SHIELDS III ESQUIRE
6 CLOUSER ROAD
MECHANICSBURG PA 17055
Re: RICHARD POWERS
CIS #: 002351204
Incident Date: 09/11/2000
Dear Attorney Shields:
This is to acknowledge receipt of payment in the amount of $16,575.67
regarding the above-referenced individual.
Your cooperation in this matter is appreciated.
Sincerely,
1 ' , ,/) f11
~ 1',,?'4tt 'Ie. ~1 M;C;~
r/ "
Jennifer Hartman
TPL Program Investigator
717-772-6962
717-772-6553 FAX
REVC1513 EX+ (9-00)
SCHEDULE J
BENEFICIARIES
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
11:> W eR.S I R-ICJ./A-tGD
))..
FILE NUMBER
RELATIONSHIP TO DECEDENT
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s)
I TAXABLE DISTRIBUTIONS [include outright spousal distributions, and transfers under
Sec. 9116 (a) (1.2)]
1. TlwtnaS 7). ~tcJe,T75' .lJ r6tAer-
, '" 03 Spr-: flJ r:. rd Te.rr4.c.e
l-l6..trislHA.r~, Ph 17/(1
I" I,,(. AJo'li! 1M. terms Dt ~ pr,'ori h'es .f
fDAfMent~ aM.cl d;sn-;1,,,,Hof16 a~ set &tH.
~ PA.~. f, ;Ja.I'4q t. C. uJ jJrtJvirles F-r Mty
re-1'fl4~t1Jnd .bo.lllJ1Ce. Ii be. tl.'sf-r;l)c.c.:ted a-b.s.olwhly
~ llINnas]). Po we t-S, dec.e.,ft>n ts' UhJlkr.
(See CDPf ,f 7i-usf 4-1/c..cht.c/ hereto)
2-/-07-
AMOUNT OR SHARE
OF ESTATE
/0010
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET
II NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1.
TOTAL OF PART Il- ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON liNE 13 OF REV-1500 COVER SHEET $
(If more space is needed, insert additional sheets of the same size)
"
".,1
SEP 0 7" ZDD~
L!...,
IN THE MATTERS OF
: IN THE COURT OF COMMON PLEAS
: CUMBERLAND COUNTY, PENNSYLVANIA
.
.
1.) The Estate of WILLIAM
J. POWERS, Deceased, Late
of New Cumberland Borough,
Cumberland County,
Pennsylvania; and
: ORPHANS' COURT DIVISION
.
.
: 1.) NO. - -1080
2.) RICHARD POWERS, an
adjudicated incapacitated
person
.
. 2.) NO. 21-00-425, I apacitated Person
ORDER OF COURT
AND NOW, this lip.. day of ~ ,2000, upon consideration
of the within Petition of Virginia D. Powers and Thomas D. Powers, in their capacities as set forth
more fully therein, it is hereby Ordered and Decreed that approval is hereby given for the
establIshment and funding of the IRREVOCABLE SPECIAL NEEDS TRUST FOR THE
BENEFIT OFRICHARD D. POWERS OF NEW CUMBERLAND, CUMBERLAND
COUNTY, PENNSYLVANIA, and for the reimbursement to Virginia D. Powers for monies
advanced for the costs of an advance funeral arrangement, in accordance with the provisions of the
within Petition.
J.
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lY', '~!JSO
ZZ: G \1 II d3S 00.
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IRREVOCABLE SPECIAL NEEDS TRUST FOR THE BENEFIT OF RICHARD D.
POWERS OF NEW CUMBERLAND~ CUMBERLAND COUNTY~ PENNSYLVANIA
VIRGINIA D. POWERS, currently of 1710 Sherwood Road, in the Borough of New
Cumberland, Cumberland County, Pennsylvania, natural mother, next of friend, natural
guardian and court appointed plenary guardian of the person and property of RI CHARD
D. POWERS, currently of the same address, an adult individual, thirty-eight (38) years of
age, an adjudicated incapacitated person, who is considered "disabled" as defined by 42
U.S.C. U382C(a)(3); THOMAS D. POWERS, currently of 22 Ardmore Circle, in the
Borough of New Cumberland, Cumberland County, Pennsylvania, natural brother and
next of friend of the said RICHARDD. POWERS; and the said RICHARD D. POWERS,
by and through his said natural mother and brother, acting pursuant to specific court
authorization and approval as per that certain court order dated the I / fI, day of
Se,~ , A.D. 2000, and signed by the Honorable
~tlUIII''' ~, 'eI ~ , J., a true and correct copy of which is attached hereto as
"Exhibit A", do hereby transfer, assign, set over, and deliver unto the said VIRGINIA D.
POWERS and the said THOMAS D. POWERS, Co- Trustees ("Trustee"), all that certain
property described in that certain inventory attached hereto as "Exhibit B", to constitute,
together with any other property that may become subject to this Trust, the Trust Estate
. .
of an express trust, to beheld, administered and distributed by the Trustee as provided
herein.
ADDITIONAL PROPERTY:
1. The Settlor, and 'any other person, shall have the right at any time, either during his
or her life Of by Will, to add other property acceptable to the Trustee to this Trust. Any' additional
property, when received and accepted by the Trustee, shall become a part of the Trust Estate ofthis
Trust.
