HomeMy WebLinkAbout02-07-08
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Bruce G. Baron, Esquire
Attorney J.D. No. 28090
Capozzi & Associates, P.c.
2933 North Front Street
Harrisburg, P A 17110-1250
Telephone: 717-233-4101
FAX: 717-233-4103
Attorneys for Respondent
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EST ATE OF BETTY R. V ALENCIK : IN THE COURT OF COMMON PLEAS
: CUMBERLAND COUNTY,
: PENNSYL VANIA
Petitioner,
: ORPHANS' COURT DIVISION
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CHESTER L. V ALENCIK, JR.,
Respondent.
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TROY A. V ALENCIK,
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PETITION TO DISMISS
DUE TO JURISDICTION OVER THIS MATTER HAVING PREVIOUSLY BEEN
ASSUMED BY THE ORPHANS' COURT IN THE 26TH JUDICIAL DISTRICT
(COLUMBIA COUNTY)
TO THE HONORABLE JUDGE OF SAID COURT:
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Respondent, Troy A. Valencik, by and through his attorneys, CAPOZZI &
ASSOCIATES, P.C., files this Petition to Dismiss the Petition filed in this matter on
February 1,2008, by Petitioner, Chester L. Valencik, Jr., for the following reasons:
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1. Chester L. Valencik, Jr. filed a Petition to Enforce Power of Attorney on
February 1,2008 (hereinafter, "the Petition"), a copy of which is attached
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hereto as Exhibit A and incorporated by reference.
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2.
At Paragraph 34 of the Petition, Petitioner acknowledges that Respondent
filed a separate petition currently pending before the Orphans' Court in the
26th Judicial District of Pennsylvania (Columbia County), on or before
January 7,2008, that includes the issues involved in the Petition filed with
this Court on February 1,2008. A copy of the petition pending before the
Columbia County Orphans' Court is attached hereto as Exhibit Band
incorporated by reference.
The Columbia County Orphans' Court has scheduled a pre-hearing
conference for that matter. A copy of the Court's scheduling order is
attached as Exhibit C.
At Paragraph 38 of the Petition, Petitioner states that he is "objecting to
the jurisdiction of the Columbia County Orphans' Court as per 20 Pa. C.S.
5512."
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5.
As of the date and time on which Respondent is filing this Petition,
Respondent has received no notice from Petitioner that Petitioner has filed
any objection with the Columbia County Orphans' Court.
The jurisdiction of the Columbia County Orphans' Court over the issues
raised in Exhibit B must in the first instance be determined by that Court,
since a court has judicial power to hear and determine questions as to its
own jurisdiction. See: Silver v. Schuylkill, 32 Pa. 356 (1859); In re
Keyser's Estate, 329 Pa. 514, 522,198 A. 125, 129 (1938); Shovel
Transfer and Storage, Inc. v. Simpson, 523 Pa. 235, 565 A.2d 1153(1989)
(hereinafter, Shovel Transfer).
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7.
The jurisdiction of the Columbia County Orphans' Court over the issues
involved in this matter as part of the proceedings pending before it
pursuant to Respondent's petition (Exhibit B) is clear from the facts
pleaded in the Petition filed with this Court on February 1, 2008 (Exhibit
A) and from those pleaded in Respondent's petition (Exhibit B), in that:
(a) Paragraph 11 of the Petition (Exhibit A) acknowledges that Betty
R. Valencik resided on "the Farm" in Columbia County for most of
her adult life.
(b)
Paragraph 22 of the Petition acknowledges that Betty R. Valencik
wished to return to the Farm and that she was returned to the Farm
by Petitioner on December 7, 2007.
The Petition acknowledges that, since December 7, 2007 and
through to the current date, Betty R. Valencik has continued to live
at the Farm.
The petition before the Columbia County Orphans' Court (Exhibit
B) establishes that since December 7,2007 Betty R. Valencik has
been living at the Farm and receiving health care and services from
the Columbia-Montour Area Agency on Aging there.
When 20 Pa. C.S. 5512 was amended in 1992 by Act of April 16,
1992, P.L. 108, No. 24, the jurisdictional text was amended from
"the county in which the incompetent is domiciled" to "the county
in which the incapacitated person is domiciled, is a resident, or is
residing in a long term care facility."
(c)
(d)
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(f)
The Supreme Court of Pennsylvania, in In re Residence Hearing
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Before the Board of School Directors, Cumberland Vallev School
District, 560 Pa. 366, 371, 744 A.2d 1272. 1275 (2000), affirming
a decision of this Court, stated that:
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"The courts of this Commonwealth have historically recognized
the classic definitions of the words domicile and residence. ....
"Residence," in contrast is "a factual place of abode" evidenced by
a person's physical presence in a particular place. [citation
omitted].
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8. The Petition concedes that Betty R. Valencik currently has her physical
presence in Columbia County at "the Farm" and was living there when
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Respondent's petition was filed with the Columbia County Court.
9.
Under the analysis in In Re Residence Hearing, 560 Pa. at 371-372, 744
A.2d at 1275, where, as here, the legislature chose to use the term
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"resides" and not primary residence or domicile, that Betty R. Valencik "is
a resident" of Columbia County under 20 Pa. C.S. 5512 is proved, as
admitted in the Petition before this Court, because she has lived in
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Columbia County since December 7,2007, stayed there during the days
and slept there at night, and is living there still.
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10.
There are differences between the facts pleaded in the Petition as to the
events of December 7,2007 when Betty R. Valencik was taken by
Petitioner to the Farm and left there for Respondent to provide for her care
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(Petition at ,-r,-r22-23) and those pleaded in Respondent's petition pending
before the Columbia County Orphans' Court (Exhibit Bat ,-r,-r36-41).
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12.
Betty R. Valencik continues to be under the care of her long time
physician, Dennis M. Sheehe, M.D., the same physician that the Petition
acknowledges at ~21 was her physician when she was receiving "in home
care" at Petitioner's home and the physician identified in the attachments
to the Petition; and, Dr. Sheehe has not prescribed skilled transitional
nursing care for Betty R. Valencik or care in any institutional setting.
The Petition contains no qualified medical support for the allegation at ~31
relating to the care needs of Betty R. Valencik.
The petition pending before the Columbia County Orphans' Court
(Exhibit B) raises questions about the fitness of Petitioner to act as the
Power of Attorney for Betty R. Valencik and his loyalty to her best
interests.
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14.
The Power of Attorney dated August 4, 2005 that is attached to the
Petition (Exhibit A) appoints Respondent to act as Power of Attorney
where Petitioner and his wife, Linda D. Valencik, are unable or unwilling
to serve.
15.
While the Petition at ~20 alleges that Betty R. Valencik received "in home
care" while living with Petitioner, "triggering" the 100-day qualifying
period of her AF&L home health insurance policy, a copy of which is
attached to Exhibit B, Petitioner does not allege that, in order to protect
the interests of Betty R. Valencik in such coverage, he or his wife filed the
necessary documentation of such care with the insurance company
required to qualify Betty R. Valencik for that coverage.
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The Petition does not allege that Linda D. Valencik continues to be willing
or able to serve as alternative Power of Attorney for Betty R. Valencik or
any attempt by Linda D. Valencik to act as Power of Attorney for Betty R.
Valencik since December 7,2007.
Petitioner and his wife, Linda D. Valencik, did not file documentation
required to qualify the "in home care" alleged in the Petition at ,-r20 to
meet the lOa-day no cover period of the AF&L home health insurance
policy to protect the interests of Betty R. Valencik; and, as a result, Betty
R. Valencik has been required to pay for her continuing home health care
until a separate lOa-day period is provided and documented.
As pleaded at ,-r41 of the petition pending before the Columbia County
Orphans' Court (Exhibit B), Respondent has been the primary caregiver
for Betty R. Valencik since December 7, 2007, including arrangements for
her to receive continuing home health services; and, Respondent is
documenting such care for submission to AF &L in order to meet the
coverage requirements of that policy for future care.
Where a court of competent jurisdiction, as here the Columbia County
Orphans' Court, acquires jurisdiction of the subject matter of a case, its
authority continues, subject only to the appellate authority, until the matter
is finally and completely disposed of, and no court of coordinate authority
is at liberty to interfere with its action. I Standard Pennsylvania Practice
2d (1995) at S 2:96.
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20.
Orderly judicial procedure dictates that the court which first acquires
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jurisdiction over a matter be pennitted to decide all questions relating
thereto, including any ancillary proceeding, such as Petitioner's. 1
Standard Pennsylvania Practice 2d (1995) at S 2:97; Tallarico v. Bellotti,
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414 Pa. 535, 538, 200 A.2d 763,765 (1964) (dismissing ancillary
proceeding without prejudice to asserting claims in pending Orphans'
Court proceeding).
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21. Since Petitioner's claims as to jurisdiction are without merit and contrary
to established Pennsylvania law on the legal issue of whether or not Betty
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R. Valencik was a resident of Columbia County when Respondent's
petition before the Columbia County Orphans' Court was filed and since
Petitioner has not raised his objections with that Court, the Petition before
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this Court must be dismissed. Tallarico v. Belloti; Shovel Transfer.
WHEREFORE, RESPONDENT REQUESTS THE FOLLOWING RELIEF:
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The Petition filed on February 1,2008 (Exhibit A) should be dismissed without
prejudice to Petitioner's right to assert his claims in the pending matter before the
Columbia County Orphans' Court.
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Respectfully submitted,
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Bruce G. Baron, Esquire
Attorney J.D. No. 28090
CAPOZZI & ASSOCIATES, P .C.
2933 North Front Street
Harrisburg, P A 17110-1250
Telephone: 717-233-4101
FAX: 717-233-4103
Email: BruceBraJ.CapozziAssociates.com
[Attorneys for Respondent]
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DA TE: FEB. 7' 2008
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Received:
Feb 7 2008 10:56am
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VERIFICATION
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I, TROY A. V AL.ENCIK, ve.-ify that the facts set forth in the tongoing
Petition are b"Qe and correct to the best of my knowledge, jnformation, and belief. I
understand that false statements herein are made subject to the penalties of 18 Paw
e.S. i 4904, relatiDg to UIlSWom falsification to authorities.
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~AL
TR~Aw V ALENCIK
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DATE: February 6, 2008
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EXHIBIT A
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Neil Warner Yahn, Esquire
Attorney LD. No. 82278
Edward P. Seeber
Attorney I.D. No. 76084
James Smith Dietterick & Connelly, LLP
P.O. Box 650
Hershey, PA 17033
Attorneys for Petitioner
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EST ATE OF BETTY R. V ALENCIK
) IN THE COURT OF COMMON PLEAS OF
) CUM.BERLAND COUNTY, PENNSYL VANIA
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) ORPHANS' COURT DIVISION
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) No. OC 2008
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CHESTER L. VALENCIK,JR.,
Petitioner
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TROY A. V ALENCIK,
Respondent
RULE TO SHOW CAUSE
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A..."ND NOW, this _ day of
, 2008, the foregoing Petition to Enforce the
Power of Attorney having been presented to this Honorable Court, upon consideration thereof
and on Petition ofNei! W. Yahn, Esquire of the law firm ofJames, Smith, Dietterick &
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Connelly, LLP, counsel for the Petitioner, it is ORDERED and DECREED that an Order be
awarded, and directed to the Respondent, Troy A. Valencik, to show cause why the requested
relief should not be granted. Rule returnable Twenty (20) Days from the date of service.
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BY THE COURT:
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Distribution:
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Neil Warner Yahn, Esquire, James Smith Dietterick & Connelly, LLP, P.O. Box 650, Hershey, PA 17033
Attorneys for Petitioner
Bruce G. Baron, Esquire, Capozzi and Associates, P.e., 2933 North Front Street, Harrisburg, PA 17110,
Telephone: (717) 233-4101
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Neil Warner Yahn, Esquire
Attorney LD. No. 82278
Edward P. Seeber
Attorney LD. No. 76084
James Smith Dietterick & Connelly, LLP
P.O. Box 650
Hershey, PA 17033
Attorneys for Petitioner
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EST A TE OF BETTY R. V ALENCIK
) IN THE COURT OF COMMON PLEAS OF
) CUMBERLAND COUNTY, PENNSYL VANIA
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) ORPHANS' COURT DIVISION
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) No. OC 2008
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CHESTER L. V ALENCI~ JR.,
Petitioner
TROY A. VALENCI~
Respondent
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ORDER OF COURT ENFORCING POWER OF ATTORNEY
NOW, THEREFORE, it is ORDERED, ADJUDGED and DECREED that the Power of
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Attorney issued to Chester L Valencik, Jr. is effective and to be so honored and Troy A.
Valencik is enjoined from acting on behalf of the estate and person of BETTY R. V ALENCIK.
BY THE COURT:
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J.
Distribution:
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Neil Warner Yahn, Esquire, James Smith Dieuerick & Connelly, LLP, PO. Box 650, Hershey, PA 17033
Telephone: (717) 533-3280; Attorneysfor Petitioner
Bruce G. Baron. Esquire, Capozzi and Associates, P.e., 2933 North Front Street, Harrisburg, P A 17110,
Telephone: (717) 233-4101
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Neil Warner Yahn, Esquire
Attorney l.D. No. 82278
Edward P. Seeber
Attorney LD. No. 76084
James Smith Dietterick & Connelly, LLP
P.O. Box 650
Hershey, PA 17033
Attorneys for Petitioner
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ESTATE OF BETTY R. V ALENCIK
) LN THE COURT OF COMMON PLEAS OF
. ) CUMBERLAND COUNTY, PENNSYLVANIA
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) ORPHANS' COURT DIVISION
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) No. OC 2008
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CHESTER L. V ALENCIK, JR.,
Petitioner
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TROY A. V ALENCIK,
Respondent
PETITION TO ENFORCE POWER OF ATTORNEY
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TO THE HONORABLE JUDGE OF SAID COURT:
Upon information and belief, the Petitioner, CHESTER L. V ALENCIK, JR. (the
"Petitioner"), by and through his attorneys, JAMES, SMITH, DIETTERICK AND
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CONNELLY, LLP, files this Petition to Enforce the Power of Attorney (the "Petition") against
the Respondent, Troy A. Valencik (the "Respondenf') for the following reasons:
1.
Betty R. Valencik. ("Betty"), an incapacitated person, resided at 5108 Inverness
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Drive, Mechanicsburg, Pennsylvania] 7050 with the Petitioner.
2.
Betty is 85 years old and was born on November 5, 1922.
3.
Betty was married to Chester Valencik, Sr., who died May 4, 2004.
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4.
Betty and Chester, Sr. had one child, namely your Petitioner herewith.
5. The Petitioner currently resides at 5] 08 Inverness Drive, Mechanicsburg,
Pennsylvania 17050 and is a resident of Cumberland County.
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. 6. Betty executed and granted the Petitioner the authority to act on her behalf as an
agent under the Power of Attorney attached hereto as Exhibit "A".
7. Betty was domiciled at the Petitioner's residence.
. 8. The Petitioner has two children, namely the Respondent currently residing at 73
Lick Run Road, Catawissa, Pennsylvania 17820 and Shelly Valencik Capozzi,
currently residing at 1655 South Holly Pike, Carlisle, Pennsylvania 17013 (herein
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"Shelly").
9. The Petitioner is currently estranged from his two children.
. 10. The Respondent currently leases the fann situated at 73 Lick Run Road,
Catawissa, Pennsylvania 17820 (herein the "Farm") from an Irrevocable Trust
(Betty is the Settlor of the Irrevocable Trust).
. II. Betty resided on the Farm for most of her adult life until on or about December
26, 2006, when Betty moved from the Fann to reside with the Petitioner for health
reasons.
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12. Shortly after relocating to the Petitioner's residence, Betty suffered a mini stroke
and was transferred to and cared for at Geisinger Health Hospital (herein
..Geisinger").
Thereafter, on or about January 19,2007, she was admitted to Bloomsburg Health
Care Clinic (herein ..Bloomsburg") for psychiatric reasons until February 23,
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2007.
Upon Betty's release from Bloomsburg in late February of 2007, Comfort Care
Home Health Services (herein "Comfort Care"), evaluated the Petitioner and his
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residence and concluded that residing with the Petitioner was suitable for her
handicap needs.
On May 23,2007, Betty suffered a major stroke, and was in lCU at Geisinger
until June 4, 2007 whereupon she was then transferred again to Bloomsburg and
HIen again to the Petitioner's residence.
Bloomsburg and Comfort Care once again engaged a thorough review of the
Petitioner's residence to assure Betty was able to receive the proper treatment.
At this time, Betty lost use of her left hand due to the stroke and suffered ancillary
ailments including, but not limited to, limited mobility and partial paralysis in her
left leg and arm.
On August 18, 2007, Betty was released from Bloomsburg to the Petitioner after
the residence was redesigned to care for Betty (including the following special
accommodations, handicap rail, ete).
19. Comfort Care monitored Betty'.s progress and engaged in extensive physical
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therapy until November of2007.
Betty also received "in home care" three days a week to assist her in day-to-day
living at the Petitioner's residence (this also triggered the 100 day no-coverage
period for purposes of Betty's Long Term Care Policy for in home care).
Contemporaneous with the "in home care" Betty was becoming very ornery and
verbally abusive. Dr. Dennis M. Sheehe, MD, her primary caretaker attributed
this behavior to her major stroke and the impact on the occipital areas of the brain
in the frontal lobe.
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averring the Petitioner was cruel for leaving Betty with the Respondent.
On or about the same date, Petitioner contacted Respondent who advised the
Petitioner he would not be permitted to see his mother, Betty, and that she was
staying with him on the Farm.
On or about December 11, 2007, Petitioner received a letter from Bruce G. Baron,
Esquire, alleging Betty's revoking of any Power of Attorney executed by Betty
nfu-ning the Petitioner as agent.
27. Remarkably, the letter revoking the Power of Attorney exemplifies the cavalier
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22.
In or about November of2007, Betty began to fixate on returning to the Farm and
in order to appease Betty, the Petitioner traveled with Betty to the Farm on
December 7,2007 to allow her to stay for the weekend with the Respondent.
Petitioner advised Respondent that the stay was temporary, and that due to her
medical problems, Betty would be required to return to the Petitioner's residence.
24. On or about December 8, 2007, Shelly called on behalf of the Respondent
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behavior exhibited by the Respondent because it presumes Betty has the capacity
to revoke the Power of Attorney (a copy of the letter is attached hereto as Exhibit
"B").
In actuality, Betty has been incapacitated since June of2007 after suffering the
major stroke and as further referenced in the psychiatric assessment attached
hereto as Exhibit "e" so Betty could not revoke the Power of Attorney.
Betty was evaluated on December 20, 2007 by Dr. DenJlis M. Sheehe, MD as
further set forth in Exhibit "e" (the "Medical Opinion"), which provides in
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relevant part that Betty's cognition is impaired due to cerebrovascular disease
resulting in dementia.
The Medical Opinion also provides that Betty's deficient judgment dates back to
June of2007.
Betty requires skilled transitional nursing care and residing with the Respondent is
inconsistent with the welfare and wen being of Betty.
Petitioner believes this matter is ripe for this Honorable Court to intervene as
Betty is unable to make decisions for herself and the Respondent is exploiting her
impuissance and now disregarding the Power of Attorney granted to the
Petitioner.
Petitioner began acting under the Power of Attorney on or about June of 2007 and
a compilation ofms actions are set forth in Exhibit "D" and is only acting in the
interest of his mother (Betty).
On or about January 7, 2008, the Respondent filed a Petition for the Appointment
of a Permanent Guardian For the Person and Estate of Betty, to Vacate all Prior
Powers of Attorney and for an accounting of the Petitioner's actions as agent
under the Power of Attorney and Trustee under the VaIencik Family Irrevocable
Trust Agreement dated August 4, 2005 (herein the "Columbia County Petition").
35. The Columbia County Petition is erroneous in that Columbia County does not
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have jurisdiction in this matter as Betty is domiciled in Cumberland County and
Respondent has disregarded the Powers granted thereunder.
In the within matter, the facts demonstrate that Betty resided at the Petitioner's
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residence and therefore, venue is appropriate with this Honorable Court.
37.
Respondent's credibility is strained in that in the present petition before the
Columbia Court, whereby Respondent concedes that Betty did not have capacity
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in December of2007 and yet, the Respondent acting via his sister Shelly's
husband, Attorney Louis J. Capozzi, Jr., issued a letter averring she had the
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capacity to revoke the Power of Attorney.
38.
. Petitioner is objecting to the jurisdiction of Columbia County Orphans' Court as
per 20 Pa.C.s ~ 5512 which provides in relevant part:
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20 Pa. C.S. 5512 (a) provides that "A guardian of the person
or estate of an incapacitated person may be appointed by the
court in which the incapacitated person is domiciled, is a
resident or is residing in a long term care facility."
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39.
Petitioner requests a hearing be granted to enforce the Power of Attorney and
enjoin the Respondent from acting on behalf of Betty and such other rellef as this
Court deems appropriate.
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WHEREFORE, THE PETITIONER REQUESTS THE FOLLOWING RELIEF:
The Power of Attorney be enforced upon the Respondent, Troy A. Valencik, and he be
enjoined from acting on behalf of Betty R. VaJencik, or in the alternative, a hefu-ing be scheduled
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to detennine the validity of the Power of Attorney, its enforcement and such other relief as the
court deems proper.
Respectfully submitted,
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Date: February~, 2008 By:
JAMES, SMITH, DIETTERICK
CONNELLY, L P
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NOTICE
THE PURPOSE OF TIllS POWER OF ATTORNEY IS TO GIVE THE PERSON YOU
DESIGNATE (YOUR "AGENT") BROAD POWERS TO HANDLE YOUR PROPERTY,
WHICH MAY lNCLUDE POWERS TO SELL OR OTIffiRWISE DISPOSE OF Al\I'Y REAL
OR PERSONAL PROPERTY WITHOUT ADV ANCENOTICE TO YOU OR APPROVAL BY
YOU.
TIllS POWER OF ATTORNEY DOES NOT IMPOSE A DUTY ON YOUR AGTh'T'f
TO EXERCISE GRANTED POWERS, BUT WHEN POWERS ARE EXERCISED, YOTJR
AGENT MUST USE DUE CARE TO ACT FOR YOUR BENEFIT AND IN ACCORDANCE
WITH TIllS POWER OF ATTORNEY.
. YOUR AGENT MAY EXERCISE THE 'POWERS GIVEN HERE THROUGHOUT
YOUR LIFETIME, EVEN - AFTER YOU BECOME INCAPACITATED, UNLESS YOU
EXPRESSLY LIMIT THE DURATION OF TIIESE POWERS OR YOU REVOKE THESE
POWERS OR A COURT ACTlNG ON YOUR BEHALF TERMINATES YOUR AGENT'S
AUTHORITY.
YOUR AGENT MUST KEEP YOUR FUNDS SEPARATE FROM YOUR AGENT'S
FUNDS.
A COURT CAN TAKE AWAY THE POWERS OF YOUR AGENT IF IT FThTl)S
YOUR AGENT IS NOT ACTING PROPERLY.
THE POWERS AND DUTIES OF AN AGENT UNDER A POWER OF . ATTORNEY
ARE EXPLAINED MORE FULLY IN 20 PA.C.S. CH. 56.
IF TIIERE IS ANYTHING ABOUT THIS FORM THAT YOU DO NOT
lJNDERSTAND, YOU SHOULD ASK A LA \VYER OF YOUR OWN CHOOSING TO
EXPLAJN IT TO YOU.
I HA VB READ OR HAD EXPLAINED TO ME TIllS NOTICE AND I lTh'T>ERSTAND
ITS CONTENTS.
AUG 0 4 2005
B~~~~
DATE
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. POWER OF ATTORNEY
KNOW ALL MEN BY THESE PRESENTS:
That I, BETTY R. V ALENCIK, having my legal residence c/o Chester L. Valencik, Jr.,
5108 Inverness Drive, Mechanicsburg, Cumberland County, Pennsylvania, have made, constituted
and appointed, and by these presents do make, constitute and appoint my son, CHESTER L.
V ALENCIK, JR, my true and lawful agent, or, if he is unable or unwilling to serve, my son's
spouse, LlNDA V AlENCIK, my true and lawful agent, or, if she is tmable or unwilling to serve,
my grandson, TROY V AIENCIK., my true and lawful agent, to act as follows, that is to say;
GIVING AND GRANTING unto my said agent full power to buy, receive, lease, accept or
otherwise acquire; to sell, convey, mortgage, hypothecate, pledge, quitclaim or otherwise encumber
or dispose of; to contract or agree to the acquisition, disposal or encumbrance of any property
whatsoever and wheresoever situate, be it real, personal or mixed, or any custody, possession,
interest, or right thereon or pertaining thereto, upon such tenns as my said agent shall think proper,
that is to say:
1. To engage in tangible personal property transactions.
2. To engage in real property transactions including the power to make, execute,
acknowledge and deliver good and sufficient deeds and conveyances for the same, either with or
without covenants of warranty.
3. To engage in stock:, bond and other securities transactions.
4. To ~ngage in commodity and option transactions.
5.
To engage in banking and financial transactions.
6. To -borrow money.
7.
To enter safe deposit boxes.
8. To engage in insurance transactions.
9. To engage in retirement plan transactions.
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To handle interests in estates and trusts.
11. To pursue claims and litigation.
12. To receive government benefits.
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To pursue tax matters.
14. To make limited gifts and, further,lsuch other gifts, of whatever nature and in such
amounts as my agent, in my agent's sole discretiot4 determines appropriate. I authorize my agent to
make such gifts even if contrary to the provisions of 20 Pa.C-S. Section 5601(e). The foregoing
gifts may be made for and on my behalf to my son, jCHESTER L. V ALENCIK, JR.
15. To create a trust for my benefit, iklcluding the power to execute a deed of trust,
designating one or more persons (including my ag~t) as original or successor trustees and transfer
to the trust any or all property owned by me as jrny agent may decide, subject to the following
conditions: .
A. The income and corpus o~ the trust shall be distnbutable to me or the
guardian of my estate, or be applied for fny benefit, and upon my death, any remaining
balance of corpus and unexpended income bf the trust shall be distributed to my estate.
. ,
B. The deed of trust may be atnended or revoked at any time and from time to
time, in whole or in part, by my agent, pro'tided that any such amendment by my agent shall
not include any provisions which could nori be included in the original deed.
16. To make additions to an existing 1:r\!J.St for my benefit.
17.
,
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To claim an elective share of the estate of my deceased spouse.
I
18. To disclaim any interest in property.
19. To renounce fiduciary positions.
20.
I
To withdraw and receive the income or corpus of a trust, including the power to:
A Demand, withdraw and receive the income or corpus of any trust over which
I have the power to make withdrawals;
B. Request and receive the inCome or corpus of any trust with respect to which
the trustee thereof has the discretionary p~wer t9 make distribution to me or on my behalf;
and ;
C. Execute a receipt and releaise or similar docmnent for the property received
under paragraphs A and B.
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21. To authorize my admission to a medical, nursing, residential or similar facility, and
to enter into agreements for my care, including the power to apply for my admission to a medical,
nursing, residential or other. similar facility, execute any consent or admission forms required by
such facility which are consistent with this paragraph, and enter into agreements for my care by
such facility or elsewhere during my lifetime or for such lesser period of time as my said agent may
designate, including the retention of nurses for me.
22. Subject to my desires set forth in a living will, if any, to authorize medical and
surgical procedures, including the power to arrange for and consent to medical, therapeutical and
surgical procedures for me, as well as the administration of drugs.
23. To appoint successor agent(s) if all of the agents in this Power of Attorney are
unable or unwilling to serve.
24. To make an anatomical gift of all or part of my body.
25. My agent shall be entitled to charge reasonable compensation for services rendered
and expenses incurred from time to time and .at any time during the term of this Power of Attorney.
26. It is my intent that the authority granted above extend to records, including
records considered "Protected Health Information", as that term is defined by the Health
Insurance Portability and Accountability Act and the regulations promulgated thereunder
(collectively, "HIPAA"). I further intend that my agent be treated as a "Personal Representative"
as that tenn is used in HIP AA, and that my medical and health care providers disclose such
Protected Health Information to my agent, consistent with the authority which has been granted
above. For purposes of such information and records covered by HIPAA, my agent's power to
act on my behalf shall be effective immediately regardless of my ability to make my own medical
or health care decisions. This authorization is intended to comply with IDPAA and all other
federal, state, and loca1laws, regulations, statutes, and codes related to privacy and the release of
medical and health care information. I intend that my agent shall have full authority to access
such information on my behalf effective inunediately.
27. This Power of Attorney shall not be affected by my subsequent disability,
incapacity, or incompetence, since it is my desire that my son, CHESTER L. V ALENCIK, JR. , or,
ifhe is unable or nnwilling to serve, my son's spouse, LINDA V ALENCIK, or, if she is unable or
unwilling to serve, my grandson, TROY V AlENCIK, has the power to act on my behalf as my true
and lawful agent should I become disabled, incapacitated or incompetent.
28.
by me.
This Power of Attorney shall revoke all other Powers of Attorney heretofore made
GNING AND GRANTING unto my said agent full power and authority to do and perform
all and every act, deed, matter, and thing whatsoever in and about my estate, property, and affairs as
fully and effectually to all intents and purposes as 1 might or could do in my own proper person if
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personally present, the above specially enumerated powers being in aid and exemplification of the
full, complete, and general power herein granted and not in limitation or definition thereof; and
hereby ratifying all that my said agent shall lawfully do or cause to be done by virtue of these
presents.
AND, I hereby deClare that any act or thing lawfully done hereunder by my said- agent shall
be binding on myself, and my heirs, legal and personal representatives, and assigns; whether the
same shall have been done before or after my death, or other revocation of this mstnnnent, unless
and until reliable intelligence or notice thereof shall have been received by my said agent.
this
IN A~S WHEREOF, I, BETTY R. V ALENC~ have hereunto set my hand and seal
AUli 0 Ii 2005 .
WITNESS:
\/~...-
\
t3~J- VahrMiel
BETI'l(1.VALENCIK
ACKNOWLEDGEMEl\7
COMM:Ol\l'WEALm OF PENNSYLVANIA
: 5S
COUNTY OF DAUPHIN
On this AUG 0 ~ Z005 , before me a notary public, the undersigned officer,
personally appeared BETTY R. V ALENCIK, known to me (or satisfactorily proven) to be the
person whose name is subscnbed to the within ins1rument, and acknowledged that she executed the
same for the purposes therein contained.
IN WITNESS WHEREOF, I hereunto set my hand and official seal.
.~-~.._-
PYPFLIC ~ OF_~
I
I ~L Hol.deI..,
5 I DM1~.~~:t,.PubIc
-'OtJmfiiIssil.'-:.' "....~
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1, CHESTER L. V ALENCIK, JR., have read the attached power of attorney and anI the
person identified as the agent for the principal. I hereby acknowledge that in the absence of a
specific provision to the contrary in the power of attorney or in 20 Pa.C.S. when I act as agent:
I shall exercise the powers for the benefit of the principal
I shall keep the assets of the principal separate from my assets.
I shall exercise reasonable caution and prudence.
I shall keep a full and accurate record of all actions, receipts and disbursements on behalf of
the principal.
AU6 0 4 2005
alL!t6bJ l
CHESTER L. ENCiK, JR.
Date
1, LINDA VALENCIK, have read the attached power of attorney and am the person
identified as the agent for the principal. I hereby acknowledge that in the absence of a specific
. provision to the contrary in the power of attorney or in 20 Pa.C.S. when I act as agent:
I shall exercise the powers for the benefit of the principal.
I shall keep the assets of the principal separate from my assets.
I shall exercise reasonable caution and prudence.
I shall keep a full and accurate record of all actions, receipts and disbursements on behalf of
the principal.
AUG 0 4 2005
~~~
LINDA V ALENCIK
Date
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1, TROY V ALENCIK, have read the attached power of attorney and am the person
identified as the agent for the principal. I hereby acknowledge that in the absence of a specific
provision to the contrary in the power of attorney or in 20 Pa.C.S. when I act as agent:
I shall exercise the powers for the benefit of the principal.
I shall keep the assets of the principal separate from my assets.
I shall exercise reasonable caution and prudence.
I shall keep a full and accurate record of all actions, receipts and disbursements on behalf of
the principal.
Date
TROY V ALENCIK
7
.
Louis J. CapozZi, Jr., Esquire'"
DMiel K. Natirboff, Esquire
D~ald-,R. lteavev. Esquire
Bruce G. Baron, Esquire
Andrew R. Eisemann, Esquire
Timothy Ziegler, Reirnb. Analyst
Karen L Fis.~er, Paralegal
Jennifer Kain, Paralegal
.. (licensed. in PA, HI and MD)
2933 North Front Street
Harrisburg, P A ! 711 0
Telephone: (717) 233-4lOl
Fax: (717) 233-4103
www.capozziassociates.com
.
Craig 1. Adler, Esq.
Of Counsel
.
December 11, 2007
.
Chester L. Valencik, Jr.
5108 Inverness Drive,
Mechanicsburg, P A 17050
BY CERTIFIED U.S. MAIL
RE: Representation of Betty R. Valencik
Revocation of Power of Attorney
.
Dear Mr. Valencik:
.
Our Firm represents your mother, Betty R. Valencik, to assist her with the resolution of
some concerns she has about her funds and the Valencik Family Irrevocable Trust, of which you
are the Trustee. '
.
Today, in oUt, Office, she signed'.aRevocationofPower of Attorney, revoking any and all
Power of Attorney documents she signed naming you as her authorized agent. A copy of the
Revocation is enclosed'to provide you with notice of the Revocation. The Revocation is being
recorded in Columbia County. The Revocation is effective today. We are requesting your help
to account for any and all transactions you may have conducted on her behalf, as her Power of
Attorney, from August 1, 2005 through to'the date of your receipt of this letter and the copy of
the Revocation.
.
We are also requesting your help, as Trustee of the Valencik Family Irrevocable Trust, to
provide us, as your mother's representatives, with a copy of the Trust instrument and a statement
of the current assets of the Trust and any pending plans, actions, or p~ceedings involving the
Trust or the sale or transfer of any Trust property, as well as copies of the Trust's financial
statements for 2005 and 2006.
.
Your mother is currently residing at the Trust property at 73 Lick Run Road, Locust
Township, Catawissa, Col~1?i!i Couno/, PehnSylvania. She is living there with your son, Troy,
and wishes to continue to reside there with Troy's assistance. She advised us that you are
planning to bring her belongings that were at yourhome during the time she resided with you
and deliver them to her at the Trust property this week. Please advise me immediately if you
have any objection to or concern about your mother and Troy living in the Trust property.
.
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Chester L. Valencik, Jr.
RE: Representation of Betty R. Valencik
Revocation of Power of Attorney
December 11, 2007
Page Two
While your mother was quite upset about her current situation while in our Office today,
she very much wants the family to resolve this situation together. Your mother was in good
health and positive spirits when we met today and is looking forward to sharing the coming
Holidays with her family.
Please let me know if you have any questions about this correspondence and if you bave
an attorney who is representing you or the Trust in this matter.
Best wishes to you and your family for the Holiday Season and throughout the New Year.
Very truly yours,
CAPOZZI & ASSOCIATES, P.c.
~4
Bruce G. Baron, Esquire
Enclosure (Revocation of Power of Attorney)
cc: Betty R. Valenclk
Troy Valencik
2
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Valencik,)3ettyR (MR. # 3104140)
DOB: 11/05/1922
.
~.~'~'~~i~~:iZ~~;~!tI~_~~~t'f~?
ProarMs NotlIs
.--T ___. ........_..___~~--,. ~~""'_r.-::~
,~.... -~_-...--~_:
~~.......__ L ... .~
.
Natit I'n.IIId&II Bv
Dennie M. Sheehe, MD
~
S1gfl<lC
I..lIIU/JlIfIlI
Ooonnls M. Sheehe, Ml;)
J.-t IIIlllD
1212ll1200711:21 Mil
Office visit is being accollplished at the request of Bruce G. BaJ::on.
Apparently this patient z:equested th..t. this 1.... firm provoke Powers crt
Attorney and the point new health-care agent, grandson Troy [who. lives as on
the farm}.
When I aslted her what is going en she gave SOllle contradictory information.
.
Claims to have been dumped on the farm QY son
Does not want to 90 back to Ha=isburg with hin
Nephew Troy & wife live with me and are thet"B all or the time
Later said grandson living '!lith bel' and nepilew only there at times
She has regular appoint~ent for blood work and physical in January.
HtNTAL STATUS EVALUATION:
.
.
Appearance~ within normal limits, age-appropriate, casual~y dressed and
_lis like fireplace S1I!oke.
Bebavior: pleasant, fidgety and hypoactive
speecb: normal pitch, normal rate. and normal voll.ll1\e
Mood: sad and apathetic
Affect: blunted and flat
Thought Process: totally oriented on single goal of 1ivir~ on the farm
Thought Content:
Delusions: No
Sallucinations: No
'Obsessions: Yes, description living on the fsom.
Komicidal: No
Suicidal: NO
Sensorium; alert and oriented to person, does Dot know me
Cognition: impaired due to cerebrovascular disease
lnsiqht: poor
Judgaent: poor
.
-ASSESSMENT-
.
.'1. Dementia. Vascular delIlentia + possible Alzheimer's dementia.
2. Status po$t frontotemporal subd=al heaorrl>age
3. Status post fron~al hemorrhagic cerebrovascular accident
4. Significant deficits in juciglllent and decision-l1Iilking dating back to June
2007
5. Generalized carebral atrophy
6. Hypertension
PrinJed 12120/07 11:21 AM
Geisinger
Page I of6
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Valencik, Betty R (MR # 3104140)
DOB: 11/05/1922
.
7. History of lymphoma
8. History of Bell's palsy
9_. Restless legs syndrome
10. Depression
11. Gastroesophageal reflu~
12. H;~erlipidemia
13. Not competent to manage financial affairs
14. Not competent to live independently_ Needs 24-hour supervision.
15. Not competent to sign release
16. Not competent to make medical decisions
.
- PLAN -
.