IRREVOCABILITY:
2. This Trost shall be irrevocable and shall not be altered, amended, revoked, or
tenninated by the Settlor or any other person.
t' c~ i..,. "f..rt !'{
EXPRESS PURPOSES:
3. The express purpose of the RICHARD D. POWERS IRREVOCABLE
SPECIAL NEEDS TRUST is to provide for RICHARD D. POWERS extra and supplemental
care in addition to and over and above the benefits that RICHARD D. POWERS receives or shall
receive as a result of his disabilities from any local, state, or federal government, including but not
limited to Medicare, Medicaid, or from any other private agency providing services or benefits to
disabled persons.
4. The Trust Estate shall NOT be used to provide basic food, clothing and shelter, nor
be available to RICHARD D. POWERS for conversion for such items, unless all local, state, and
federal benefits have been fully expended for such purposes. It is the express purpose of the
Settlorsrrrustors to establish the Trust in accordance with 42 D.S.C. ~ 1396p (d)(4)(A), and any
provisions herein shall be construed accordingly.
EXPENDITURES:
5. During the lifetime of RICHARD D. POWERS (hereinafter, the "Beneficiary"),
the Trustees may expend for his benefit, so much of the net income and, if necessary, principal of
the Trust Estate to carry out the purposes set forth in the above recitals, as the Trustees, in their sole
and absolute discretion, consider advisable, in view of other funds or benefits available from
governmental or other sources, both public and private, of which they have knowledge.
6. By means of illustration, and in no manner attempting to limit the Trustee's
discretion, the Trustee may make distribution of the net income and, if necessary, principal of the
Trust Estate, to or for the benefit of the Beneficiary, for such purposes as, but not limited. to training
to develop skills and abilities, transportation, educational support, tutoring, home and residential
adaptation assistance, medical and dental expenses not covered by medicaid or medicare, medical
and dental insurance, equipment, entertainment, essential dietary needs, treatment programs, and
experimental medical services, supplemental nursing care not covered by medicaid, medicare, or
other publicly funded program, recreation, cultural experience, outings and travel, telephone and
television, exercise equipment and unreimbursed therapy, and any other programs to provide for the
-2-
special needs of "life enrichment" of the beneficiary as may be pennitted by law.
7. It is the intention of the Settlors that distributions of income andlor principal from
the Trust Estate shall be used only to supplement, not supplant, any benefits to which the
Beneficiary may be entitled under any governmental program, and if the existence of this Trust
should at any time be used by any governmental agency as an excuse for denying the Beneficiary
such benefits, then the Trustees are authorized, in their sole and absolute discretion, to terminate the
Trust Estate by distributing the then remaining principal and any income accrued or on hand to the
beneficiaries named in Paragraph 8.C. below upon the terms and conditions set forth therein.
Notice of intention to terminate the Trust shall first be provided to the Commonwealth of
Pennsylvania, Department of Public Welfare, Third Party Liability Section, Harrisburg,
Pennsylvania, its successor, or other appropriate federal or state agency administering Medicaid or
Medical Assistance (the '~Agency"). The Trustee may accumulate and reinvest any income that is
not paid out pursuant to this Section.
ESTA TE ADMINISTRATION AND DISTRIBUTION:
8. Upon the death of the Beneficiary, the Trustee shall pay and distribute the remaining
balance of the Trust Estate and any accumulated, undistributed net income thereon as follows:
A. As per the order of payment specified in the Pennsylvania P.E.F. Code, Sect. 3392:
(1) The costs of any administration of the Beneficiary's Estate,
including but not limited to: costs of filing any papers or petitions with the Office
of the Regist~r of Wills andlor Clerk of the Orphan's Court, inheritance tax retUrn, .
any trust or beneficiary income tax return, accountings, and the like, as well as any
. attorney's, accountants, administrator's, or trustee's fees associated with such estate
administration and settlement.
B. (Re: INQUIRY AND REIMBURSEMENTS): If the beneficiary has received
or is receiving Medicaid or Medical Assistance benefits at the time of his death, or if i~ is unknown
if the Beneficiary has received Medical Assistance, or if the Trust is otherwise terminated, the
-3-
L. .. ... ........._.....m...._~._..._.._...__
Trustees, if required under 62 P.S. U412(b) or any amendment thereto or any successor
statute, before making any distributions, shall request a written statement from the Third Party
Liability Section of the Pennsylvania Department of Public Welfare, P. O. Box 8486, Harrisburg,
P A 17105 reporting the amount of Medical Assistance paid for the Beneficiary from the date of the
establishment of this Trust. Upon receipt of the Benefit Amount Statement, the Trustee, if
required by then current statutes and regulations, shall pay and distribute to the Agency an
amount as required up to equal the Medical Assistance amount out of the remaining balance of the
Trust Estate and any accumulated and undistributed net income thereon to first reimburse the
Commonwealth of Pennsylvania andlor any other governmental entity, as required by 42 U.S.c.~
1396p (d)(4)(A) or any amendment thereto or any successor statute, out of the Trust Estate for
the cost of medical assistance provided to RICHARD D. POWERS on or after the funding of this
Trust before making any other distributions, excepting those specified in Paragraph A. above. In
no event, however, shall any amount be repaid or otherwise reimbursed to the s~tid
Commonwealth unless required by then current statutes and regulations. . I
C. If there is no such reimbursement due to the Commonwealth of Pennsylvania andlor
any other governmental entity, or any remaining balance after the reimbursement to the
Conunonwealth of Pennsylvania and/or any other governmental entity, then the remaining balance
of the Trust Estate and any accumulated, undistributed net income after the payment of all death and
other taxes that may first be due thereon shall be distributed as follows:
(1) All the balance to the Beneficiary's brother, THOMAS D.