Current outpatient prescriptions:
SYNTHROIO 50 HCG OR TABS, one tab by mouth daily, Disp; 3 month supply, &fl:
3
fREVACID 30 MG PO PACK, one daily in the am, Disp: 3 month supply, RH: 3
CELEXA 20 KG P<l TABS, 1 tab daily, Cisp: 90, Rfl: 3
HIRTAZAPINE 15 MG P<l TABS, at bedtime, Cisp: 90, Rf1: 3
MOLTI-VITAHIN PO TABS, 1 tab daily, Oisp: , Ml:
.
Follow up: Return for re ck in Jan as sched on a wed am.
Dennis M Sheehe, M.D.
Associate Fa~ly Medicine
Geriatrics CAQ
.
Geisinger Medical Group Catawissa
353 Main St.
Catawissa fA, 17820
570-356-2351
VItals
'::lIiSlM
0::==_
120/f;8
~~~-~~:-~.:~~~~~;;;.::..~~~; ~~-~.~:-~~-
72
36.3 'C (97.4 "F)
(Oral)
16
~~~!!:.:;~~~
61.256 kg (113lb$) Postmenopausal
.
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3U"C{lI7.4
"F) -cl
~..Ilted 12fl0l07 11;21 AM
Geisinger
Page2of6
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8ummary of Checking account since May 2007
check number June Check number July Check numb August
. 1185 200 1192 14.54 1191 200
1186 281.98 1193 500 1198 105
1187 349.8 1194 Chet/work 5000 1199 648.06
1188 135.82 1195 well 1089.68 1200 150
1189 verizon 61.36 1196 verizon 95.15 1201 500
1190 dishnet 103.86 1197 well 3725.9 1202 200
1132.82 10425.27 1203 500
. Deposits 1204 595.34
5/30 282.93 6/18 410.25 1205 1700
6/1 8.S. Check 1138 7/3 ss check 1138 1206 420.89
5/11 cd 14700.56 7/12 806.03 1207 100
5f11 633.78 813 ss check 1138 1208 500
1675527 349228 - 1210 743;33
. 6362.62
Check number September Check Number October Check Numt November
1209 11.54 1223 209.88 1231 72
1211 28.5 1224 54.75 1232 16.63
1212 1500' 1225 500 1235 123
1214 368 1226 290.38 1236 -150
. 1215 500 1227 75.45 1237 23
1216 42.75 1228 209.25 1238 400
1217 40 1229 94.5 1240 276
1219 304 1230 276 1241 287.5
1220 verizon 171.94 1233 1000 1244 276
1221 dishnet 103.86 1234 389.5 1247 743.33
1222 80 1248 500
. 3150.59 3099.71 2867.46
Deposits
8120 806.03 10/3 8.S. check 1138
8/31 8.S. check 1138 11/2 S.S check 1138
9/6 633.78 11/9 806.03
11f9 172.25
. 2577.81 3254.28
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Total Banking Statement
PNC Bank
~PNCBANl
)
For the period 05/t5l2OO7 to 0611412007
Primary account number: 90-1146-8865
Page 1 of 4
Number of enclosures: 0
.
.G
BETTY R VAlENCIK
73 LICK RUN RD
CATAWISSA PA 17820-8718
Q For 24-hour banking, .and transaction or
interest rate information, sign on to
tr PNC Bank Online Banking at pnc.com.
For customer service call1-888-PNC-BANK
between the hours of 6 AM and Midnight ET.
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1 Relationship Overview
1
I ... Depoeit Accoanta
I ." Descrlptton
!
! Interest Checking
! Retirement Account( s )
1 Total Deposits
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Para servicio en espai'roi, 1-866-HOLA-PNC
Moving? Please contact us at '-888-PNCBANK
I:i!S1 Write to: Customer SefVioe
PO Box 609
Pittsburgh PA 15230-9738
8 Visit us at pne.com
Iiil TOO terminal: 1-800-531-1648
I!!l For hearing impaired clienb only
.
.
Account Number
Deposit Balance
19,742.20
9,059.90
28,80 2.1 0
90-1146-8865
Total of2
.
Senior .......... Plan
In......t ChecIdng Account Summary
Account number: 90-1146-8865
Betty R Valencik
.8I.n-o. Smnmary
4
Deposits and Checks and other Ending
other additi ons deductions balance
16,756.91 1,152.82 19,742.20
Average monthly . Charges
balance and fees
5,926..56 20.00
Checl<. Card POS Check: CardlBank:card
signed transactions PCB PIN tranSactions
0 0
PNC Bank other Bank
A TM transactlons A TM transactions
0 0
Number of clays Average collected Interest Paid
in Interest per!o<I balance for APYE thl s period
31 5,886.30 1.64
Please see the Activity Detail section for
additional infonnation.
.
Beginning
balance
4,138.11
T...naaoIion SInnmary
.
Check:s paldl
withdrawals
TotalATM
transactions
o
.
Interest SaDlDlary
Ann uat Percentage
Yield Earned (APYE)
As of 06/14, a total of $4... in interest was
paid this year.
0_33X
.
.
FORM953R-1005
. Total Banking Statement
.Q. For 24-hour infonnation, sign on to PNC Bank Online Bank.lng
on pnC.com.
Account nmnber: 90-1146-8865 - continued
..
For the period OSf1512007 to 06/14/2007
BETTY R VALENCIK
Primary account number: 90-1146-8865
Page 2 of4
'.
Activity Detail
Deposits and Other Addition.
Date Amount Description
05/30 282.93 Deposit Reference No 026044446
06/01 1,138.00 Direct Deposit - Sac Sec
US Treasury 303 XXXXX200lD
Deposit From CDA 030 it 31500226437
Deposit Reference No 027419379
Interest Payment
.
06/11
06/11
06/14
14,700.56
633.78
1.64
There were 5 Deposits and Other Additions
totaling $16.758.91.
Re{erence
number
.
Checks and Sub.titute Checks
C~k ~e
number Amount paid
1185 200.00 05/18
U86 281.98 OS/21
0~298695
027575494
... Gap in check sequence
Check
number
]187
1188
.
Online and Electronic Banking Deductions
Date Amount Description
otV04 103.86 Payment,E-Check Disbckpymt
Echostar Communi 1190
otV04 61.36 Payment,E-Check Check Pymt Vemon ARC 1189
Amount
Description
Other D.....ctions
.
Data
06/14
Type Hd
20.00 Calculated Service Charge
Daily Balance DetaR
Dale Balance
05/15 4,138.11
05/18 3,938.11
OS/21 3,306.33
Date
OS/23
05/30
06/01
Balance
3,170.51
3,453.44
4,591.44
.
Date
00/04
06/11
06/14
Balance
4,426.22
19,760.56
19,742.20
Amount
349.80
135.82
Date
paid
OS/21
OS/23
Reference
number
O!!7104~8!i
025802955
There were 4 checks listed totaling
$967.60.
There were 2 Online or Electronic Banking
Deductions totaling $185.22.
There was 1 Other Deduction totaling
$20.00.
SENIOR PREMIUM PlAN - Service Charge Explanation
Account type Account number Balance type
Interest Checking XX.XXXX-8865 This Cycle Avg Balance
Certificate(s) of Deposit XXXXXX1206 Current Value
Retirement Accaunt(s) XXXXXX8458 Current Value
Retirement Account(s) XXXXXX8379 Current Value
.
.
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As of
06/15
06/13
06/13
06/13
Balance
5,927.21
.00
1,566.31
7,493.59
These accounts were reviewed to meet
the balance requirements of your Senior
Premium Plan Account. Since balance
requirements were not met this month, a
$20.00 fee was deducted from this
account.
.
Total Banking Statement
a For 24--hour information, sign on to PNC Bank Online Banking
on pnc.oom. .
AccountnUBnber:90-11~865-contD1ued
For the period 05/.5/2007 to 06/14/2007
BETTY R V ALENCIK
Primary account number: 90-1146-8865
Page 4 of 4
Retirement Accounts
.
Investment Description
number
75500027320 115 Month(s) FIXed Rate
. I nve$bnent Oescri pt; on
number
75100027411 115 Month(s} Fixed Rate
Betty R Valencik
Maturity date Interest Original or Currl!l'
rate renewal value vatu
03/18/2014 4.89% 7,849.97 7,493.5!
Betty R Valencik
Maturity date Interest Original or Curren
rate renewal value valll<
02/28/2014 4.89% 1,635.79 1,566.31
Total current value 9,O59.9(
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Total Banking Statement
-v'lllli:ll
o PNCRANl
.9. For 24-hour infonnation, sign on to PNC BankOn!lne Banking
on pnc.com.
Account number: 90-1146-8865 - continued
For the period 05/15/2007 to 0611412007
BETlY R VALENClK
Primary account number. 90--1146-8865
Page3of4
.
IMPORTANT INFORMATION ABOUT TRANSACTIONS AT NON-PNC BANK ATMS
AB &oonvenience, under certain conditions we will allow you to overdraft your checking or money market account when using your PNC
Bank Visa Check Card or PNC Bank A TM card at Non-PNC A Th1s. At PNC Bank A 1Ms you are given an opportlmity to cancel the
transaction ifit would cause an overdraft. You will not receive this choice when using & non-PNC Bank A1M. If you would prefer not to
have overdraft access at non-PNC Bank AIMs, call our Telephone Banking service at 1-877 -222.:540 1 between 6 am _ 12 midnight, Eastern
Time, seven days a week.
.
If you have previously caUed to opt-out, you do not need to call again.
Formore information, please see our Consumer Schedule of Service Charges and Fees, Other Account Charges and Services and/or Account
Agreement for Personal Checking and Savings Accounts, Withdrawals section.
· Buying a New Home or Looking to Refinance? Let PNC Mortgage Show You now
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OffervaIid from 6/1/07 - 8/31/07. See www.tcbonus.oom for oomplete telmS and conditions.
COMPLIMENTARY FINANCIAL REVIEW
Chart Your Flnandal Future Today
Investments * Eductztion * Retirement * And More
.
PNC Investments can help you plot the course of a solid financial journey. Whether it's planning fur financial freedom, education or
retirement, PNC Investments can h.elp navigate your future through our free monthly checkups and reviews.
Jue - Free CoI/egrJ Planning Checbtp
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Formore infoonation call1-800-PNC-61 11, stop by your local PNC Bank Branch, or visit pnc.com
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Not FDIC Insured. May LOlIe Value. No Bank Guarantee.
Important IlllIeStor Information: Securi~ and brokerage services are provided by PNC Invesimenfs LLC, member NASD and SIPC. Annuities
and other insurrmce products are ojJered by PNCl1fSUmnce Services, LLC a licensed ins&fmnce agency.
.
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FOAM953A.1005
.
G PNCBANl<
Total B~..nking Statement
PNC Bank
.
For the period 06115/2007 to 07/16/2007
L
M
BETTY R VALENCIK
5108 INVERNESS DR
MECHANICSBURG PA 17050-8319
.
;.
Primary account number. 90-1146--8865
Page 1 of 2
Number of enclosures: 0
Q For 24-hour banking, and transaction or
interest rate infonnation, sign on to
1:1' PNC Bank Online Banking at pne.com.
For customer service call 1-888-PNC-BANK
between the hours of 6 AM and Midnight ET.
Para sarvicio en espal'lol, '-866-HOLA-PNC
Moving? Please contact us at 1-888-PNC-BANK
E83 Write to: Customer Service
PO Box 609
Pittsburgh PA 15230-9738
a Visit us at pnc.com
I TOO termlnal:1-SQO-531-1648
For hearing impaired clients only
.
Relationahip Overview
..... Deposit Accounts
Oesc:rlption
Interest Checking
Retirement Account( s)
Total Deposits
Account Number
90-1146-8865
Total of2
Deposit Balance
11,677.36
9,098.78
20,776.14
.
Betty R Vaiencik
Senior Premium Plan
Interest Checking AcoOlRlt.S...naary
Account number. 90-1146-8865
Balance Sumlllary.
Please see the Activity Detail section for
additional information.
.
Beginning
balance
19,742.20
Deposits and
other additions
2,360.43
Checks and other
deductions
10;425.27
Ending
balance
1l~677.36
Charges
and fees
.00
.
Transaction Summary.
Checks paldl
withdrawals
Total ATM
transactions
Average monthly
balance
14,140.06
Check Card POS
signed transactions
Check Cardl8ankcard
POS PIN transactions
o
o
.
Interest Summary
As of 07/16, a total of $11.1 t in interest wa
paid this year.
Annual Percentage
Yield Earned (APYE)
O.50'/.
.
.
5
o
PNC Bank
A TM transactions
other Bank
ATM transactIons
o
o
Number of days
in Interest period
Average collected
balance for APYE
32
14,073.43
Interest Paid
thl s period
6.15
FORM963R. '005
. Total Banking Statement
Q For 24-hour information, sign on to PNC Bank Online Banking
C=S on pnc,com.
Accowlt l1U111 her: 90-1146-8865 - continued
For the period 06/1512007 to 07/16/2007
BETTY R VALENCIK
Primary account number: 90-1146-8865
Page 2 of 2
.
Activity Detail
Deposits and Other Additions
Ol!te Amount Description
06/18 410.25 Deposit Reference No 027431219
07/03 1,138.00 Direct Deposit - Soc See
US Treasury 303 XXXXX2001D
806.03 Deposit Reference No 024305801
6.15 Interest Payment
There were 4 Deposits and Other Additions
totaling $2.380A3.
.
07/12
07/16
CheCks and Substitute Checks
Check Date
number Amount paid
1192 14.54 06/15
1193 r>oo.oo 06/18
1194 5,000.00 06/19
Reference Check
number number
0253825]] 1195
027325528- r;zo/ 1197 *
024117979 - /l! f: ,. y""" /.<A111.~ ~~.
Amount
1,089.68
3,725.90
Date
paid
06/20
07/10
Reference
number
086737\47 -I
H220722063 .
I
.
tt Gap in check sequenoe
There ware 5 checks listed totaling
$10.330.12.
There was 1 Online or Electronic Banking
Deduction totaling $95.15.
Online and Electronic Banking Deductions
Date Amount Description
07/10 95.15 Payment,E-Check Check Pymt Vernon ARC II96
.
DaDy Balance Detail
Date Balance
06/15 19,727.66
06/18 19,637.91
Dale
06/19
06/20
Balance
14,637.91
13,548_23
Date
07/03
07/10
Balance
14,686.23
10,865_18
Date
07/12
07/16
&.Iance
11,671.21
II ,677.36
.
Renters, are your valuables covered? If a frre or other tmexpected event occurs, your landlord's instl.rance isn't likely to cover l-eplacement
of your personal property. Rente1'S insurance can help you protect yourself For more infomlation and a free no obligation quote visit
pue.com/iusurance. Product not available ill FL, NC and NJ.
.
Your PNC Bank Visa Check Card offers convenience and rewards. Use YOUl." card to setup automatic bill payments WitllOUt stamps,
checks, or trips to the post office. Plus, with your em'oIled Visa check card, you'll earn Visa Extras Rewards Points, redeemable for exciting
gifts. It's free to set up at pnc.comlpaybycard.
Retire.ent Accounts
115 MontJl(s) Fixed Rate
Betty R Valencik
MatLJrity date Interest Original or Current
rate renewa I va I ue value
03/18/2014 4.89% 7,849.97 7,525_75
Betty R Valencik
Maturity date Interest Original or Currenl
rate renewal valLJe value
02/28/2014 4.89% 1,635.79 1,573_03
Total current value 9,098.78
.
Investment
number
75500027320
Description
Investment
number
75100027411
Description
115 Month(s) Fixed Rate
.
.
.
--
.
Total Banking Statement
PNC Bank
~PNCBAN1<
For the period 07/17/2007 to 08/14/2007
Primary account number: 90-114S-8865
Page 1 of 3
Number of enclosures; 0
.
BETTY R VALENCIK
5108 INVERNESS DR
MECHANICSBURG PA 17050-8319
S For 24-hour banking, and transaction or
interest rate information, sign on to
ft PNC Bank Online Banking at pno,oom.
For customer servioe call1-8S8-PNC-BAN K
between the hours of 6 AM and Midnight ET.
.
Para serviclo en espano!, '-865-HOLA-PNC
Movingl Please contact us at 1-888-PNC-BANK
.
I2!5l Write to: Customer Service
PO Box 609
Pittsburgh PA 15230-9738
a Visit us at pnc.oom
I TOD terminal: 1-800-531-1648
For hearing impaired clients ollly
.
Relationship Overview
-Bank o.poeit Accounts
Description
Interest Checking
Retirement Account(s)
Total Deposits
Account Number
Deposit Balance
6,433_87
9,134.16
15.568.03
9{J..1146-8865
Totalof2
.
- Effective October 9, 2007, PNC will ~ail paper advices of wire transfers only to those customers who have a Wire Transfer agreement with
PNC Bank, Treasuxy Management, orwho notifY us that they wish to continue to receive mailedadvices. Additionally, if you are a consumer
customer, who has signed a consumer Funds Transfer Agreement, PNC will no longer mail paper advices of wire transfers, unless notified that
they wish to continue to receive mailed advices. Please note that wire transfer transactions will continue to app"'..aI on your monthly account
statement Online access to wire information is also available. Please go to pnc.com and log on accoroing to yom account type. For Personal
accounts, click on the Personal tab and log on to Online Banking. For Small Business or Corporate & Institutional accounts, ciick on either
the Small Business or Coxporate & Institutional Tab and log on to Online Banking or PINACLEiXl Web, respectively.
.
If you would like to oontUme to receive mailed paper advices ofwD.'e transfers, please submit your request in writing that you would like to
continue to receive mailed debit and credit wire transfer advices and include your account number(s), name(s) and addressees) and mail to:
.
PNC Bank, N.A.
500 First Ave
Mailstop: P7-PFSC-03-W
Attn: Mail Advice Change Request
PittSburgh, P A 15219
After mailing yoUr request, please allow at least 30 days for the change to be made. If you have additional questions, please contact your PNC
Bank: bIanch or call1-888-PNC-BANK.
.
Let PNC Mortgage help you bund your dreams.
.
Building your own home allows you to create a home truly suited to your needs, your family, and your desires. PNC Mortgage has a variety
of options specifically designed to simplifY new constmction f'mancing for you.
We're here to help you rmd the program that best suits you.
For More Infonnatioo:
> Ask to speak with your PNC Home Mortgage Consultant
> Visit pncmortgage.com
> Call 1-800-778-6678
.
Your individual account statements begin on the following page
FOAM963A-l0OS
. Total Banking Statelnent
For the period 07117/2007 to 08114/2007
BETTY R VALENCIK
Primary account number: 90-1146-8865
Page 2 of 3
tlll. J.U1tl mOfl~g~ IJlUlWCUi al4: OlI~lC;U lUlU pnJVluc::U D1 t 1'V\...; !Vlunga.ge~ LLL... IT~l., JVlul~agc.~ LLl..,.. Ui lJCGDSt:U m j-"ew Jel1it.:y a..o; .1 UCpllllUlClJl Vi nauALUg lV1UiLgilgc: J:\iult\.ca aHU
Secoodary Mortgage Loan Licensee. PNC Mortgage, llC IIllI}' not be available ill YllUI' area. Credit subject to approval. Iufonnaliou is accurate as of the date of printing :lud is
subject to change without notice. .02007 PNC Mortgage, llC. AIl Rights Reselved. 49113' 6107-9/07
a For 24-hour information, sign on to PNC Bank Online Banking
on pnc.com.
.
Senior Premiwn Plan
Interest Checking Account Summary
Account number. 90.1146-8865
Betty R Valencilc
.
Please see the Activity Detail section for
additional information.
Balance Summary
o
Deposits and Checks and other End i ng
other additions deductions balance
1,139.13 6,382.62 6,433.87
Average monthty Charges
balance and fees
7,558.54 20.00
Check Card POS Check Card/Bankcard
signed transactions POS PIN transactions
0 0
PNC Bank other Bank
ATM transactions ATMtransactions
0 0
Number of days Average collected Interest Paid
In inter:est period balance for APYE this period
29 7,558.54 1.13
Beginning
balance
11,677.36
.
.Transaction Summary
Checks paid!
withdrawals
13
.
Total ATM
transactions
.
Annual Percentage
YIeld Earned (APYE}
0.19%
As of 08114, a total or $'12.24 in interest wa
paid this year;
Intet'est Summary
Activity Detail
Deposits and Other Additions
Date Amount Description
08/031,138.00 Direct Deposit. Soc See
US Treasury 303 XXXXX2001D
08/14 l.13 Interest Payment
There were 2 Deposits and Other Additions
totaling $1.139.13.
.
Checks and Substitute Checks
Check Dale Reference Check Dale Reference
number Amount paid number number Amount paid number
1191 200.00 07/17 024115063 1204 595.34 07/23 086625292
119B * 105.00 07/23 026846422 1205 1,700.00 07/20 028092357
. 1199 648.06 07/17 0287'12456 1206 420.89 08/06 083778221
1200 150.00 07/17 028761831 1207 100.00 07/31 088497123
1201 500.00 07/18 0277'71031 1208 500.00 08/06 0285G84JO
1202 T 200.00 07/17 026252146 1210 * 743.33 08/14 028089048
1203 500.00 07/19 024630849
* Gap in check sequence "r Teller Cashed Check There were 13 checks listed totaling
. $6.382.82.
Other Deductions There was 1 Other Deduction totaling
Dale Amount Description $20.00.
08/14 20.00 Calculated Service Charge Type Hd
Daily Balance Detail
Date Balance Date Balance Date Balance
. 07/17 10,479.30 07/20 7,779.30 08/03 8,116.H6
07/18 9,979.30 07/23 7,078.96 08/06 7,196.07
07/19 9,479.30 07/31 6,978.96 08/14 6,433.87
.
.
Total Banking Statement
..
~PNCBANK
Q For 24-hour information, sign on to PNC Bank Online Banking
on pnc.com.
Account number: 90-114fHJ865 - continued
· SENIOR PRENIIUM PLAN - Service Charge EJrpIanation
For the period 07/'1712.807 to 08/14/2007
BETTY R VALENC1K
Primary account number: 90-1146-8865
Page3of3
ACcount type
lnterest~ecking
Certificate(!) of Deposit
Retirement Account( s)
Retirement Account( s)
Account n\.lmber
XX-XXXX-8B65
XXXXXX1206
XXXXXX8458
XXXXXX8379
Balance type
This Cycle A vg Balance
Current Value
Current Value
Cun-ellt Value
As of
08/]5
08/]3
08/13
08/]3
Balance
7,559.23
.00
1,579.15
7,555.01
These accounts were reviewed to meet
the balance requirements of your Senior
Premium Plan Account. Since balance
requirements were not met this month, a
$20.00 fee was deducted from this
account.
.
Are yon temporarily without health insurance? Au illness or injury could set you back finandaUy.Shl1rt Term Medical msurance can
provide health coverage with convenient payment options. To learn more vWt pne.com/insurance or call 1-877-284-4793.
.
Relax and let your PNC BaDk V'l8a@ Check Card pay the bills. Use your can!. to schedule one-time or recurring payments. You pay what
you need without looking for stamps, writing checks, or traveling to the post office. It's that easy. Find out IDOl'e at pnc.com/paybyc81u.
RetireJllent Acco...ts
. Investment Description
number
75500027320 1]5 Month(s) rlXed Rate
Inwstment Description
number
. 75100027411 115 Month{s) FIXed Rate
Betty R Valenclk
Maturity date I nten!st Original or Current
rate renewal val ue value
03/18/2014 4.89% 7,849.97 7,555.01
Betty R Valencik
Maturity date Interest Original or Current
rate renewal val ue value
02/28/2014 4.89% 1,635_ 79 1,579.15
Total current value 9,134.16
.
.
.
.
.
FORM953A-1006
.
.. ~.
. Reviewing Your Statement
Please review this statement carethlly and reconcile it with your records. Call tile telephone number on the upper right side ofthe fll'St page
of this statement if:
· you have any questions regarding your aCCowlts(S);
· your name or address is incorrect;
· you have a business account and your tax identification number is missing or incorrect;
· you have any questions regarding interest paid to an interest-bearing account.
.
TIle activity detail section of your statement to your account register.
All items in your account register that also appear on your statement. Remember to begin
wiilithe ending date of your last statement. (An asterisk {*} will appear in the Cllecks
section if there is a gap in the listing of consecutive check nwnbers.)
Any deposits or additions including interest payments and A TIvI or electronic deposits
listed on tlle statement that are not already entered in your register.
Auy accowlt deductions including fees and A 1M or electronic deductions listed on the
statement that are not already entered in your register.
Balancing Your Account
. Update Your Account Register
Compare:
Check Off:
.
Add to Your Account Register
Balance:
Subtract From Your Account
Register Balance:
.
Update Your Statement Information
.
Step 1:
Add together
deposits and
oUler additions
listed in your
accmmt register
but not on your
statement.
Amount
Step 2:
Add together
checks and otller
deductions listed
in your accolmt
register but not on
your statement.
Date of Oep_it
.
Total A
.
Step 3:
Enter the ending balance reconied ou your statement $
Add deposits aud otl1er additions not recorded Total A + $
.
Subtotal= $
Subtract checks and other deductions not recorded Totnt B _ $
The result should equal your account register balance = $
Check........ Dr
Ded.clio. ~io. Amount
Total 8
Verification of Direct Deposits
To verify whether a direct deposit or other transfer to your account has occurred, call us 7 days a week from 6:00 A.M. to Midnight (El) at
the customer service number listed on the upper right side ofthe fIrst page ofthis statement.
Electronic Funds Transfers
10: C~ of CllIUIli or questions abont your electnmic Ir.lDSfe~ or if YOll need more inf(l(lIlauon about a tnlDsfer, callus 7 days a week flUm 6:00 A.M. to Midnight (E1) at tile
cnsteJmer service nnmber listed OIl tbeupperright side of tile first page of this sllltement Or, if you prefer, please write us at Customer Service, P.O. Box 609, PiUsburgB, PA
15230-0609. If you believe there is a problem. YOll mustcootlct us no later thau 60 d.,ys after the ending d..,te of tile Ont statement OIl whil;h the error or problem appeared.
Y OIl wiD need to provide the following inform.nuon:
· Yonrname:md acc:olIntnllJllber{s);
· A description of the error 01' the transfer YOll are quesliouing. Please explain as clearly a5 YOll can why yoo need more i1iformalion Of' why you believe an error was made;
· The dollar nmoont of the sllspected enur.
We will investigate yonr complaint a1l(1 will correct any error promptly. If the investigatioo lakes longer than 10 business days, we will credit your BCCOIlIIt for the
amonnt yoo think is in elTOf, 80 that you \villhave use of the funds during the time it takes u.~ to complete our mvestigatioo.
.
.
.
Member FDIC
~ Equal Housing Lender
Il~
).;
.
Total Banking Statement
PNC BaIlk
. 0
For the period 08/15/2007 to 08/1312007
BETTY R VALENCIK
5108 INVERNESS DR
MECHANICSBURG PA 17050-8319
.
.
1
~PNCBANK
Primary account number. 90.1146-8865
Page 1 of3
Number of enclosures: 0
.Q For 24;.hour banking, and transaction or
interest rate information, sig"n on to
'D' PNC Bank Online Banking at pnc.com.
" For customer service call1-888-PNC-BANK
between the hours of 6 AM and Midnight ET.
Para servicio en espallol, 1-866-HOLA-PNC
Moving" Please contact us at 1-888-PNC-BANK
~ Write to: Customer Service
PO Box 609
Pittsburgh PA 15230-9738
Q Visit us at pnc.com
I
TOO terminal: 1-800-531-1648
For hearing impaired c1iellts only
.
Relationship Overview
Bank Deposit Accounts
Description
Interest Checking
Retirement Account( s)
Total Deposits
Account Number
90-1146-8865
Total of2
Deposit Balance
5;841.75
9,170.90
15,012.65
.
Betty R Valencik
Senior Premi... Plan
Interest Checking Account Summary
Account number: 90-1146-8865
Balance Summary
Please see the Activity Detail section for
additional information.
.
Beginning
balance
6,433.87
.
Transaction Summary
Checks paidl
withdrawals
Total ATM
transactions
.
9
Depos!ts and Checks and other Ending
otlKlr additions deductions balanCE!
2,578.47 3,170.59 5,841.75
Average morrthly Charges
balance and fees
5,562.94 20.00
Check Card POS Check. Cardl8ankcard
signed transactions POS PIN transactions
0 0
PNC Bank. other Bank
ATM transactions ATM transactions
0 0
Number of clays Average collected Intenlst Paid
In interest period balance for APYE this peri ad
30 5,447.27 .66
Interest Summary
o
Annual Percentage
Yield Earned {APYEj
O.15X
.
.
As of 09113, a total of $12.90 in interest was
paid this year.
FORM963R-l005
. Total Banking Statement
a. For 24-hollr information, sign on to PNC Bank Online Banking
on pnc.com.
Account number: 90-1146-8865 . continued
For the period 0811512007 to 09/1312007
BEllY R V ALENCIK
Primary account number. 90-1146-8865
Page 2 of 3
.
Activity Detail
Deposits and Other Addition.
Date . Amount Description
08/20 806.03 Deposit Reference No 027107175
08/31 1,138.00 Direct Deposit - Soc Sec
US Treasury 303 X.XXXX2001D
633.78 Deposit Reference No 027663146
.66 Interest Paymenl
There were 4 Deposits and Other Additions
totaling $2,57BA7.
.
09/06
09/13
Check. and Substitute Checks
Check . Date Reference
number Amount paid number
. 1209 11.54 08/16 027436602
. 1211 "' 28.50 OS/15 0870872'79
1212 1,500.00 08/16 087322626
1214 * T 368.00 08/24 026146159
1215 T 500.00 08/28 027631454
Check
number
1216
1217
1219 * T
1222 * T
Date Reference
Amount paid number
42.75 09/05 086132028
40.00 08/31 028054528
304.00 09/04 027236907
80.00 09/11 026510~2
* Gap in check sequence
"1" Teller Cashed Check
There were 9 checks listed totaling
$2.874.79.
There were 2 Online or Electronic Banking
Deductions totaling $275.80.
.
Online and Electronic Banking Deductions
Date Amount Description
" .
09/07 171.94 Paymenl,E-Chec.k Check Pymt Venzon ARC 1220
" 09/10 103.86 Payment,E.Check Dishckpymt
Echostar Communi 1221
Other Deductions
.
Date
Amount Description
20.00 Calculated Service Charge
There was 1 Other Deduction totaling
$20.00.
09/13
Type Hd
Daily Balance DetaO
Date Balance
08/15 6,405.37
08/16 4,893.83
08/20 5,699.86 .
08/24 5,331.86
Date
08/28
08/31
09/04
09/05
Balance
4,831.86
5,929.86
5,625.86
5,583.11
Date
09/06
09/07
09/10
09/11
Balance
6,216.89
6,044.95
5,941.09
5,861.09
Dale
09/13
Balance
5,841.75
.
.
SENIOR PREMIUM PLAN - Service Charge Explanation
Account type ACcount number Bala!lC9 type
Interest Checlc.ing XX.XX,.XX.8865 This Cycle Avg B..tallce
Certificate(s) of Deposit XXXXXXI206 Current Value
Retirement Account(s) XXXXXX8458 . Current Value
Retirement Account(s) XXXXXX8379 Current Value
As of
~/14
09/12
09/12
09/12
Balance
5,563.61
. .00
1,585.50
7,585.40
These accounts were reviewed to meet
the balance requirements of your Senior
Premium Plan Account. Since balance
requirements were not met this month, a
$20.00 fee was deducted from this
account.
.
Pick up a bilingual Sesame Street "Happy, Healthy Ready for School" kit at any PNC Bank bmnch. It's all new and FREE.
Elmo and friends turn everyday moments into fun learning opportunities. Includes a DVD, a magazine for parents and caregivers, an activity
book and activity cards.
.
.
-I.'
.
Total Banking Statement
~PNCBANK
Q For 24-hour information, sign on to PNC Bank Online Banking
on pnc.com. .
Account number: 90-1146-8865 - continued
. Retirement Accounts
For the period 08f15/2G07 to 09/1312007
BETIY R V ALENCIK
Primary account number: 90-1146-8865
Page3of3
Investment Description
number
75500027320 115 Month(s) FIXed Rate
.
investment Descri ption
numbar
751000274i1 115 Month( s) FL'l:ed Rate
Betty R Valencik
Maturity date Interest Original or Current
rate renewal value value
03/18/2014 4.89% 7,849.97 7,585.40
Betty R Valencik
Maturity date Interest Original or Current
rate renewal value . value
02/28/2014 4.89% 1,635.79 1,585.50
Total current v..... 9,170.90
.
.
.
.
.
.
.
.
FORM953R. laOS
Reviewing Your Statement
Please review this &.1.tement earen.llly and reconcile it with yourreconls. Call the telephone number on the upper right side ofthe first page
of this statement if:
· you have any questions regarding your accounts(s);
· your name or address is incorrect;
· you have a lmsiness account and your tax identification number is missing or ineon-ect;
· you have any questions regarding interest paid to an interest-bearing account.
.
.
1.-.-..
TIle activity detail section ofyonr statement to your account register.
All items in your aCCOWlt register that also appear on your statement. Remember to begill
with tIle ending date of your last statement. (An asterisk {"'} will appear in the Checks
section inhere is Ii gap in the listing of consecutive check nwnbers.)
Any deposits or additions including :interest payments and ATM or electronic deposits
listed on the statement that are not already entered in yow' register.
Any accO\wt deductions including fees and A 1M or electronic deductions Listed on the
statement that are not already entered in your register.
Balancing Your Account
Update Your Account Register
Compare:
Check Off:
.
Add to Your Account Register
Balance:
Subtract From Your Account
Register Balance:
· Update Your Statement Information
.
Step 1:
Add together
deposits and
other additions
listed in your
account register
but not on your
statement.
Am-..t
Step 2:
Add together
checks and other
deductions Hsted
in your account
register but not on
your statement.
Date of Depoait
.
T..... A
.
Step 3:
Enter tlle ending balance recorded on your statement $
Add deposits and other additions not recorded Total A + $
.
Subtotal= $
Subtract checks and other deductions not recorded Total B _ $
The result should equal your account register balance _ . $
Clleck ........ or
Ded.ctfe. Descriptio. Amount
1'.,., B
Verification of Direct Deposits
To verify whether a direct deposit or oUler transfer to your account has occlIlTed, call us 7 &ys a week from 6:00 A.M. to Midnight (E1) at
the customer seIVice Ilwnber listed on the upper right side oftlle flI'St page oftbis statement.
Electronic Funds Transfers
iii. Cll8e of errors 01" qaestiOllS abollt YOlIr electroDic: trausfers or ifyOlI need more WOODatian about a Irnnsfer, CllIl os 7 days a week from 6:00 AM. to Midnight (E'I) at the
customer service Wlmber listed on the ~rrigllt side oflhe first page oftlJis statement Or, if you prefer, please Wlite UB at Cllstomer Service. P.O. Box 609, Pittsburgh, PA
15230-0609. If YOll believe there is a problem, you must COIImct us 110 later tbaa 60 days after the ending date of the first statement 011 which lhe erroc or problem appeared
Y 011 will need to provide the follOWing iIlfonnatioa: .
. Yoar lIame and accOWlt Damber(s);
· A de6cription oftbe error or 1I1e tr.msferyoI are questioning. Please explain as clearly as YOll can why YOll ueed more infCl!U1ation or why yoo believe an error was made;
. The dollar RmOllDt of tile saspected error.
We will inve&ti!Jltl: yoar compJaiot a!ld will C01TeCt IIIIY error promptly. If the investigatiOllIllkes longertbau 10 business days, we will credit your lICCOIlIIt for Ihe
1Ol00000t you tbiuk is ill error, so that yoo willlmve use oftbe fiu1ds during 1I1e time it takes 1IIl to COOlll1ete our iIlvestigalioo.
.
.
Member FDIC
tal Equal Housing Lender
.
. Total Banking Statement
.
.
.
.
~ For 24-hour information, sign on to PNC Bank Online Banking
= on pnc.com.
Account numher: 90.} 146-88(,5 - continued
Fer the period 09/14/2007 to 10/15/20Q7
BETTY R VAlENCIK
Primary account number: 90-1146-8865
Page 2 of 2
Activity Detail
Deposits and Other Additions
Date Amount Description
~'l>i _ ~
10/03 . 1,138.00 Direct Deposit. Soc See
US Treasury 303 X,'\XXX200 I D
10/15 .68 Intet'est Payment
There were 2 Deposits and Other Addition~
totaling $1.138.68. .
Reference
numtter
Checks and Substitute Checks
Check Date
number Amount paid
1223 209.88 09/19
1224 54.75 10/01
1225 500.00 09/24
1226 290.38 00/24
1227 75.45 H~/ll
025358364
0286185]5
02-l6fJ9496
087] 26,>62
02~387('6
Chec k
number
1228
1229
1230 T
1233 *
1234 T
Date Reference
Amount paid number
299.25 10/01 028625252
94.50 10/11 02803.~7l>5
27G.oO 10/09 0275f>635 I
1,000.00 . 10/12 083696466
389.50 Hi/15 021;162859
There were 10 checks listed totaling
$3.189.71.
There was 1 Other Deduction totaling
$20.00.
Date
10/15
Type He!
i
I
I
I
1
i
I
I
I
!
1
I
i
I.
l
.
I
I
.J
j
1
I
I
I
I
1
I
1
I
--j
I
SENIOR PREMIUM PlAN - Service Cha-:ge Explanation
Account type Account number Balance type
Inter'est Checking X.XcX.'CXX.8865 TIlis Cycle Avg Bal;mce
Retirement Ac.count(s) .XXXxx.,X8458 . Cun-cut Value
Retirement Acco.ullt(s) x..TIXXX8379 Cun'ent V..lne
Bal ance
5,193.57
1,592.30
7,617.95
* Gap in check sequence
"T' Teller Cashed Check
.
.