POWERS, in his own right absolutely.
(2) In the event that the said THOMAS D. POWERS has predeceased
the Beneficiary, then the balance shall be divided and distributed as follows;
T ANY A DANlELA POWERS:
One hundred (100%) per cent
(3) In the event that Beneficiary's above-named niece haspredecea<;ed
him, then her share shall go to her surviving issue, per stirpes. In the event she is
not survived by issue, then her share shall go to her mother, SANDRA R.
-4-
POWERS. In the event she is also deceased, then this share shall be divided and
distributed as per the laws of intestacy of the Commonwealth of Pennsylvania.
SPENDTHRIFT CLAUSES:
9. Notwithstanding any other provision of this Irrevocable Special Needs Trust, the
Beneficiary, RlCHARD D. POWERS, shall not and does not have the power to assign, encumber,
direct, distribute or authorize distribution from the Trust established hereby.
10. No beneficiary shall have the power to sell, assign, encumber, or in any manner
anticipate his or her interest in the Trust Estate, or in the income produced thereby.
DISTRffiUTION TO ANY MINOR:
11. If any beneficiary who is entitled to receive a share of the principal of the Trust
Estate shall be a minor, the Trustee is hereby authorized and empowered to continue to hold ~d
manage such share for the benefit of the minor during his or her minority as the minor's guardian
and may use all of the income from the minor's share, together with such amounts of principal as
the Trustee deems advisable for his or her health, education, maintenance, and support. This shall
be construed as a power only and shall not operate to suspend the absolute ownership thereof by
the minor nor to prevent the absolute vesting thereof in the minor.
12. In the disbursement of the funds directed to be paid to or for the use and benefit of
any beneficiary who shall be a minor, the Trustee may make payment of the same to the parent,
guardian, or such other person who may have custody of the person of that minor at the time such
payments are made, to be used for the health, education, maintenance, and support of the minor, but
without liability on the part of the Trustee to see to the application of said payments by the payee.
The receipt of any such person shall be a full acquittance of the Trustee as to any amounts so paid;
or the Trustee may make payment of the same directly to or for the benefit of the minor beneficiary.
13. For purposes of interpretation of this Trust, the word "minor" whenever used
herein shall mean any person under the age of eighteen (18) years, notwithstanding any law to the
-5-
contrary.
ADDITIONAL POWERS OF TRUSTEE:
14. In addition to the powers conferred by law, the Tru~tee shall have the following
discretionary powers which may be exercised without approval of any court:
A. To retain any and all property, real or personal, without any duty of diversification.
B. To sell any and all real estate held as a trust asset, at public or private sale, for such
prices and upon such tenns as the Trustee shall believe advisable, and to make, execute, and deliver
any deed or deeds therefor, conveying title thereto in fee simple absolute or for any lesser estate to
any purchaser or purchasers, freed and discharged of any and all trusts hereunder.
C. To sell, grant options to purchase, exchange, and alter assets of any trust created
hereunder or of any part thereof, at any price and upon such terms which the Trustee shall deem
proper.
D. To invest and reinvest in all forms of property, including but not limited to common
and preferred stocks, or any bond or other debt security.
E. To retain the services of any financially responsible professional investment
manager, special needs advisor, brokerage service, bank, credit union, savings and loan association
or other financial institution to assist and advise the Trustee in the management and investment of
the assets of the Trust Estate, including to execute security transactions through such institution or
institutions.
F. To purchase real property whether improved or not and to lease property on any
terms and conditions and for any term of years, even though extending beyond the pe:ibd of any
trust created hereunder.
G. To insure, improve, repair, alter, abandon, and partition real estate; erect or raze
-6-
. .,
improvements; grant easement; subdivide and dedicate to public use.
H. To cause any of the investments which may be delivered or acquired by the Trustee
to be issued, held, or registered in the name of the Trustee, in street name negotiable form, in the
name of the nominee, or in any form in which title will pass by delivery. Any corporation or its
transfer agent may presume conclusively that said nominee is the actual owner of the securities
submitted for transfer.
1. To vote in person or by proxy any securities held in the Trust Estate and, in such
connection, to delegate powers, discretionary or otherwise, for any purpose to one or more
nominees or proxies with or without power of substitution and to make assignments to and deposits
with committees, trustees, agents, depositories and other representatives; to retain any investments
received in exchange in any reorganization or recapitalization; to subscribe for stocks and bonds; to
grant, obtain or exercise options; and generally to exercise all rights of security holders.