Other Deductions
Amount Description
20.00 C'.akulated Sen,ice Charge
Daily Balance Detail
Date Sa I a nee
09/14 5,841.75
09/19 5,631.87 .-
09/24 4,841.49
Date
10/01 .
10/03
10/09
Balance
4,487.49
5,625.49
5,349.49
Date
10/11
10/12
10/15
Balance
5,179.54
4,179.54
3,770.72
These accounts were reviewed to meet
the ba.lance requirements of your Senior
Premium Plan Account. Since balance
requirements were not met this month, a
$20.00 fee was deducted from this
account.
As of
10/16
10/12
10/12
Take eonh-ol with your PNC Uank Visa@ Check Card. Use your card to pay your bills automatically _ set payment schedules, amounts,
even the number of bills you want to pay. TIle fimds come right from your checking aCcOlwt and the payments nre listed on your monthly
.statement. Leam more at pnc.com/paybycanI. .
.
Retir8mentAccounb
.
Betty Po Valencik
Maturity date Inte....st Original or Currer
rate. renewal value vaiUf
03/18/2014 4.89 % 7,8'19_97 7,617.9!
Betty R Valencik
Maturity date Interest Original or Curren
rate renewal value valu,
02/28/2014 4.89% 1,635.79 1,592.3(
Total cwrent value 9,21ll.2f
Investment
number
75500027320
Description
115 Month(s) Fi.-.ed Rate
.
.
Investment
number
75100027411
Description
115 MOIlth(s) Fixed R,lte
.
Total Banking Statement
PNC Bank
~ PNCBANl<
For the period 09/14/2007 to 10/15/2007
Primary account number. 90-1146-8865
Page 1 of 2
Number of enclosures: 0
.
BETTY R VAlENCIK
5108 INVERNESS DR
MECHANICSBURG PA 17050-8319
Q For 24-hour banking, and transaction or
interest rate information, sign on to
tt PNC Bank Online Banking at pnc.com.
For customer service call 1-888-PNC-BANK
between the hours of 6 AM and Midnight ET.
.
Para servicioen espal'iol, 1-866-HOLA-PNC
Moving? Please contact us at 1-888-PNC-BANK
E!!SI Write to: Customer Service
PO Box 609
Pittsburgh PA 15230-9738
Q Visit us at pnc.com
III IDD tenninal:1-800-531-1648
For he1l1"D1g impaired clients only
.
.
Relationship Overview
Bank Deposit Accounts
Descri ption
Account Number
Deposit Balance
'!J,770.72
9,210.25
12,980.97
Interest Checking
Retirement Account( s)
Total Deposits
90-1146.8865
Total of2
.
Set up a solid financial plan for any goal; education, retirement or a new home. With PNC Investments as your trusted guide, you can
determine a strategy to help you n:ach your goals. Call us at 1-800-PNC-6111 to schedule a complimentary fmancial assessment.
Not FDIClRsured. May Lon Value. No Bank Guarantee. Important Investor Information: Securities and brokerage services are provided by PNC lDvestmen1s lie,
member FINRA and SIPC. Annuitiea and other iIlsurBnce prodaclB are offered by PNC InsUIll1lCe SelVices, lie a licensed in!lllmlJCe agency.
.
Betty R Vatancik
Senior Premi.... Plan
Inter.st Checking .Account Summary
Account number: 90-1146-8865
Balance Summary
.
Beginning
balance
5,841.75
Deposits and
other additions
1,138-68
Checks a nd other
deductions
3,209.71
Endi nl!
balance
3,770.72
Please see the Activity Detail section for
additional information.
Transaction Summary
, Average monthly
balance
5,192.94
Charges
and fees
20.00
.
Checks paid!
withdrawals
Check Card POS
signed transactions
Check Card/Bankcard
POS PIN transactions
10
o
o
Total ATM
tra n sad I ot";s
PNC Bank
A TM transactions
other Bank
ATM transactions
o
o
o
.
Interest Summary
Annual Percentage
Yield Eamed (APYE)
Number of days
In Interest period
Average collected
balance for APYE
Interest Paid
tllis period
As of 10/15, a total of $13.58 in interest wal
paid this year.
0.15%
32
5,192.94
.68
.
FDRM953R.l0OS
.
'- ~.,. ~ j ~ ~ .' ~ ~,~" " "-
" ~ ,
G PNC13ANl<
.
PNC BANK, NATIONAL ASSOCIATION
RETIREMENT SERVICES
P. O. BOX 3499
PITTSBURGH,PA 15230
000030
Tel 1-888-762-4727
Bank Fin 22-1146430
BETTY R VAlENCIK
73 lICK RUN RD
CATAWISSA PA 17820-8718
Statement Period
01-01-07 Thru 06-30-07
.
Date
07-24-07
Page
1
Plan Type: TRADITIONAL IRA
Plan Number: 6000828379
Social Security iXXX-XX-3836
.
.
Principal Balance as of 01-01-07
Contributions Information
Current Year
Prior Year
Rollover
Interest Credited
Distribution Information
Principal Balance as of 06-30-07
Interest Accrued, Not Yet Credited
7,318.19
0.00
0.00
0.00
0.00
180.41
0.00
7,498.60
12.07
.
SUMMARY OF INVESTMENTS
.
Account Maturity Interest Current Interest. Total
Number Rate Date Credited Value Accrued Value
75500027320 4.894 03-18-14 180.41 7,498.60 12.07 7,510.6
-----..-_--- ------....----- ....--------- ------.....-----
Summary Totals 180.41 7,498.60 12.07 7,510.6
.
.
.
NOW IS THE PERFECT TIME FOR AN IRA CHECKUP!
CAll 1-888-PNC-IRAS (1-888-762-4727) AND HAVE ONE OF OUR
SPECIALISTS REVIEW YOUR IRA TODAY. MEMBER FDIC.
.
fFlAC09' t 1103
FORM953R.1tlOS
.
Notice of Withholding on Distributions from Retirement Accounts
If federal income taxes have been withheld from the distribution or withdrawal payments you are receiving and if you do
not wish to have taxes withheld, 'you should notify PNC Bank. However, if you elect not to have withholding apply to your
distribution or withdrawal payments, or if you do not have enough Federal inoome tax withheld from your payments, you
may be responsible for payment of estimated tax. You may incur penalties under the estimated tax rules if your
withholding and estimated tax payments are not sufficient.
.
!f federal income taxes are not being withheld from your payments because you have elected not to have withholding
apply and if you wish to revoke that election and have federal income taxes withheld from your payments, you should
notify PNC Bank.
.
.
.
.
.
.
.
.
.
.
G PNCBANl<
.
PNC BANK, NATIONAL ASSOCIATION
RETIREMENT SERVICES
P. O. BOX 3499
PITTSBURGH,PA 15230
000030
Tel 1-B88-762-4727
Bank Fin 22-1146430
BETTY R VALENCIK
73 LICK RUN RD
CATAWISSA PA 17820-8718
Statement Period
01-01-07 Thru 06-30-07
.
Date
07-24-07
Page
I
Plan Type: TRADITIONAL IRA
Plan Number: 6000828458
Social Security #XXX-XX-3836
.
.
Principal Balance as of 01-01-07
Contributions Information
Current Year
Prior Year
Rollover
Interest Credited
Distribution Information
Principal Balance as of 06-30-07
Interest Accrued, Not Yet Credited
1,532.10
0.00
0.00
0.00
0.00
37.77
0.00
1,569.87
0.00
.
SUMMARY OF INVESTMENTS
Account Maturity Interest Current Interest Total
Number Rate Date Credited Value Accrued Value
. 75100027411 4.894 02-28-14 37.77 1,569.87 0.00 1,569.8
---------- ------------ ---------- ------------
Summary Totals 37.77 1,569.87 0.00 1,569.8
.
.
.
NOW IS THE PERFECT TIME FOR AN IRA CHECKUP!
CAll I-BB8-PNC-IRAS (1-888-762-4727) AND HAVE ONE OF OUR
SPECIALISTS REVIEW YOUR IRA TODAY. MEMBER FDIC.
.
'RAC09 11103
FORM953R- 'OOl
.
Notice of Withholding on Distributions from Retirement Accounts
If federal income taxes have been withheld from U,e distribution or withdrawal payments you are receiving and if you do
not wish to have taxes withheld, you should notify PNC Bank. However, if you elect not to have withholding apply to your
distribution or withdrawal payments, or .if you do not have enough Federal income tax withheld from your payments. you
may be responsible for payment of estimated tax. You may incur penalties under the estimated tax rules jf your
withholding and estimated tax payments are not sufficient.
.
If federal income taxes are not being withheld from your payments because you have elected not to have withholding
apply and if you wish to revoke that.election and have federal income taxes withheld from your payments, you should
notify PNC Bank.
.
.
.
.
.
.
.
.
.
.
Total ~Banking Statelnent
PNC Bank
~PNCBANK
.
For the pedod '10/16/2007 to t 1/t4/2007
Primary account number: 90-1146-8865
Page 1 of 3
Number of enclosures: 0
BETTY R VAlENCIK
5108 INVERNESS DR
MECHANICSBURG PA 17050-8319
e For 24-hour banking, and transaction or
interest rate information, sign on to
'!t PNC Bank Online Banking at pnc.com.
For customer service call 1-888-PNC-BANK
between the hours of 6 AM and Midnight ET.
.
Para servicio en espai'lot, 1-B66-HOLA-PNC
Moving? Please contact us at 1-888-PNC-BANK
.
~ Write to: Customer SelVice
PO Box 609
Pittsburgh PA 15230-9738
Q Visit us at pnc.com
I TOO terminal; 1-800-531~1648
FOT hearing impaireddientJ only
.
Relationship Overview
Bank Deposit AcCounts
Description
Interest Olecking
Retirement ACCOUDt(S)
Total Deposits
Account Number
Deposit Balance
90-1146-8865
Total of2
2,999.97
8,646.28
11,646.25
.
Give the gift ofPNC Bank Visa@ Gift Cards this holiday season. Perfect for everyone and available in whole dollar amounts up to $500. Sto
by a paIticipatin~ PNC Bank bmnch for more details.
Senior Pr..i.- Plan Betty R Valencik
In....... Checking AccountSmnmary
Account number: 90-1146-8865
.
Balance Summary
o
. Deposits alld Checks and other Ending
other additions deductions balance
2,116.71 2,8.'37.46 2,999_97
Average monthly Chacpa~
balanc@ and fees
3,608.25 20.00
Check Card POS Check CardlBankcard
signed transactions POS PIN transactions
0 0
pNC Bank Other 8ank
A TM transactions ATM transactions
0 0
Number 01 days Average collected Interest Paid
In interest period balance for APYE this period
30 3,504.52 .43
Please see the Activity Detail section for
additional information.
Beginning
balance
3,770.72
.
Transaction Summary
Checks paidl
withdrawal s
11
.
Total ATM
transactions
..Intereat Summary
.
Annual Percentage
Yield Earned (APVE)
0.15%
As of 11114, a total of $14.01 in interest We
paid this year.
.
FORM9531l.100!
.
Total Banking Statement
C For 24-hour information, sign on to PNC Bank Online Banking
~ on pnc.com.
Account number: 90.114fH3865 - continued
"
For the period 1011612007 to 11/1412007
BETTY R V AlENCIK
Plimary account number. 90-1146.6865
Page 2 of 3
.
Activity Detail
Deposit. and Other Addition.
Dale Amount Description
llj02 1,138.00 Direct Deposit. Soc See
US Treasury 303 XX,-XXX2001D
Dep<....sit,Reference No T0400117020117
Deposit Referenc.e No T0400117020115
Interest Payment,
.
11/09
Ilj09
11/14
806.03
172.25 .
.43
There were 4 Deposits and Other Additions
totaling $2,1'6.71.
Check. and Substitute Check.
Check Date Reference
number Amount paid number
1231 72.00 10/22 026698756
. 1232 16.63 10/18 01928-1\169
1235 '" 123.00 10/22 026698757
-1236 T 150.00 10/29 026300472
12c17 23.00 10/26 026745256
J238 T 400.00 10/26 026027584
Check
number
1240 * T
1241T
1244 * T
1247 '*
1248
* Gap in checIc seqllence
.r- Teller Cashed Check
.
Other Deductions
Date
Amount Description
20.00 C:llcu1ated SerVice Charge
Type He!
11/14
.
Daily Balance Detail
Dale BalanCE!
10/16 3,770.72
10/18 3,754.09
10/22 3,559.09
Bal a nee
3,5GO.59
4,538.87
2,999.97
Date
10/26
10/29
11j02
Balance
3,136.09
2,710.09
3,848.09
Date
U/05
I1j09
Ilj14
Dale Reference
Amount "aid number
276.00 ]0/29 0263004 73.
287.50 11/05 02779] 352
27tl.OO 11/14 024227855
743.33 11/14 0'l.t345!!72
500.00 11/14 027050766
There were 11 checks listed totaling
$2.867 A6. .
There was 1 Other Deduction totaling
$20.00.
.
SENIOR PREMIUM PLAN - Service Charge Explanation
Account type Account number Balance type
. Interest (;heekillg XX-x'"XXX-8865 This Cycle Avg Balance
Retirement AccoulIt(s) XXXXXX8458 Current Value
Retirement Account(s) XXXXXX8379 Current Value
IV 15
11/13
11/13
As of
Balance
3,608.9'2
1,495.00
7,151.28
These accounts were reviewed to meet
the balance requirements of your Senior
Premium Plan Account Since balance
requirements were not met this month, a
$20.00 fee was deducted from this
account.
.
Make your holiday shopping easy and rewaniing this year when you use your PNC Bank Visa@ Check Card or PNC Bank Visa@ P Jatinum
Credit Can!. Acce ted at more than 20 million locations worldwide and online.
Have a goal? Get a l)lan. Come in for your complimentary financial assessment_
You have a better chance of realizing your goals when you write them down. That includes [mancial goals. A PNC
Financial Consultant can help you create a plan for education expenses. a new home. retirement and any dream you
have. Call1-800-PNC-611l, visit us at pnc.com or stop by the nearest PNC Bank Branch.
.
Nllt FDIC rnlur~d. May LOH V alue. ~'Bank Guarantee. ImllOrtant Investor InformaUon: Secnrilies aDd bmkernge services are provided by PNC Investments I.LC,
member FlNRA 2Ild SIPC. Annuities ood other illsDlOInce pmdncts are, offered /ly PNC In&mlUIce Services. LLC a Iiceused iusarnnce RgellCY.
.
.
.
Total Banking Statement
0PNCBANl<
Q For 24-hour infonnation, sign on to PNC Bank Online Banking
on pnc.com.
Account number: 90-1146-8865 - continued
· Retir...ent Accounts
For the pariod 10/16/2007 to 11/14/2007
BETIY R VAlENC!K
Primary account number: 90-1140-8865
Page 3 of 3
Description
Maturity date
Betty R Valencik
Interest Original or Currer
rate renewal value valu
4.89% 7,849.97 7,151.2:
Betty R Valencik
Inlerest Original or Currer
rale renewal value valU
4.89% 1,635.79 1,495.01
Total cUlTent value' 8,646.2:
Investment
number
75500027320
115 Month(s) Fixed Rate
Maturity date
.
Investment
number
75100027411
Descri phon
115 Month(s) Fixer.i Rate
02/28/2014
.
.
.
.
.
.
.
.
///
./
~//
V
03/18/2014
FORM953A-100!
· Reviewing Your statement
Please review this statement carefully and reconcile it ~'ith your recoros. Call the telephone number on the upper right side oftlle first page
oftllill statement if:
· you have any questiolls regarding your accoLUlls(s);
· your name or address is incorrect;
. you have a husiness accom~t and your tax identification number is missing or incoID:}ct;
. · you have any questions l'egal'dulg interest paid to an intcrest-beatiug account.
Balancing Your Account
Update Your Account Register
Compare:
Check Off;
.
".
The activity detail section of your statement to your account register.
All items ill your account register that also appear on your statement. Remember to begin
with the ending date of your last statement. (An asterisk {*} \vill appear in the Cllecks
section if there is a gap in the listing of consecutive check numbers.)
Any deposits or additions including interest 'payments nnd A TM or electronic deposits
listed on the statement that are not already entered in your register.
Any aCCOlmt deductions including fees and A TM or el~ctronic deductions listed on the
statement that are not already elltel'ed in your register.
Add to Your Account Register
Balance:
Subtract From Your Account
Register Balance:
· Update Your Statement Information
.
Step 1:
Add togeUler
deposits and
olher additions
listed in your
a~'Ount register
but not on your
statement.
.
.
I
Date of Depo.it Amount
"
"
T.... A
Step 2:
Add together
checks WId other
deductions listed
in your account
register but not on
your statement.
Step 3:
Enter the ending balance recorded on your statement $
Add deposits and other additions not recorded Total A + $
.
Subtotal= $
Suhl.tuct chcvk:,l and cUler deductions not n:coroe.J Total B. $
TIle result should equal your aCCOWlt register balance $
Verification of Direct Deposits
To verify wbetltera direct deposit or other transfer to your accOlmt has occurred, call us 7 days a week from 6:00 A.M. to Midnight (El) at
the customer servicenwnoer listed on the upper right side oHhe frrst page ofthis statement .
Electronic Funds Transfers
In cnse of errors oc questioas abont YOlI!' electronic: trnll/lfern or ifynn need more infonnatiOllllltoot a transfer, call us 7 days a week fmlD 6;00 A.M. It> Midlli!IIt (E1) at the
cnstomer service number listed on tbe upper rigbt side of the fllllt page of this statement. Or. ifyoo prefer, please write us at CuslomerService. P.O. Box 609. Piltsbul'l1b. P A
15230-0609. IfYC)l1 believe there is a problem, YOll must cootlct liS Jlt> later tb:tn 60 days after the endiag date of the first strtemeut on which the error or problem nppe:m:d.
Y 011 willlleed to pmville the following information; .
· Y()\lr name and accouDtnumber(s);
· A de~liplioll ofthe en'\)(" or the transfer you an: qllestiooiat;. Please explain as clearly as yon can why yon Deed more information or wily YOll believe au em.... was made;
· The IloUar amOllut of tlte SlISpected enOl".
We wiU in\'e.~tigntc: yoor complaint and will correct ally error promptly. If the investigation lakes loogerthnn J 0 business days. we will credit Yl1lll' account for the
lIIIlllllDI you think is ill error, so lhat YOII wiU Itave ase of !he fllnd!l lIlIIing the lime it lakes lIS 10 COlDIJlele Ollr iRvesligatiou.
.
.
Member FDIC
.
rQr Equal Housing Lender
CIIecIc ......... or
Dechletle. Descriptio. Amount
.
Total B
. .
.
.
VERIFICATION
.
I, CHESlER L V ALENCIK, JR., verify that the facts set forth in the foregoing
document are true and correct to the best of my information, knowledge and belief. I understand
that false statements herein are made subject to the penalties of 18 Pa C.S. S4904, relating to
unsworn falsification to authorities.
.
. (J~,.ljJ~J~J 04.
. CHES L. V ALENCIK, JR If <..
.
.
.
.
.
.
.
.
.
.
Neil Warner Yahn, Esquire
Attorney I.D. No. 82278
Edward P. Seeber
Attorney J.D. No. ~6084
James Smith Dietterick & Connelly, LLP
P.O. Box 650
Hershey, P A 17033
Attorneys for Petitioner
ESTATE OF BErrY R. V ALENCIK
) IN THE COURT OF COMMON PLEAS OF
) CUMBERLAND COUNTY, PENNSYL VANIA
)
) ORPHANS' COURT DIVISION
)
) No. OC 2008
)
)
)
.
CHESTER L. V ALENCIK, JR.,
Petitioner
.
TROY A. V ALENCIK~
Respondent
CERTIFICATE OF SERVICE
.
I, Neil Warner Yalm~ Esquire, do hereby certifY that I served a true and correct copy of the
foregoing PETITION TO ENFORCE THE POWER OF ATTORNEY upon the following
.
below-named individuals by U.S. Mail, first class postage prepaid, at Hershey, Pennsylvania this
--L- day of February, 2008.
SERVED UPON:
.
Bruce G. Baron, Esquire
Capozzi and Associates, P.c.
2933 North Front Street
Harrisburg, P A 17110
Telephone: (717) 233-4101
l ~ /J~
NEIL WARNER Y ~HN, rSQUIRE
Attorney I.D. #8220
.
.
.
EXHIBIT B
IN THE COURT OF COMMON PLEAS
OF COLUMBIA AND MONTOUR COUNTIES, PENNSYL VANIA
ORPHANS' COURT DIVISION
INRE:
BETTY R. V ALENCIJ(,
AN ALLEGED INCAPACITATED PERSON,
AND
CHESTER L. V ALENCIK, JR.,
INDIVIDUALLY, AND IN HIS CAPACITY
AS DURABLE POWER OF A ITORNEY
FOR BETTY L. V ALENCIK AND IN HIS
CAPACITY AS TRUSTEE OF THE
V ALENCIK FAMILY IRREVOCABLE
TRUST DATED AUGUST 4, 2005
AND
LINDA D. VALENCIK, IN HER CAPACITY
AS SUBSTITUTE DURABLE POWER OF
ATTORNEY FOR BETTY L. V ALENCIK
~~;:n6~;:': ','" ,r
I'" ~ 'j~\lJ
L .." (;',.."
n \ .--;-\ d - \\,1 ,.,,,-
'-'I I ',-"
,\ b \1.\:~j H.~~ ';, :~. ',,' U ::,
)
)
) No. :)::LF!~ -~-L{
)
)
) PETITION FOR THE APPOINTMENT
) OF A PERMANENT GUARDIAN
) FOR THE PERSON AND ESTATE OF
) BETTY R. V ALENCIK, TO V ACA TE
ALL PRIOR POWERS OF ATTORNEY
APPOINTING CHESTER L. V ALENCIJ(,
JR. OR LINDA D. V ALENCIK, FOR AN
ACCOUNTING BY CHESTER L.
V ALENCIK, JR., AS POWER OF
ATTORNEY li'OR BETTYR. V ALENCIK
AND AS TRUSTEE ~FTHE V ALENCIK
FAMILY IRREVOCABLE TRUST
DA TED AUGUST 4, 2005, AND
FOR OTHER RELIEF
Filed on Behalf of Petitioner:
Troy A. Valencik
73 Lick Run Road
Catawissa, Columbia County, P A 17820
(Telephone: 570-799-0208)
Grandson of Betty R. Valencik
Counsel of Record for Petitioner:
CAPOZZI AND ASSOCIATES, P.C.
Bruce G. Baron, Esquire
Attorney ID No. 28090
2933 North Front Street
Harrisburg, P A 1711 0-1250
(717) 233- 4101 (phone)
(717) 233- 4103 (fax)
Email: BruceB@CapozziAssociates.com
1
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IN THE COURT OF COMMON PLEAS
OF COLUMBIA AND MONTOUR COUNTIES, PENNSYL VANIA
INRE:
BETTY R. VALENCIK
.
AN ALLEGED INCAP ACIT A TED
PERSON,
AND
.
CHESTER L. V ALENCIK, JR.,
INDIVIDUALLY, AND IN HIS CAPACITY
AS DURABLE POWER OF A TIORNEY
FOR BETTY L. V ALENCIK AND IN HIS
CAPACITY AS TRUSTEE OF THE
V ALENCIK FAMILY IRREVOCABLE
TRUST DATED AUGUST 4,2005
.
AND
.
LINDA D. V ALENCIK, IN HER CAPACITY
AS SUBSTITUTE DURABLE POWER OF
A TTORNEY FOR BETTY L. V ALENCIK
.
) ORPHANS' COURT DIVISION
)
)
) No.
)
) PETITION FOR THE APPOINTMENT
) OF A PERMANENT GUARDIAN
) FOR THE PERSON AND EST A TE OF
) BETTY R. V ALENCIK, TO VACATE
ALL PRIOR POWERS OF ATTORNEY
APPOINTING CHESTER L. V ALENCIK,
JR. OR LINDA D. V ALENCIK, FOR AN
ACCOUNTING BY CHESTER L.
V ALENCIK, JR., AS POWER OF
ATTORNEY FOR BETTY R. V ALENCIK
AND AS TRUSTEE OF
THE V ALENCIK FAMILY
IRREVOCABLE TRUST DATED
AUGUST 4, 2005, AND FOR OTHER
RELIEF
IMPORTANT NOTICE / CITATION WITH NOTICE
.
TO: BETTY R. V ALENCIK, 73 Lick Run Road, Catawissa, Pennsylvania
A PETITION HAS BEEN FILED WITH THIS COURT TO HAVE A PERMANENT
GUARDIAN APPOINTED AND TO MAKE. A DETERMINATION OF WHETHER YOU
SHOULD BE DECLARED AN INCAPACITATED PERSON. IF THE COURT FINDS YOU
TO BE AN INCAPACITATED PERSON, YOUR RIGHTS WILL BE AFFECTED,
INCLUDING YOUR RIGHT TO MAKE PERSONAL DECISIONS. A COpy OF THE
PETITION, WHICH HAS BEEN FILED BY ATTORNEY BRUCE G. BARON, ESQUIRE, IS
ATTACHED.
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YOU ARE HEREBY ORDERED TO APPEAR AT A HEARING TO BE HELD IN
COURTROOM NO. , COLUMBIA COUNTY COURT HOUSE, 35 WEST MAIN
STREET, BLOOMSBURG, PENNSYLVANIA 17815, ON AT
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2
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- O'CLOCK, _.M. TO TELL THE COURT WHY IT SHOULD NOT FIND YOU TO
BE AN INCAP ACIT A TED PERSON AND APPOINT A GUARDIAN TO ACT ON YOUR
BEHALF.
TO BE AN INCAP ACIT A TED PERSON MEANS THAT YOU ARE NOT ABLE TO
RECENE AND EFFECTNEL Y EV ALUA TE INFORMATION AND COMMUNICATE
DECISIONS AND THAT YOU ARE UNABLE TO MAKE NECESSARY DECISIONS
ABOUT WHERE YOU WILL LNE, WHAT MEDICAL CARE YOU WILL GET, OR HOW
YOUR MONEY WILL BE SPENT.
A T THE HEARING, YOU HAVE THE RIGHT TO APPEAR, TO BE REPRESENTED BY
AN ATTORNEY, AND TO REQUEST A JURY TRIAL. IF YOU DO NOT HAVE AN
ATTORNEY, YOU HAVE THE RIGHT TO REQUEST THE COURT TO APPOINT AN
A TTORNEY TO REPRESENT YOU AND TO HAVE THE ATTORNEY'S FEES PAID FOR
YOU IF YOU CANNOT AFFORD TO PAY THEM YOURSELF. YOU ALSO HAVE THE
RIGHT TO REQUEST THAT THE COURT ORDER THAT AN INDEPENDENT
EV ALUA TION BE CONDUCTED AS TO YOUR ALLEGED INCAPACITY.
IF THE COURT DECIDES THAT YOU ARE AN INCAPACITATED PERSON, THE
COURT MAY APPOINT A GUARDIAN FOR YOU, BASED ON THE NATURE OF ANY
CONDITION OR DISABILITY AND YOUR CAPACITY TO MAKE AND COMMUNICATE
DECISIONS. THE GUARDIAN WILL BE OF YOUR PERSON AND WILL HAVE EITHER
LIMITED OR FULL POWER TO ACT FOR YOu.
IF THE COURT FINDS YOU ARE TOTALLY INCAPACITATED, YOUR LEGAL
RIGHTS WILL BE AFFECTED AND YOU WILL NOT BE ABLE TO MAKE A CONTRACT
OR GIFT OF YOUR MONEY OR OTHER PROPERTY. IF THE COURT FINDS THAT YOU
ARE PARTIALLY INCAPACITATED, YOUR LEGAL RIGHTS WILL ALSO BE LIMITED
AS DIRECTED BY THE COURT. IF YOU DO NOT APPEAR AT THE HEARING (EITHER
IN PERSON OR BY AN ATTORNEY REPRESENTING YOU) THE COURT WILL STILL
HOLD THE HEARING IN YOUR ABSENCE AND MAY APPOINT THE GUARDIAN
REQUESTED.
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By:
Clerk, Orphans' Court
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IN THE COURT OF COMMON PLEAS
OF COLUMBIA AND MONTOUR COUNTIES, PENNSYLVANIA
.
INRE:
BE TTY R. V ALENCIK
.
AN ALLEGED INCAP ACIT A TED
PERSON
AND
.
CHESTER L. V ALENCIK, JR.,
INDIVIDUALLY, AND IN HIS CAPACITY
AS DURABLE POWER OF ATTORNEY
FOR BETTY L. V ALENCIK AND IN HIS
CAPACITY AS TRUSTEE OF THE
V ALENCIK F AMIL Y IRREVOCABLE
TRUST DATED AUGUST 4,2005
.
AND
LINDA D. V ALENCIK, IN HER CAPACITY
AS SUBSTITUTE DURABLE POWER OF
. A TTORNEY FOR BETTY L. V ALENCIK
) ORPHANS' COURT DIVISION
)
)
) No.
)
) PETITION FOR THE APPOINTMENT
) OF A PERMANENT GUARDIAN
) FOR THE PERSON AND EST A TE OF
) BETTY R. V ALENCIK, TO VACATE
ALL PRIOR POWERS OF ATTORNEY
APPOINTING CHESTER L. V ALENCIK,
JR. OR LINDA D. V ALENCIK, FOR AN
ACCOUNTING BY CHESTER L.
V ALENCIK, JR., AS POWER OF
ATTORNEY FOR BETTY R. VALENCIK
AND AS TRUSTEE OF THE V ALENCIK
FAMILY IRREVOCABLE TRUST
DATED AUGUST 4, 2005, AND FOR
OTHER RELIEF
IMPORTANT NOTICE/CITATION WITH NOTICE
TO: CHESTER L. V ALENCIK, JR. , Individually,
and as Power of Attorney for Betty R. Valencik
5108 Inverness Drive
Mechanicsburg, P A 17050
and
Chester L. Valencik, Jr., as Trustee of
The Valencik Family Irrevocable Trust dated August 4, 2005
5108 Inverness Drive
Mechanicsburg, P A 17050
And
Linda D. Valencik, as Substitute Power of Attorney for Better R. Valencik
5108 Inverness Drive
Mechanicsburg, P A 17050
.
.
.
A PETITION HAS BEEN FILED WITH TillS COURT TO HAVE A PERMANENT
GUARDIAN APPOINTED FOR THE PERSON AND ESTATE OF BETTY R. VALENCIK,
REPLACING YOU AS HER DURABLE POWER OF ATTORNEY, SEEKING AN
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4
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ACCOUNTING OF YOUR ACTIVITIES AS HER POWER OF ATTORNEY, AND SEEKING
AN ACCOUNTING AND RELATED INJUNCTNE RELIEF WITH RESPECT TO YOUR
ADMINISTRA TION AS, AND YOUR REPLACEMENT AS TRUSTEE OF THE V ALENCIK
F AMIL Y IRREVOCABLE TRUST DATED AUGUST 4,2005. A COPY OF THE PETITION,
WHICH HAS BEEN FILED BY ATTORNEY BRUCE G. BARON, ESQUIRE, IS
ATTACHED.
.
.
AND NOW, this day of
consideration of the aforementioned petition, it is hereby ordered that:
(1)
, 200_, upon
Chester L. Valencik, Individually, and as Power of Attorney for Betty R. Valencik,
and as Trustee of the Valencik Family Irrevocable Trust and Linda D. Valencik, as
Substitute Power of Attorney for Betty R. Valencik, shall Show Cause why the
Petitioner, Troy A. Valencik, is not entitled to the relief requested;
(2) the Respondents, Chester L. Valencik, Jr. and Linda D. Valencik, shall file an answer
to the Petition within _ days of this date;
the Petition to revoke all prior appointments of Chester L. Valencik, Jr. and Linda D.
Valencik, as Power of Attorney for Betty R. Valencik and declare Troy A. Valencik
as successor or substitute Durable Power of Attorney thereunder, for an accounting
by Chester L. Valencik, Jr., as Power of Attorney for Betty R Valencik for all periods
from February 20, 2003 to the present, to obtain copies of all prior Powers of
Attorney signed after February 20, 2003 appointing Chester L. Valencik, Jr., as
Power of Attorney for Betty L. Valencik, to obtain a copy of the Valencik Family
Irrevocable Trust dated August 4, 2005, for an accounting by Chester L. Valencik, Jr.,
as Trustee of the Valencik Family Irrevocable Trust dated August 4, 2005 for all
transactions involving that Trust from August 4, 2005 to the present, for the discharge
and replacement of Chester L. Valencik, Jr., as Trustee of the Valencik Family
Irrevocable Trust dated August 4, 2005, to obtain copies of documents related to the
formation of such Trust and the replacement of Life Insurance obtained prior to the
formation of such Trust with Life Insurance naming you as beneficiary; and for
related discovery and for injunctive and protective relief to preclude Chester L.
Valencik, Jr. from any interference with the interests of Betty R Valencik in the quiet
enjoyment and use of the property of the Valencik Family Irrevocable Trust dated
August 4,2005, shall be decided under Pa. RC.P. No. 206.7;
(4) depositions shall be completed within _ days of this date;
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(3)
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(5) argument shall be held on
No. of the Columbia County Court House; and,
(6) notice of the entry of this Order shall be provided to all. parties by the Attorney for
Petitioner.
, 2008, in Courtroom
BY THE COURT:
.
J.
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6
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IN THE COURT OF COMMON PLEAS
OF COLUMBIA AND MONTOUR COUNTIES, PENNSYLVANIA
. INRE: ) ORPHANS' COURT DIVISION
)
BETTY R. V ALENCIK ) No.
)
AN ALLEGED INCAP ACIT A TED ) PETITION FOR THE APPOINTMENT
. PERSON ) OF A PERMANENT GUARDIAN
) FOR THE PERSON AND EST A TE OF
AND ) BETTYR. VALENCIK, TO VACATE
) ALL PRIOR POWERS OF ATTORNEY
CHESTER L. VALENCIK, JR., ) APPOINTING CHESTER L. V ALENCIK,
. INDNIDUALLY, AND IN HIS CAPACITY ) JR. AND LINDA D. V ALENCI, FOR AN
AS DURABLE POWER OF ATTORNEY ) ACCOUNTING BY CHESTER L.
FOR BETTY L. V ALENCIK AND IN HIS ) V ALENCIK, JR., AS POWER OF
CAPACITY AS TRUSTEE OF THE ) ATTORNEY FOR BETTY R. V ALENCIK
V ALENCIK F AMIL Y IRREVOCABLE ) AND AS TRUSTEE OF
. TRUST DATED AUGUST 4,2005 ) THE VALENCIKFAMILY
) IRREVOCABLE TRUST DATED
AND ) AUGUST 4, 2005, AND FOR OTHER
) RELIEF
LINDA D. V ALENCIK, IN HER CAPACITY
AS SUBSTITUTE DURABLE POWER OF
. A TTORNEY FOR BETTY L. V ALENCIK
PRELIMINARY ORDER OF COURT
.
AND NOW, this
day of
, 200_, the foregoing
Petition having been presented in open Court, upon consideration thereof and on motion of
Bruce G. Baron, Esquire, for the Petitioner, it is ORDERED and DECREED that a Citation be
.
issued by the Register of Wills and directed to Betty R. Valencik, to show cause why a
Permanent Guardian of her Person and Estate should not be appointed, returnable the
.
day of
,200_at
o'clock, _.M., Prevailing
Time, in the Columbia County Court of Common Pleas, Orphan's Court Division, Court Room
No. . Columbia County Courthouse, 35 West Main Street, Bloomsburg, Pennsylvania
.
17815.
7
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The time and place of the hearing on the Petition for the Appointment of a Permanent
Guardian of the Person and the Estate of Alleged Incapacitated Person are fixed for the
day of ,200_ at o'clock, _.M., Prevailing Time, in the
Columbia County Court of Common Pleas, Orphan's Court Division, Court Room No._,
Columbia County Court House, 35 West Main Street, Bloomsburg, Columbia County,
Pennsylvania 17815. Advance written notice of the hearing on the Appointment of the
Permanent Guardian of her Person and Estate shall be given to BEITY R. V ALENCIK, the
alleged incapacitated person, by serving her personally with the Citation and the Order of Court
and a copy of the foregoing Petition together with an explanation of the content and terms of the
Petition. Written notice of the Petition and hearing on appointment of a Permanent Guardian
shall be given to the following: All persons residing within the State of Pennsylvania who are sui
juris and would be entitled to share in the estate of the Alleged Incapacitated Person if she were
to die intestate; to the person or institution providing residential care to the alleged incapacitated
person; and to the following other parties in interest: (a) ALL NEXT OF KIN; (b) Columbia-
Montour Area Agency on Aging (Attention: Annie Reilly); (c) Chester L. Valencik, Jr.,
individually, as Durable Power of Attorney and as Trustee of the Valencik Family Irrevocable
Trust dated August 4,2005; (d) Linda D. Valencik, as Substitute Durable Power of Attorney; and
(e) Shelly Valencik Capozzi (granddaughter). Such notice of the hearing to persons other than
the Alleged Incapacitated Person shall be made either personally or by registered or certified
mail.
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BY THE COURT:
.
J.
8
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IN THE COURT OF COMMON PLEAS
OF COLUMBIA AND MONTOUR COUNTIES, PENNSYLVANIA
. ORPHANS' COURT DIVISION
INRE: )
)
BETTY R. V ALENCIK, ) No.
)
AN ALLEGED INCAPACITATED PERSON ) PETITION FOR THE APPOINTMENT
. ) OF A PERMANENT GUARDIAN
AND ) FOR THE PERSON AND ESTATE OF
) BETTY R. V ALENCIK, TO VACATE
CHESTER L. V ALENCIK, JR., ) ALL PRIOR POWERS OF ATTORNEY
INDIVIDUALLY, AND IN HIS CAPACITY ) APPOINTING CHESTER L. V ALENCIK,
. AS DURABLE POWER OF ATTORNEY ) JR. AND LINDA D. V ALENCIK, FOR AN
FOR BETTY L. V ALENCIK AND IN HIS ) ACCOUNTING BY CHESTER L.