J. To settle, compromise, contest or abandon claims or demand in favor of or against
any trust created hereunder.
K. To borrow money, assume indebtedness, extend mortgages, and encumber by
mortgage or pledge.
L. To distribute the principal of any trust created hereunder in kind or in cash; or party
in kind and party in cash.
M. To allocate receipts and disbursements to principal or income, or partly to each as
the Trustee deems proper.
N. To retain a consultant knowledgeable in the subject of Medical Assistance andlor
Medicare benefits or other public or private benefits available to the Beneficiary and to advise the
Trustee concerning discretionary distributions of income or principal so that such distributions will
be made in a manner consistent with the purpose of the Trust.
-7-
O. To deal in every way and without limitation with the representatives of any trust or
estate in which the Beneficiary has any existing or future interest, even though the Trustee is acting
as the representative of such other trust or estate, without liability for loss resulting from said
transaction.
P. To employ such agents, attorneys, accountants, investment counsel, and professional
advisors as may be required in managing, protecting and investing the assets of the Trust Estate and
to pay their reasonable compensation.
Q. To pay any taxes due from or by the trust from time to time, and to file all proper tax
returns.
15. The Co-Trustees ("Trustee") may act in all matters individually or jointly; the
actions of either individual Co-Trustee shall be construed by all persons having dealings therewith
as being with the full knowledge and authority of the other Co-Trustee, unless such persons have
prior written notice to the contrary from the other Co-Trustee.
SUCCESSOR TRUSTEES:
16. If VIRGINIA D. POWERS or THOMAS D. POWERS cease to act as Trustee
hereunder for any reason, then the remaining indi vidual Co-Trustee shall continue and assume
solely the rights, powers and obligations of Trustee. Should both VIRGINIA D. POWERS and
THOMAS D. POWERS, or the then remaining Co-Trustee cease to act as Trustee hereuilderfot
any reason, then SANDRA R. POWERS, currently of 22 Ardmore Circle, New Cumberland,
Pennsylvania, shall serve as Trustee, with the same powers and authority as the original Co-Trustees
had herein. If she is unable or unwilling to serve or act or to continue to serve or act as Trustee for
any reason, then WAYNE SCHMOYER, currently of 423 West Main Street, Annville, PA 17003,
shall serve as Trustee, with the same powers and authority as the original Co-Trustees had herein.
Upon transfer of the assets of the Trust Estate, the predecessor Trustee(s) shall provide an
accounting to the Successor Trustee, with a copy to the Third Party Liability Section of the
Department of Public Welfare. No Successor Trustee shall be liable for any act or failure to act of
a predecessor Trustee. A Successor Trustee may accept the account furnished, if any, . and the
-8-
property delivered by or from a predecessor Trustee without liability for doing so. If no objection
is made promptly by the Agency, such acceptance shall be a full and complete discharge to the
predecessor Trustee.
ACCOUNTINGS:
17. The Trustees shall provide a written annual account of their activities on behalf of
the Trust to the Third Party Liability Section of the Department of Public Welfare and may, at their
option, file formal accountings with the Orphans' Court from time to time, costs therefor to be paid
from the Trust.
TRUSTEE CO MPENSA TION:
18. Any Trustee which may be acting hereunder shall be entitled to deduct as
compensation reasonable fees, and for any corporate trustee the fees shall be in accordance with the
then prevailing rate of compensation charged by such Trustee for like services at the time such
services are rendered. In addition to the such Trustee's normal compensation, such Trustee shall be
entitled to deduct such fees as shall reasonably compensate such Trustee for such additional
services which such Trustee may be required to perfonn, and to employ and pay any other person
including but not limited to accountants, attorneys, or any other similar party employed by the
Trustee in aiding and assisting Trustee in the carrying out of Trustee's duties.
WAIVER OF BOND:
19. No bond shall be required in any jurisdiction of any Trustee or of any Successor
Trustee or, if a bond is required by law, no surety on such bond shall be required.
ACCEPTANCE AND APPROVALS:
20. This Trust Agreement has been delivered to and accepted by the Co-Trustees in the
Commonwealth of Pennsylvania, and all questions pertaining to the validity and interpretation of
this Trust Agreement and to the management and distribution of the Trust Estate hereunder shall be
-9-
determined in accordance with the laws of the Commonwealth of Pennsylvania, and any applicable
federal law or regulation.
21. This Trust document has been submitted to and approved by counsel for the
Department of Public Welfare of the Commonwealth of Pennsylvania, which department has
indicated its consent to its establishment as is evidenced by letter of counsel attached hereto as
"Exhibit C".
22. This Trust document has also been submitted to and approved by counsel for the
Department of Revenue of the Commonwealth of Pennsylvania, which department has indicated its
consent to its establishment as is evidenced by letter of counsel attached hereto as "Exhibit D".
IN WITNESS WHEREOF, the Settlor and Trustees have hereunto set their hands and seals as of
this 6rJe day of So.p ~n.M..~ , A.D. 2000.
Witness:
P//~
/
(SEAL)
MAS D. POWERS, as natural
brother and next. of fri. end O~f HARD
D:1?WERS ~.' J. .. ....... ~ ...... '
I\~IJ, ~..,. .