CAPACITY AS TRUSTEE OF THE ) V ALENCIK, JR., AS POWER OF
V ALENCIK F AMIL Y IRREVOCABLE ) A TTORNEY FOR BETTY R. V ALENCIK
TRUST DATED AUGUST 4, 2005. ) AND AS TRUSTEE OF
. ) THE V ALENCIK FAMILY
AND ) IRREVOCABLE TRUST DATED
) AUGUST 4,2005, AND FOR OTHER
LINDA D. V ALENCIK, IN" HER CAPACITY ) RELIEF
AS SUBSTITUTE DURABLE POWER OF )
. A TTORNEY FOR BETTY L. V ALENCIK
.
PETITION FOR THE APPOINTMENT OF PERMANENT GUARDIANS
OF THE PERSON AND OF THE ESTATE OF AN ALLEGED INCAP ACIT A TED
PERSON. FOR THE VACATING OF ALL PRIOR POWERS OF ATTORNEY
APPOINTING CHESTER L. V ALENCIK. JR. AND LINDA D. V ALENCIK AS POWER
OF ATTORNEY FOR BETTY R. V ALENCIK. FOR AN ACCOUNTING OF ALL
TRANSACTIONS BY CHESTER L. V ALENCIK. JR.. AS POWER OF ATTORNEY
FOR BETTY R. V ALENCIK. AND FOR AN ACCOUNTING OF ALL TRANSACTION
BY CHESTER L. V ALENCIK. JR.. AS TRUSTEE OF THE V ALENCIK FA MIL Y
. IRREVOCABLE TRUST DATED AUGUST 4.2005. FOR THE REMOVAL OF
CHESTER L. V ALENCIK. JR.. AS TRUSTEE. AND RELATED DECLARATORY AND
INJUNCTIVE RELIEF TO PROTECT THE INTERESTS OF BETTY R. V ALENCIK.
INDIVIDUALL AND
AS A BENEFICIARY OF SAID TRUST
.
.
AND NOW COMES Petitioner, Troy A. Valencik, through his attorney, Bruce G.
.
Baron, Esquire, and presenting this Petition to this Honorable Court for the Appointment of
9
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Permanent Guardians of the Person and of the Estate of Betty R. Valencik, an Alleged
Incapacitated Person, and other related relief, representing as follows:
1. Petitioner, Troy A. Valencik, is an adult who resides at 73 Lick Run Road,
Catawissa, Columbia County, P A 17820 (Telephone: 570-799-0208).
2. The Alleged Incapacitated Person is BETTY R. V ALENCIK, an 85 year-old
widow, residing at 73 Lick Run Road, Catawissa, Columbia County, P A 17820. Her date of
birth is November 5, 1922. Her parents are deceased. Troy A. Valencik, Petitioner, is the
grandson of the Alleged Incapacitated Person and the father of great grandchildren of the
Alleged Incapacitated Person.
3. The names and addresses of the presumptive adult heirs of the Alleged
Incapacitated Person are as follows:
(a) Chester L. Valencik, Jr. (her son), 5108 Inverness Drive,
Mechanicsburg, Cumberland County, Pennsylvania 17050;
Petitioner, Troy A. Valencik (her grandson and the son of
Chester L. Valencik, Jr.), 73 Lick Run Road, Catawissa,
Columbia County, Pennsylvania 17820; and,
Shelly Valencik Capozzi (her granddaughter and the daughter
of Chester L. Valencik, Jr.), 1655 South Holly Pike, Carlisle,
Cumberland County, Pennsylvania 17013.
(b)
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(c)
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4. Petitioner is an interested party because Petitioner is the grandson and current
caregiver for the Alleged Incapacitated Person and is filing this Petition in order to assist his
grandmother to spend her retirement years in her family farm home at 73 Lick Run Road,
Catawissa, Columbia County, Pennsylvania, consistent with her frequently expressed wishes and
.
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the intent of the family trust she and husband created with respect to their farm and other
property at that location, which has been in the Valencik family for several generations, and to
help her assure that the assets she and her husband placed in trust for her benefit and the
management of her estate have been and are used for her benefit and are available for use for her
benefit.
.
.
5. The Alleged Incapacitated Person is not being provided with professional
residential services at this time since she is living at her family home with assistance from
visiting nurses and certified nurse aides and from the Columbia-Montour Area Agency on Aging.
6. The Alleged Incapacitated Person was diagnosed with dementia (ICD-9
Diagnosis Code 294.8), an acquired organic mental disorder with loss of intellectual abilities of
sufficient severity to interfere with social and occupational functioning, which is progressive and
affects her judgment faculties, by her family physician, Dr. Dennis M. Sheehe, M.D., 353 Main
Street, Catawissa, Columbia County, Pennsylvania 17820 (Telephone: 570-356-2531).
7. During the last three (3) years, the Alleged Incapacitated Person has resided at
the following addresses: (a) 73 Lick Run Road, Catawissa, Columbia County, Pennsylvania
17820; and, (2) 5108 Inverness Drive, Mechanicsburg, Cumberland County, Pennsylvania
17050.
8. During the last three (3) years, the following persons are known to have
administered all or part of the fmancial affairs of the Alleged Incapacitated Person: Chester L.
Valencik, Jr., her son, as Durable Power of Attorney and Trustee of the Valencik Family
Irrevocable Trust dated August 4,2005.
9. The Alleged Incapacitated Person currently does not have a court-appointed
guardian. There is currently uncertainty as to who is authorized to act on her behalf as her Power
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of Attorney and whether that individual has been and is acting in her best interests consistent
with law.
10. The Alleged Incapacitated Person is known to have a Will. A copy of the
Will is attached hereto as Exhibit F and will be available for production at the time of hearing.
Petitioner is the named Executor in the attached Will.
11. Because of her physical and mental condition, the Alleged Incapacitated
Person requires 24-hour supervision and assistance in her activities of daily living in order to
continue to live in her home, including assistance with the management of her finances and
making improvements to her home necessary to accommodate her desire to live there with the
ongoing changes in her physical and mental abilities.
12. According to the examination and assessment of the Alleged Incapacitated
Person conducted by Dr. Sheehe on December 20, 2007, the Alleged Incapacitated Person is
incapable of handling her personal affairs, however minor, and if called upon to grant infonned
consent to any medical procedure she would be unable to grant it because of her inability to
comprehend the nature of the procedure. Additional infonnation is set forth in the attached
reports from her treating and attending physician, Dr. Dennis M. Sheehe, which are incorporated
by reference and attached hereto marked "Exhibit - Competency."
13. The Alleged Incapacitated Person is not expected to recover from her current
condition to become sufficiently independent to manage her own affairs and care.
14. After reasonable investigation Petitioner has detennined that the Alleged
Incapacitated Person has the following next of kin and interested parties in addition to Petitioner:
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Columbia-Montour Area Agency on Aging (Attention: Annie Reilly)
702 Sawmill Road (Suite 201)
Bloomsburg, P A 17815
.
Chester L. Valencik, Jr. (son), individually and as Power of Attorney and
Linda D. Valencik (daughter-in-law), individually and as Substitute Power Of
Attorney
5108 Inverness Drive
Mechanicsburg, P A 17050
.
Chester L. Valencik, Jr., as Trustee of
The Valencik Family Irrevocable Trust dated August 4, 2005
5108 Inverness Drive
Mechanicsburg, P A 17050
Shelly Valencik Capozzi (granddaughter) and family
1655 South Holly Pike
Carlisle, P A 17013
.
15. The Alleged Incapacitated Person reqUIres protective relief pending the
appointment of a Permanent Guardian or the determination of whether Petitioner is authorized to
.
act as her substitute or successor Durable Power of Attorney in order to assure her health and
safety and to preserve her assets and interest from any waste or conversion by her son, Chester L.
Valencik, Jr., and to preclude and restrain Chester L. Valencik, Jr., her son, from: exercising any
.
authority over her, her assets, and her interests that have been transferred into the Valencik
Family Irrevocable Trust dated August 4, 2005, of which her son is the Trustee, including any
.
authority pursuant to any prior Durable Power of Attorney or other appointment given prior to
the date of this Petition. Such relief is required until the Court has appointed a Permanent
Guardian or determined that Petitioner is authorized to act on behalf of the Alleged Incapacitated
.
Person as her substitute or successor Durable Power of Attorney under appointments made after
February 20, 2003, copies of which are not yet in the possession of Petitioner or of the Alleged
Incapacitated Person.
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16. Chester L. Valencik, Jr. is the son of the Alleged Incapacitated Person and
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was born on November 24, 1949. Chester L. Valencik, Jr., is currently married to Linda D.
Valencik, a licensed phannacist; and, they reside at 5108 Inverness Drive, Mechanicsburg,
Cumberland County, Pennsylvania 17050.
.
17.
Chester L. Valencik, Jr., is the father of Petitioner and of Petitioner's married
sister, Shelly Valencik Capozzi, and is divorced from their mother.
.
18. Linda D. Valencik is not the mother of Petitioner or his sister and has no
children by Chester L. Valencik, Jr.
19. Shelly Valencik Capozzi is the granddaughter of the Alleged Incapacitated
.
Person and the mother of great grandchildren of the Alleged Incapacitated Person. She resides at
1655 South Holly Pike, Carlisle, Cumberland County, Pennsylvania 17013.
20. The situs of the Valencik Family Irrevocable Trust, on information and belief,
.
is Columbia County, Pennsylvania, since property of the Trust is located in Columbia County
and the Settlor's principal residence is in Columbia County. Petitioner has sought a copy of the
.
Trust from counsel for the Trustee who was involved in the transfer of property into the Trust in
2004, but has not been provided with such copy to date. There is no copy of the Trust in the
books and records currently at the residence of the Alleged Incapacitated Person.
.
21.
The Alleged Incapacitated Person previously appointed her son, Chester
L.Valencik, Jr., as her alternate Durable Power of Attorney on February 20, 2003. A copy of
such appointment is attached as Exhibit A. The Alleged Incapacitated Person also appointed her
.
son, Chester L. Valencik, Jr., as her Power of Attorney on August 4,2005, in a document on file
with AF&L Insurance Company (Telephone: 800-659-9206), with which the Alleged
I
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i.
Incapacitated Person has Home Health Care insurance (Policy Plan HHC-4, Policy Number
14
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132688), purchased in July 2004, which document also appoints Linda D. Valencik as a
Substitute Power of Attorney in the event Chester L. Valencik, Jr., is unable or unwilling to
serve, and which appoints Petitioner as successor or substitute agent when Chester L. Valencik,
Jr. and Linda D. Valencik are unable or unwilling to serve. Petitioner has recently received a
copy of the AF&L document from the Company; however, prior to that there was no copy of it
in the papers of the Alleged Incapacitated Person located at 73 Lick Run Road, Catawissa,
Pennsylvania. A copy of the AF &L document is attached as Exhibit A-I.
22. The Durable Power of Attorney in Exhibit A was prepared and executed as
part of an estate planning effort by the Alleged Incapacitated Person and her husband, Chester L.
Valencik, Sr., now deceased, that included other related documents executed that same day and
related insurance and annuity provisions, which documents were prepared on their behalf by
Todd Garry, CA, CEP, of the Patriot Group, 985 Old Eagle School Road (Suite 510), Wayne, PA
19087 (Telephone: 888-339-6147); Barry O. Bohmueller, Esquire, 900 East Eighth Avenue
(Suite 300), King of Prussia, PA 19406 (Telephone: 610-337-0387); and, Beatrice E. Reiber,
PNC Insurance, 50 West Main Street, Bloomsburg, PA 17815 (Telephone: 570-387-4502).
23. After the death of Chester L. Valencik, Sr. on May 5, 2004, the Alleged
Incapacitated Person was the Trustee of the Chester L. Valencik, Sr. and Betty R. Valencik
Revocable Living Trust dated February 20, 2003, which held title to various assets of the
Alleged Incapacitated Person, including her residence at 73 Lick Run Road, Catawissa,
Columbia County, P A, with the farm acres attached and the contents therein.
24. After the death of Chester L. Valencik, Sr. on May 5, 2004, the Alleged
Incapacitated Person transferred her "trust interests" in a METLIFE insurance policy, valued at
$958.77, to joint ownership with her son, Chester L. Valencik, Jr. on July 30,2004.
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25. After the death of Chester L. Valencik, Sr. on May 5, 2004, her son, Chester
L. Valencik, Jr., signed checks for withdrawals from the PNC bank account in the name of the
Valencik Family Living Trust, of which his mother, Betty R. Valencik, was the surviving
Trustee.
26. On December 6, 2004, a check for $3,000 made payable to Chester L.
Valencik, Jr., was cashed against the PNC bank account in the name of the Valencik Family
Living Trust, with a caption of "Christmas" but not entered in the check register that the Alleged
Incapacitated Person kept for that account. A copy of such check and of the related register
pages is attached as Exhibit B.
27. The Alleged Incapacitated Person, as Trustee, signed a Deed on August 4,
2005 that transferred title to the property at 73 Lick Run Road, Catawissa, PA (parcel No. 20,07-
028-00,000) to Chester L. Valencik, Jr., as Trustee for the Valencik Family Irrevocable Trust
dated August 4, 2005, which Deed is of record with the Columbia County Recorder of Deeds;
however, no copy of the identified Irrevocable Trust is currently of record with either the
Columbia County Recorder of Deeds or the Pennsylvania Department of Revenue. . A copy of
such Irrevocable Trust was requested from Chester L. Valencik, Jr., by letter of December 11,
2007; however, no copy has been received. A copy of the form of Deed available on the
electronic record service for the Columbia County Recorder of Deeds is attached as Exhibit C.
28. There are no documents at the home of the Alleged Incapacitated Person at 73
Lick Run Road, Catawissa, Columbia County, Pennsylvania, that indicate that the Alleged
Incapacitated Person, while Trustee of the Chester L. Valencik, Sr. and Betty R. Valencik
Revocable Living Trust Agreement dated February 20, 2003, signed any written notices after
May 5, 2004 concerning any withdrawal of property from or amendment or revocation of that
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Trust pursuant to the tenns of that Trust; and, on that basis, Petitioner believes that Trust to be
continuing and that, if the Alleged Incapacitated Person is found to be incapacitated, Petitioner is
the Joint Successor Trustee of such Trust jointly with Chester L. Valencik, Jr., as to all property
that remains in that Trust, including the contents of the family home at 73 Lick Run Road,
Catawissa, Columbia County, Pennsylvania and all bank accounts in the name of the Trust, as
well as the Settlors' reserved rights during their lifetime to the full possession and management
of that residence free of rent, and the automobile titled in the name of Chester L. Valencik, Sr.
29. Pursuant to Section 2.05 (Residence) of the Chester L. Valencik Sr. and Betty
R. Valencik Revocable Living Trust Agreement dated February 20, 2003, the Alleged
Incapacitated Person, as one of the Settlors, "shall have possession of and full management of
the residence and shall have the right to occupy it free of rent." A copy of the documentation of
such Trust is attached as Exhibit G and incorporated by reference. Petitioner is named in Exhibit
G, at Section 9.01 (Trustees) as a Joint Successor Trustee of the Trust. .
30. On June 23, 2004, after the death of her husband on May 5, 2004, the Alleged
Incapacitated Person signed an application for Life Insurance benefits with Columbus Life
Insurance Company that indicated that it would replace the Life Insurance benefits that she and
her husband had put in place as part of their estate planning efforts and named her son, Chester
L. Valencik, Jr., as the sole beneficiary, with his current wife, Linda Valencik, as contingent
beneficiary. A copy of the Columbus Life Insurance Company application and policy materials
is attached as Exhibit D.
31. The documents in Exhibit D identify the Life Insurance Policy being replaced
as one from Glenbrook Life, P.O. Box 94042, Palatine, Illinois 60094 (Telephone: 800-755-
5275). There is no copy of the Glenbrook Life Insurance Policy is the estate planning materials
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currently at the residence of the Alleged Incapacitated Person. The Glenbrook Life Insurance
Company has confIrmed to Petitioner's counsel that a copy of the policy is currently in their
records and can be provided if authorized by the Alleged Incapacitated Person, the Court or by
the Alleged Incapacitated Person's authorized Power of Attorney.
32. During the estate planning efforts by Chester L. Valencik, Sr. and the Alleged
Incapacitated Person, Petitioner and his sister, Shelly Valencik Capozzi, were advised by their
grandparents that the Life Insurance provisions of the estate planning included support for the
college education of Petitioner's children.
33. Shelly Valencik Capozzi and her husband, Louis J. Capozzi, Jr., have advised
Petitioner that they recall seeing documents that were part of estate planning efforts of Chester L.
Valencik, Sr. and the Alleged Incapacitated Person thf!.t expressly provided funds for the
education of Petitioner's children.
34. The materials now located at the residence of the Alleged Incapacitated
Person concerning the estate planning efforts do not include any documentation, including the
materials for the Special Directives attached to the Living Trust documents or insurance policy
documents, that mentionsany efforts by Chester L. Valencik, Sr. or Betty R. Valencik to make
provisions for the college education of the children of Petitioner. The materials also do not
include attachments identifying the beneficiaries of the Trust. Information was requested from
Barry O. Bohmueller, Esquire, on December 12, 2007, to determine whether the materials in the
possession of the Alleged Incapacitated Person are complete; however, no response has been
received to date. Petitioner has been unable to verify to date whether any of the materials
originally provided to the Alleged Incapacitated Person by her estate planners have been changed
or deleted.
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Pennsylvania. The Alleged Incapacitated Person arrived with $5.00 in her wallet along with her
Medicare and some other insurance cards. On December 7,2007, Chester L. Valencik, Jr. also
advised AF&L Insurance Company, which previously had issued a Home Health Care insurance
policy for the Alleged Incapacitated Person, that Rhonda Kahle was then the caregiver for the
Alleged Incapacitated Person; however, he did not request or receive permission from Rhonda
Kahle to do so or advise her of this designation on December 7, 2007.
37. When Chester L. Valencik, Jr. brought the Alleged Incapacitated Person to 73
Lick Run Road, Catawissa, Pennsylvania, on December 7,2007, to be cared for by Petitioner and
Rhonda Kahle, Chester L. Valencik, Jr. knew that Petitioner and Rhonda Kahle's automobile did
not have a working heater and that, therefore, it could not be used to transport the Alleged
Incapacitated Person until the heater was fixed or the car replaced. Chester L. Valencik, Jr. did
not make arrangements at that time to traI\sport from his home in Mechanicsburg the automobile
that was still titled in the name of Chester L. Valencik, Sr., for use to transport the Alleged
Incapacitated Person and has let the insurance on that vehicle lapse. Petitioner has since
obtained a newer vehicle with a working heater that is suitable to transport the Alleged
Incapacitated Person.
38. When Petitioner called Linda D. Valencik to obtain information about the
health and medication of the Alleged Incapacitated Person, she provided information only about
the medications prescribed and refused to give any information about the conditions for which
they were prescribed, whether there was other insurance coverage and any policy numbers.