~~~
HARD . POWERS, by VIRGINIA .
D. POWERS, as plenary guardian
-<SEAL)
.#U/~
/
-10-
IN THE MATTERS OF
: IN THE COURT OF COMMON PLEAS
: CUMBERLAND COUNTY, PENNSYL VANIA
.
.
1.) The Estate of WILLIAM
J. POWERS, Deceased, Late
of New Cumberland Borough,
Cumberland 'County,
Pennsylvania; and
: ORPHANS' COURT DIVISION
2.) RICHARD POWERS, an
adjudicated incapacitated
person
.
.
: 1.) NO. 21-99-1080
:\
: 2.) NO. 21-00-425, Incapacitated Person
PETITION TO ESTABLISH AN IRREVOCABLE SPECIAL NEEDS TRUST
Virginia D. Powers, currently of 1710 Sherwood Road, in the Borough .of New
Cumberland, Cumberland County, Pennsylvania, as natural mother, next of friend, natural guardian,
and court appointed plenary guardian of the person and property of Richard D. Powers, currently
of the same address, an adult individual, thirty-eight (38) years of age, an adjudicated incapacitated
person,who is considered "disabled" as defined by 42 D.S.C. 91382C(a)(3); Thomas D. Powers,
currently ofl2 Ardmore Circle, in the Borough of New Cumberland, Cumberland County,
Pennsylvania, natural brother and next of friend of the said Richard D. Powers; and the said
Richard D. Powers, by and through his said natural mother and natural brother in the said capacities
above stated, as Settlors or Trustors do hereby request your Honorable Court to approve the
establishment of an irrevocable special needs trust for the said Richard D. Powers.
1. Your Honorable Court has jurisdiction, venue, and authority herein under 20 Pa.
c.s. 9711(1), (3), (10) and (12).
2. William 1. Powers departed this earthly life on October 25, 1999, intestate, surVive.d
by his spouse, the said Virginia D. Powers, and two (2) sons, the said Thomas D. Powers and the
said Richard D. Powers.
3. Letters of Administration were duly issued by the Register of Wills of Cumberland
County, Pennsylvania to Virginia D. Powers on October 29, 1999.
4. Richard D. Powers has been adjudicated an incapacitated person by your Honorable
Court by Court Order of June 29, 2000. (See true and correct copy attached hereto as Exhibit
"A".)
5. Virginia D. Powers has been appointed plenary guardian of the person and property
of Richard D. Powers by the same Court Order referred to in Paragraph 4 above.
6. The estate has been properly advertised but since the family has been familiar with
the decedent's affairs, it has not been deemed necessary to incur the delay and expense of a formal
accounting.
7. Decedent's single name estate consists primarily of accounts, deposits and
certificates of deposits at the Pennsylvania State Employees Credit Union.
8. Intestate distributions are controlled by 20 Pa. C.S. ~2101, et seq., which provides in
cases such as this one that the first thirty thousand ($30,000.00) dollars plus one-half (112) of the
balance of the estate goes to the surviving spouse and that the other one-half (112) of the balance
goes in equal shares to the issue of the decedent.
9. An inheritance tax return has been filed and your petitioners are awaiting a review
and the issuance of a zero balance sheet.
10. After the payment of all bills, costs and the expenses associated with the
administration of the estate, as well as all inheritance taxes due thereon, it is estimated that the share
of Richard D. powers will be approximately forty-five thousand ($45,000.00) dollars.
11. Charles E. Shields, ill, as attorney for the estate of William D. Powers and for
Virginia D. Powers, has been in contact with Jean E. Graybill, Counsel for the Pennsylvania
Department of Public Welfare as to the content and wording of the Special Needs Trust. The
Department has indicated its consent as evidenced by Ms. Graybill's letter attached hereto as
Exhibit HE".
2
12. Charles E. Shields, ill, in the same capacity, has also been in contact with 1. Paul
Dibert, Business and Trust Valuation Manager, Pennsylvania Department of Revenue, Inheritance
Tax Division, as to the content and wording of the Special Needs Trust. The Department has
indicated its consent as evidenced by Mr. Dibert's letter attached hereto as Exhibit "C".
13. Once Virginia D. Powers, as Administrator of the Estate of William D. Powers, has
set aside the approximate intestate share due and payable to Richard D. Powers, she will divide it
into three (3) portions, the first portion, in the amount of thirty-five thousand ($35,000.00) dollars
will be transferred, assigned, set oyer and delivered to Virginia D. Powers and Thomas D. Powers,
as Co-Trustees of the Special Needs Trust. The second portion, in the amount of four thousand
four hundred sixty-two and 001100 ($4,462.00) dollars will be used to repay the said Virginia D.
Powers for the amount she advanced from her personal funds to Parthemore Funeral Home of New
Cumberland for advance payment of burial and plot for Richard D. Powers. Counsel has discussed
this matter with counsel for the Department of Public Welfare and the Department has no obj~ction
to such reimbursement. The remaining portion will be held in the estate until a zero balance sheet is
received from the Department of Revenue or until appropriate adjustments are made in the event of
additional taxes be due. After the taxes are finally adjusted, the final portion of the intestate share of
Richard D. Powers shall likewise be delivered to the Co-Trustees.
14. The purposes and provisions of the Trust are set forth fully and in detail in the
proposed IRREVOCABLE SPECIAL NEEDS TRUST FOR THE BENEFIT OF
RICHARD D. POWERS OF NEW CUMBERLAND, CUMBERLAND COUNTY,
PENNSYLVANIA which is made a part hereof, incorporated by reference herein, and is attached
hereto as Exhibit "D".
15. . Virginia D. Powers and Thomas D. Powers evidence their consent to se'i:v'e as Co-
Trustees of the Special Needs Trust by their signatures below.
3
WHEREFORE, the Settlorsn'rustors do hereby request your Honorable Court to sign an
order approving the establishment and funding of the IRREVOCABLE SPECIAL NEEDS
TRUST FOR THE BENEFIT OF RICHARD D. POWERS OF NEW CUMBERLAND,
CUMBERLAND COUNTY, PENNSYLVANIA in accordance with its provisions and the
contents of this Petition.
-~~
)Y1tness
p~
Witness
4
COMMONWEALTH OF PENNSYLVANIA)
: SS:
COUNTY OF CUMBERLAND )
On this, the d day of 3~t~bt1 ,2000, beforeme.Notary Pnblic, the
undersigned officer, personally appeared IRGINIA D. POWERS and THOMAS D.
POWERS, known to me (or satisfactorily proven) to be the persons whose names are subscribed
to the within Petition and stated that the contents thereof were true to the best of their knowledge,
information and belief, and acknowledged that they executed the same for the purpose therein
contained.
IN WITNESS WHEREOF, I hereunto s m
Notarial Seal .
l~M. Encinias. Notary PubIlo
..t:t-r P~on T~., Dauphln County
"'7 ColTllTl/sslon Expires Sept. 11, 2000
Membe('Pfl4Jf1SYlvanla A~ociation of Notanti'
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
P.O. Box 2675, Harrisburg, PA 17105-2675
Jean E. Graybill
Senior Assistant Counsel
Office of Legal Counsel
June 23, 2000
Telephone: 717-783-0881
Fax: 717-772-0717
E-mail: ;wavbill(ii).dpw.stote.pa.us
Charles E. Shields, III, Esquire
6 Clouser Road
Mechanicsburg, Pennsylvania 17011
Re: SpecialNeeds Trust for Richard D. Powers
Dear Charles:
This letter is submitted with the understanding that it will be attached as an exhibit to a
petition you plan to file with the Orphans Court of Cumberland County to create an irrevocable
special needs trust for the benefit of Richard D. Powers, whom you have indicated is under age
65 and is disabled as defined by 42 U.S.C. S 1382(c)(a)(3).
I have reviewed the special needs trust which you drafted. It complies with the
requirements of 42 U.S.C. S 1396p(d)(4)(A) and thus will be exempt from consideration as a
resource for Medical Assistance eligibility purposes pursuant to that statute. Note that while this
trust is exempt from consideration as a resource and will not prevent him from r~eiving Medical
Assistance benefits, that exemption and eligibility are contingent upon the provision set forth in
this trust which provides forreimbursement of the state Medicaid agency, .the Pennsylvania
Department of Public Welfare for certain Medical Assistance benefits the beneficiary receives
after he attains age 55, from any funds remaining in the trust at the time of his death.
Because this trust meets all the requirements to be a special needs trust as defined by 42
V.S.C. S 1396p(d)(4)(A), the creation of that trust is also exempt from the transfer of assets rule
pursuant to 42 U.S.C. ~ 1396p(c)(2)(B)(iii) and will not disqualify him or his mother from
eligibility for Medical Assistance benefits, "
Yours truly,
9l"eL~ c!: ~/Ut
Jean E~ Graybill
'r cI
1::...; hi brL 13
.-v:;'" {/~
COMMONWEAL THOF PENNSYLVANIA
DEPARTMENT OF REVENUE
,,',BUREAU OF INDIVIDUAL TAXES
DEPARTMENT 280601
HARRISBURG, PA 17128-0601
August 11, 2000
Telephone
717 783-0972
Charles E. Shields, III J Esquire
6 Clouser Road
Mechanicsburg, PA 17101
Re: Estate of N/A
File Number N/A
Dear Mr. Shields:
This letter is in response to your June23,2000, letlerin which you asked the Department to
review the proposed IRROVACABLE SPECIAL NEEDS TRUST FOR THE BENEFIT OF RICHARD D.
POWERS OF NEW CUMBERLAND, CUMBERLAND COUNTY,PENNSYLVANIA. The Department
foresees no problem with the trust and feels that the Department is fully protected in the area of
Pennsylvania inheritance tax that may be due in the future. This letter may be used to inform the Court
of the Department's approval of the trust instrument.
The Department wishes to thank you for the ability to preview the trust instrument and the
precautions instituted for the protection of the Commonwealth of Pennsylvania.
If you have any questions concerning this letter, please contact me at the phone number noted
above.
sinceWo~
. Paul Dibert
Business & Trust Valuation Manager
Inheritance Tax Division
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LOCAL REGISTRAR'S CERTIFICATION OF DEATH
WARNING: It is illegal to duplicate this copy by photostat or photograph.
Fee for this certIficate. $6,00
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P 13550544
C-.:rtification Number
This is to certify that the information here given]
correctly copied from an original Certificate of Deat
duly filed with me as Local Registrar. The origim
certificate will be forwarded to the State Vit<
Records Office for permanent filing.
~ /Jl ~UN J 8 ZO~7
Local Reglstrar Date Isslled
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REV 1112006
I PRINT IN
'o4ANENT
CK INK
COMMONWEALTH OF PENNSYLVANIA. DEPARTMENT OF HEALTH. VITAL RECORDS
CERTIFICATE OF DEATH
(See Instructions and examples on reverse)
STATE FILE NUMBER
d. \ ~t) tH;as
1. Name of Decedent (FIrst, middle, last, suffix)
Richard
D.
Powers
6. Dale 01 Birth (Month, cia , year)
7.l3lrthplace(C'
5, Af;e (LastBirttldajI
ad. facility Name ill not Institution, grve streel al'\d number)
,S, Hershey Medical Center
- 45 y"
April 20. 1962
Harrisburg, PA
Dauphin
11. Decedent's Usual lion Kind 01 wock: done au mo&t cl lite. 00 not stale re~
Kind of Wo~ KiM of _'lndu,lIy
none disabled
. 16. Decedent's Maillng AQdress IStreet, city I town, state, zip code)
1710 Sherwood Road
New Cumberland, PA 17070
18. Fatt\er's Name (Rrs\. middle, last, suffix)
William J. Powers
13. Decedenl" Educ811of1 (Spec;fy only highest glade ccmpteled)
Elementary / Secondary (0-12) College (1-4 Gr 5+)
2
12. Was Decedent EMIr in the
U,S. Armed ForcElS?
Dyes UlINo
Decedent's
AcluaIAesidenCe 17a. Stale
11b. COU1'1ty
Pennsylvania
Cumberland
-58
4. Dale 01 Death (Month, day, YEffir)
2694 June 14, 2007
Other:
DOfller . Specify:
10, Race: American Indian, Slack, While, ele.
(SpecifY)
white
14. Marital Status: Married, Never Married,
Widowed. DMl<to<! ISpecityj
Never Married
Did Decedent
U'fflina
Townshi9?
17C. 0 Yes, Decedent Uved in
t 7d IXI No, Decedenl Lived wffhin
Actual Limilsof
Twp.
New Cumberland
Ci\y lBoro
19. Mother's Name {First. middle, maiden surname)
Virginia D. Davis
2Qb. Informant's MaNlng Address (Street, city ftown, state, zip COde)
1710 Sherwood Road, New Cumberland, PA 17070
21c. Place of Disposition (Name of cemetery, crematory or other place) 21d. location. (City (town, stale, z~ eode)
Indiantown Gap National Cemetery Hanover Twp., PA 17003
23a. 0 \tie besl oj my krlowI6dge, death occurred al the lime, date and place staled. (Signature and tille)
22c. Name and Address of Facility
Parthemore FH & CSt Inc., P.O. Box 431, New Cumberland, PA 17070
23b. \Jcense Number
23c. Date Sigoed (Monlh, day, year}
24. rime ot Death 25, Dille Pronounced Dead (Month, day, year)
10 "';:.-) PM \)"'f1<E' N ,:.OO,?-
CAUSE OF DEATH (See Inatructlons and aomp\08)
"ern 21. Partl: Enter lhe ~ - diseases, injuries, Of compIication!l- ht cireclly caused the death. DO NOT enter termmat events such as c;vdiac arrest,
~ arrest, Of ventr\culaJ' Nation wllhOtJl showing the etiology. US! only one cause ()(l each line.
ttems- 24-26 must be completed by person
. who pronounces death.
I Approximate interval:
I Onselto Death
I
,
\
,
,
I
,
I
,
I
I
,
I
,
I
I
=~i=~dsea=
C"''4EL IIIf/"AKC,/ ;<V...]
Due to (or as a con~ 01)'
b. Vt'L.vUL.v,)
Due to (or as a consequence 00:
a.
~:-l.a~'~~:a.
~ UNDERLYING CAUSE
(ciseaseor"rl)\nYthatinillatedthe
_Is ""ulllilg ~ deattJ) LAST.
Due to (or as a conseQlJ6nC8 of)'
d.
308. Was an Autopsy
Pertonned'?
3Ob. Were.&.utopsy Findings
Available Prior\o~on
of Cause o! Qe!.lh?
31. Manner 01 Death
~alUllII D Homicide
D _I D P""'ng Invesl~11ofI
D SuiQd, D Cou~ Nof be OeI,nnined
M
Dyes CillNo
Dyes DNo
32d. TimeoflnjtJl)'
330. c.rtilier I""'" "*Y one)
Cer\ttyk'Ig physlciln (Physician certifying cause of death when another physician has pronouOC8d death and completed Item 231
To \lie be,to! ""I "-ledga, death occurred due 10 \lIecause(') and ma....r es olaled.. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ___ - _ - _ - - - - D
~~~~=~=;~i:::~~':ce~ :;:~:~=~~a~~ manner as staled-.................... _............ 0
~::"~"':~= and I or Investigation, in my opinion, cleat" occurred at the time, datfJ, end place, end due to 1he cause(s) and manner as stated.. 0
I 0;, lid 1/ 1/ I
DiSpoSition Pennit No
11'7 I ( _ ( ,
26. Was }ase Fleferred 10 Medical Examiner I Corooer fO( a Reason Other than Cremation Of DOl\atiOfl?
[3'Yas D No
Part II: Enter other sionIlIcanl conditions contritllJtioo to deam. 28. Did Tobacco Use Contribute 10 Death?
bul not resu~ng In \he _ng "'us< g,..., In Part I. D Y.. D Probab~
DNo ~"""n
29. "Female:
o Not preg1ant within past year
D Prngnanl at time of death
D Not~. but pregnant wilhin 42 days
01 death
o No\. pregnant, but pregnant 43 days 10 1 year
belore death
o Unknown if pregnant within 1M past ~a!
32c. PIact Gf lrIiw'Y: Home, Farm. Street, Factory,
Office Building, etc. (Specify)
32g. Location or Injury (Street, c:ily flown, slale)
,^-'
L<.'I\-....., /,"7 1'\
33d. Date Signed (Mooth, day, yearl
W7 1'-1; - ;!~1
34. Name and Address ot P6l'$OO Who CompIeled Cause 01 Death (1Iem 27) Type f PMnl
MS. Hershey Medical Ctr
Hershey, PA 17033
,)A 1'1 [J'
('0/'-10
*'
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
PO BOX 2B0601
HARRISBURG PA 17128-0601
'. "'NOTICE OF INHERITANCE TAX
APPRAISEMENT, ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS AND ASSESSMENT OF TAX
DATE 02-18-2008
ESTATE OF POWERS RICHARD D
DATE OF DEATH 06-14-2007
FILE NUMBER 21 00-0425
COUNTY CUMBERLAND
ACN 101
APPEAL DATE: 04-18-2008
( See reverse side under Objections)
Amount Remittedl I
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE -+ RETAIN LOWER PORTION FOR YOUR RECORDS +-
-------------------------------------------------------------------------------------------
REV-1547 EX AFP (03-05) NOTICE OF INHERITANCE TAX APPRAISEMENT, ALLOWANCE OR
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF POWERS RICHARD D FILE NO. 21 00-0425 ACN 101 DATE 02-18-2008
r' rl.' '."-"'. ?2
'j r .. t) 1_
(,r: ! !: 1[.
CHARLES E SHIELDS ljI
6 CLOUSER RD
MECHANICSBURG PA 17055
TAX RETURN WAS: (X) ACCEPTED AS FILED
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Stock/Partnership Interest (Schedule C)
4. Mortgages/Notes Receivable (Schedule D)
5. Cash/Bank Deposits/Misc. Personal Property (Schedule E)
6. Jointly Owned Property (Schedule F)
7. Transfers (Schedule G)
8.
Total Assets
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expenses/Adm. Costs/Misc. Expenses (Schedule H)
10. Debts/Mortgage Liabilities/Liens (Schedule I)
11.
12.
13.
14.
Total Deductions
Net Value of Tax Return
REV-1547 EX AFP (06-05)
( ) CHANGED
(1)
(2)
(3)
(4)
(5)
(6)
(7)
.00
.00
.00
.00
.00
.00
36,571.16
(8)
36,571.16
NOTE: To insure proper
credit to your account,
submit the upper portion
of this form with your
tax payment.
(9)
ClO)
1,619.60
16.757.67
(11 )
Cl2)
Cl3)
Cl4)
18.377.")7
18,193.89
.00
18,193.89
Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J)
If an assessment was issued previously, lines 14, 15 and/or 16, 17, 18 and 19 will
reflect figures that include the total of ALL returns assessed to date.
ASSESSMENT OF TAX:
15. Amount of Line 14 at Spousal rate
16. Amount of Line 14 taxable at Lineal/Class A rate
17. Amount of Line 14 at Sibling rate
18. Amount of Line 14 taxable at Collateral/Class B rate
19. Principal Tax Due
TAX CREDITS:
PAYMENT
DATE
11-08-2007
Net Value of Estate Subject to Tax
NOTE:
RECEIPT
NUMBER
CD008928
DISCOUNT (+)
INTEREST/PEN PAID (-)
.00
* IF PAID AFTER DATE INDICATED, SEE REVERSE
FOR CALCULATION OF ADDITIONAL INTEREST.
Cl5)
Cl6)
Cl7)
Cl8)
.00
.00
18,193.89
.00
.00
.00
2,183.27
.00
2,183.27
X 00 =
X 045 =
X 12 =
X 15 =
Cl9)=
AMOUNT PAID
2,183.27
TOTAL TAX CREDIT
BALANCE OF TAX DUE
INTEREST AND PEN.
TOTAL DUE
2,183.27
.00
.00
.00
( IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED. ~
IF TOTAL DUE IS REFLECTED AS A "CREDIT" (CR), YOU MAY BE ~UE~
A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.)