39. Chester L. Valencik, Jr., has not brought the rest of his mother's things,
including her additional changes of clothing, from his home in Mechanicsburg, Pennsylvania to
her current residence at 73 Lick Run Road, Catawissa, Columbia County, Pennsylvania, to date.
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40. On December 7, 2007, Petitioner was living at 73 Lick Run Road, Catawissa,
Pennsylvania, while recovering from a work-related accident for which he is seeking
compensation.
41. Since December 7, 2007, Petitioner has been the primary caregiver for the
Alleged Incapacitated Person and has made arrangements for her to receive home health
services, protective services from the Columbia-Montour Area Agency on Aging, for her
evaluation and ongoing care by her family physician, Dr. Dennis M. Sheehe, M.D., and for a full
neurological and psychiatric evaluation at Geisinger Health Center in Danville scheduled for
January 8, 2008, for the review, establishment and security of her personal bank accounts at
Union Bank and PNC Bank in Bloomsburg (including her receipt of annuity and Social Security
income through those accounts), and for the protection of her interests through this Petition.
Chester L. Valencik, Jr. has not made any inquiry of Petitioner or of Rhonda Kahle about the
health or welfare of the Alleged Incapacitated Person since December 7,2007, but has called the
Alleged Incapacitated Person by phone.
42. Chester L. Valencik, Jr. physically abused Petitioner's mother, his sister and
Petitioner (who were then minors), while the family was living in New Cumberland, Cumberland
County, Pennsylvania in the 1980's, which abuse resulted in the divorce of Petitioner's parents
and intervention by the New Cumberland Police Department.
43. Chester L. Valencik, Jr.. has not been employed for the last 15 years and has
no personal means of support other than a rental property he owns in Harrisburg, Pennsylvania
and his wife; although, he has an inactive Pennsylvania license as vehicle salesperson and was
formerly employed in that capacity by Spankey's Auto Sales, Inc. in Mechanicsburg,
Pennsylvania.
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44. Chester L. Valencik, Jr. was convicted of drunk driving in 1994 and 2001 and
incarcerated for the offenses in 2001.
45. Chester L. Valencik, Jr. has thrown the Alleged Incapacitated Person to the
ground on at least one occasion when he was angry at her while she was staying at his home in
Mechanicsburg because her rocking chair was touching the blinds.
46. While the Alleged Incapacitated Person was staying with Chester L. Valencik,
Jr. at his home in Mechanicsburg, Pennsylvania, she repeatedly expressed the desire to return to
live at her home at 73 Lick Run Road, Catawissa, Columbia County, Pennsylvania; however,
Chester L. Valencik, Jr. made no effort to find a way for his mother to live safety at her home as
she desired but instead has repeatedly threatened to put her in a nursing home instead.
47. The Alleged Incapacitated Person has expressed her desire and intent to live
out her days in her home at 73 Lick Run Road, Catawissa, Columbia County, Pennsylvania, to
her treating physician, Dr. Dennis M. Sheehe, M.D.
48. While the Alleged Incapacitated Person was staying at the home of Chester L.
Valencik, Jr. and Linda D. Valencik in Mechanicsburg, Cumberland County, Pennsylvania,
Linda D. Valencik and the Alleged Incapacitated Person frequently argued and yelled at each
other.
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49. Petitioner requested Protective Services assistance from the Columbia-
Montour Area Agency on Aging to prevent Chester L. Valencik, Jr. from abusing, mistreating, or
misappropriating the funds of the Alleged Incapacitated Person, including threats to put her in a
nursing home unless she signed an acknowledgement that all of the [mancial transactions he
made with respect to her funds and interests had been authorized by her.
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50. The Colombia-Montour Area Agency on Aging has interviewed the Alleged
Incapacitated Person and assessed her needs and has been in contact with Chester L. Valencik,
Jr. The Agency's case manager assigned for this matter is Annie Reilly.
51. Chester L. Valencik, Jr. has threatened to evict Petitioner from 73 Lick Run
Road, Catawissa, Pennsylvania unless Petitioner ceases efforts to remove Chester L. Valencik,
Jr. as the Trustee and Power of Attorney with respect to the interests of the Alleged Incapacitated
Person.
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52. Chester L. Valencik, Jr. has been making repeated telephone calls to his
mother in which he has been accusing Petitioner and other family members of not acting in her
best interest and of seeking to steal her funds and home.
53. Both Petitioner and Chester L. Valencik, Jr. advised the Columbia-Montour
Area Agency on Aging Protective Services staff that they have no objection to the appointment
of an Independent Guardian for the Estate of Betty R. Valencik, the Alleged Incapacitated
Person.
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54. Petitioner believes and avers that the following steps were taken in order to
find a less restrictive alternative to Guardianship: (a) review of a telephone message from
Chester L. Valencik, Jr. to Petitioner in which he advised that he would voluntarily vacate his
positions as Durable Power of Attorney and Trustee and permit Petitioner to serve as the Power
of Attorney for the Alleged Incapacitated Person and later confirmation by Chester L. Valencik,
Jr. that he would continue to seek to exercise those positions; (b) discussions with AF&L
Insurance Company about the existence of a later Durable Power of Attorney that listed
Petitioner as an alternative Durable Power of Attorney for the Alleged Incapacitated Person and
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request for a copy of same; and (c) requesting the Columbia-Montour Area Agency on Aging to
assess the needs of the Alleged Incapacitated Person.
55. The best interest and welfare of the Alleged Incapacitated Person will be
served by granting Guardianship because of the facts set forth in this Petition.
56. Petitioner consulted with the Columbia-Montour Area Agency on Aging to
identify area resources for guardianship services for the Alleged Incapacitated Person's
Guardianship; and, they recommended Deborah L. Berrigan, President of ElderCare Solutions,
Inc., P.O. Box 755, Williamsport, Lycoming County, Pennsylvania 17703 (Telephone: 570-326-
6565), a Registered Guardian by the National Guardianship Foundation.
57. ElderCare Solutions, Inc. is a 501(c)(3) nonprofit organization that has
liability insurance coverage. Additional information on ElderCare Solutions, Inc. is attached as
Exhibit E. Petitioner and his sister support the appointment of ElderCare Solutions, Inc. as
Guardian Ad Litem and Permanent Guardian for the Estate of the Alleged Incapacitated Person.
58. ElderCare Solutions, Inc. is willing to act as Permanent Guardian for the
Estate of the Alleged Incapacitated Person, including as substitute Trustee for the Valencik
Family Irrevocable Trust dated August 4, 2005. A copy of their Consent is attached to this
Petition.
59. Petitioner is willing to act as Permanent Guardian of the Person of the Alleged
Incapacitated Person to the extent required if he is not determined to currently have authority as
her successor or substitute Durable Power of Attorney under appointments possibly made after
February 20,2003. A copy of Petitioner's Consent is attached to this Petition.
60. The Alleged Incapacitated Person has assets, including those that may be part
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of the Valencik Family Irrevocable Trusts dated August 4, 2005, including the Columbus Life
Insurance Policy with cash surrender and advancements provisions, an AF&L Insurance Policy,
Plan HHC-4 (Home Health), an annuity with Allianz Life Insurance Company ($600/month
income), Social Security Income, and funds and IRA's on deposit at Union Bank and PNC Bank
in Bloomsburg, the antiques, including the cherry wood furniture, in the house at 73 Lick Run
Road, Catawissa, Columbia County, Pennsylvania; and, the token rental from the farm acreage
attached to 73 Lick Run Road, Catawissa, Columbia County, Pennsylvania, from its farming use
by neighbors. An inventory of the known assets of the alleged incapacitated person, including
estimates as to the values thereof and the net income of the alleged incapacitated person from all
sources is attached hereto and incorporated by reference as Exhibit INVENTORY. Petitioner is
presently without sufficient information about the assets of the Valencik Family Irrevocable
Trust dated August 4,2005 and the interests of the Alleged Incapacitated Person in those assets.
61. The appointment of a Permanent Guardians for the Alleged Incapacitated
Person is necessary: (a) to assure the health, safety, and solvency of the Alleged Incapacitated
Person, including protecting her interests against any waste or conversion, harassment or abuse
by her son, individually, as Power of Attorney or as Trustee; (b) to determine whether any of her
property has been improperly diverted or converted by her son, individually, as Power of
Attorney, or as Trustee, from the intent of her and her husband, as SettIors, of the family trust,
and, if so, to regain her interests; (c) to obtain an accounting and documentation of the
transactions involving the family trust property since the death of her husband in 2004 during the
period when her son exercised influence over her affairs as her Power of Attorney and the
Trustee for the family trust, including obtaining a copy of all documents related to the creation of
the Irrevocable Trust dated August 4, 2005 and the replacement of the prior Life Insurance that
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was part of the Settlors' original estate plan; (d) to eliminate and void all authority under any
prior Power of Attorney given by the Alleged Incapacitated Person to Chester L. Valencik, Jr.;
and, (e) to maintain the Alleged Incapacitated Person's interests in her and Trust property and
her rights to occupy her home at 73 Lick Run Road, Catawissa, Pennsylvania pending the
determination by the Court of whether Petitioner shall be declared to be the substitute or
successor Durable Power of Attorney for the Alleged Incapacitated Person and whether
ElderCare. Solutions, Inc., as Permanent Guardian of the Estate of the Alleged Incapacitated
Person shall be declared the substitute Trustee for the Valencik Family Irrevocable Trust dated
August 4,2005.
62. In addition to the appointment of a Guardian, injunctive relief is also required
against Chester L. Valencik, Jr., individually and as Trustee of the Valencik Family Irrevocable
Trust dated August 4,2005, to preclude and restrain him from exercising such authority to evict
Petitioner or the Alleged Incapacitated Person from the quiet enjoyment and use of the Trust
Property at 73 Lick Run Road, Catawissa, Pennsylvania, and from otherwise harassing Petitioner
or the Alleged Incapacitated Person during their residence at that property.
63. In order for the Alleged Incapacitated Person to continue to live at her home at
73 Lick Run Road, Catawissa, Columbia County, Pennsylvania, some improvements are
required to the premises so that she does not have to climb steps to use the bathroom, including
putting in a bathroom on the fIrst floor and modifying some space on the fIrst floor for her use as
a bedroom and updating the coal stove heating system.
64. The Alleged Incapacitated Person has sufficient personal funds, including
funds from the cash value or advancement provisions of her Life Insurance, to pay for such
improvements; however, these improvements may also require the consent of the Trustee
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holding title to the property and a declaration as to validity of and the Alleged Incapacitated
Person's rights under the Valencik Family Irrevocable Trust dated August 4,2005.
65. After her return to 73 Lick Run Road, Catawissa, Columbia County,
Pennsylvania, the Alleged Incapacitated Person expressed the desire to revoke all prior
appointments of Chester L. Valencik, Jr. as her Power of Attorney and a concern that he had
taken some of her funds; and, she signed a revocation on December 11, 2007. A copy of this
document is attached as Exhibit H.
66. On December 11, 2007, the Alleged Incapacitated Person also signed a
document appointing Petitioner as her Health Care Agent. A copy of this document is attached
as Exhibit 1.
67. On December 20, 2007, Chester L. Valencik, Jr. and his wife, Linda D.
Valencik, came to 73 Lick Run Road, Catawissa, Columbia County, Pennsylvania and expressed
their intent to take the Alleged Incapacitated Person and to get her evaluated for competency,
claiming that his Durable Power of Attorney was still valid and that the Alleged Incapacitated
Person was not competent. The Locust Township Police and the Columbia-Montour Area
Agency on Aging were called and provided with copies of a revocation of the said Durable
Power of Attorney and of Petitioner's appointment as her health care agent that had been signed
by the Alleged Incapacitated Person on December 11, 2007; and, discussed the incident with
Petitioner's counsel by phone. The Alleged Incapacitated Person did not wish to go with Chester
L. Valencik, Jr. or his wife at that time. The Alleged Incapacitated Person was not taken into the
custody of Chester L. Valencik, Jr. and his wife, but was taken by Petitioner for a physical
examination and mental evaluation by her family physician, Dr. Dennis M. Sheehe, M.D., in
Catawissa, which was arranged by the Columbia-Montour Area Agency on Aging. By
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correspondence of December 13,2007, Dr. Sheehe previously had been requested by Petitioner's
counsel to schedule an appointment for the examination and evaluation of the Alleged
Incapacitated Person, but had indicated to Petitioner that no appointment was available until the
following month.
68. On December 21,2007, while Petitioner was out Christmas shopping and the
Alleged Incapacitated Person was being cared from by a visiting nurse, an intruder claiming to
be "an attorney from Harrisburg" who wanted to talk to the Alleged Incapacitated Person, but
who refused to otherwise identify himself, sought to enter the house at 73 Lick Run Road,
Catawissa, Pennsylvania, over the objections of the nurse and the Alleged Incapacitated Person.
This intruder challenged the rights of the nurse and the Alleged Incapacitated Person to refuse
him entry and pushed the door open with his arm, but retreated when confronted by Petitioner's
dog, stating that he would return later that day at 2:00 p.m. Petitioner reported the incident to the
Locust Township Police and to the Columbia-Montour Area Agency on Aging. The Locust
Township Police came to the house. The intruder did not return at 2:00 p.m. or otherwise later
that day; and, Petitioner has received no further contact from the intruder or anyone representing
the intruder. The nurse advised Petitioner that, because of this intruder incident, she was
unwilling to provide further services at the house; however, the nurse since has returned to care
for the Alleged Incapacitated Person. Petitioner has not received any report from the Locust
Township Police with respect to this incident to date.
69. Neither Petitioner's attorney, nor Petitioner's sister's husband, Louis J.
Capozzi, Jr., who is an attorney, nor any other member of Mr. Capozzi's Law Finn, which is
located in Harrisburg, Pennsylvania, were in Catawissa or at 73 Lick Run Road in Catawissa on
December 21, 2007.
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70. Chester L. Valencik, Jr. was represented by Edward P. Seeber, Esquire, of
JAMES, SMITH, DIETTERICK AND CONNELLY, LLP, P.O. BOX 650, Hershey, Dauphin
County, PA 17033, in the transaction transferring the family trust property into the Valencik
Family Irrevocable Trust dated August 4, 2005. Petitioner does not currently know whether
Chester L. Valencik, Jr., is presently represented by an attorney or whether such attorney is
"from Harrisburg" or was present in Catawissa on December 21, 2007.
71. On information and belief, Chester L. Valencik, Jr. is no longer fit, willing or
able to serve as the Durable Power of Attorney for the Alleged Incapacitated Person in the best
interest of the Alleged Incapacitated Person as required by 20 Pa. C.S.A. 9 5601(e); and,
Petitioner is currently without sufficient information concerning whether the Alleged
Incapacitated Person has previously appointed Petitioner as her substitute Power of Attorney to
exercise such authority on her behalf, as suggested to him by the representatives of AF&L
Insurance Company.
72. On information and belief, Linda D. Valencik is not willing to act as the
Durable Power of Attorney for the Alleged Incapacitated Person in place of her husband.
73. On information and belief, Chester L. Valencik, Jr. has not kept a full and
accurate record of all actions, receipts and disbursements on behalf of the Alleged Incapacitated
Person taken as her Power of Attorney since February 20,2003 as required by 20 Pa. C.S.A. 9
5601(e)(4) or as Trustee for the Valencik Family Irrevocable Trust dated August 4,2005.
74. On information and belief, Chester L. Valencik, Jr. has breached his fiduciary
obligations to the Alleged Incapacitated Person, as her Power of Attorney and as Trustee, by
exercising undue influence over her to transfer property of the Valencik Family Living
[revocable] Trust dated February 20, 2003 into the Valencik Family Irrevocable Trust dated
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August 4, 2005; to convert the p,lans for the disposition of the Life Insurance from those intended
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by the Alleged Incapacitated Person and her husband for the benefit of Petitioner's children to
benefit instead Chester L. Valencik, Jr. and his wife, thereby effectively disinheriting his own
grandchildren and redirecting the estate planning intent of the original Settlors for the benefit of
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their great grandchildren to himself; and, by failing to administer her assets and resources and
those of the Trust in her best interests, including by failing to apply her personal and the Trust's
assets to assist her to live out her years, consistent with her repeatedly expressed desire and the
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intent of the Settlors, at her home at 73 Lick Run Road, Catawissa, Columbia County,
Pennsylvania.
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75.
Chester L. Valencik, Jr. has advised Petitioner that he believes the. revocation
dated December 11, 2007 (Exhibit H) is ineffective because the Alleged Incapacitated Person
was not competent to revoke the prior Powers of Attorney on December 11, 2007.
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76.
The Alleged Incapacitated Person signed a Durable Power of Attorney for
Health Care on February 20, 2003, appointing Chester L. Valencik, Jr. as her alternate agent, a
copy of which is attached hereto as Exhibit J.
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77. The Alleged Incapacitated Person signed a Living Will (Advance Health Care
Declaration) on February 20, 2003, designating Chester L. Valencik, Jr. as her agent or
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surrogate, a copy of which is attached hereto as Exhibit K.
78. Petitioner requests the Guardian of the Person of the Alleged Incapacitated
Person be assigned the following additional powers below described:
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Making Medical and personal decisions, which would include but not be
limited to:
i.
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. iii.
medication, antibiotics, hydration, tube feeding, respirator use;
situations related to the active dying process;
hospice selections;
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IV.
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selecting or replacing the attending physician;
skilled care and acute care placement;
working with the Area Agency on Aging and other public
agencies to assure that necessary services are provided
taking any and all legal actions in cooperation with the
Guardian of the Estate of the Alleged Incapacitated Person to
assure her rights, including her rights to recoupment of any of
her property wrongly diverted or converted and her rights of
occupancy and enjoyment of the Trust property at 73 Lick Run
Road, Catawissa, Pennsylvania, with consideration of her
desire and intent to spend her last years to the extent possible
and in her best interests at her home at 73 Lick Run Road,
Catawissa, Pennsylvania.
Vlll. bringing any actions, including those seeking injunctive or
other relief, required to protect of the alleged incapacitated
person from abuse, harassment, exploitation, or criminal
activity.
IX. providing for the continuing family relationships of the Alleged
Incapacitated Person, including visits with her son,
grandchildren, great-grandchildren and others, consistent with
the wishes and best interests of the Alleged Incapacitated
Person.
Petitioner requests that the Guardian of the Estate of the Alleged Incapacitated Person be
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assigned the following additional powers below described:
Maintaining order in the [mancial affairs of the Alleged Incapacitated Person
which would include but not be limited to:
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xi.
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xiii.
xiv.
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establishing the Guardianship bank account;
marshalling the Respondents assets;
paying bills for the incapacitated person, including bills for nursing
care and services;
making bank deposits;
writing checks for expenses;
performing all other acts necessary to avoid and correct waste with
respect to the assets of the Alleged Incapacitated Person in cooperation
with the Guardian of the Person of the Alleged Incapacitated Person.
taking actions in consideration of the desire and intent of the Alleged
Incapacitated Person to spend her last years to the extent possible and
in her best interests at her home at 73 Lick Run Road, Catawissa,
Pennsylvania.
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XVII. Administering the Valencik Family Irrevocable Trust dated August 4,
2005, should such Trust be determined valid.
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Petitioner requests that the Guardian Ad Litem, if required, be assigned to work with
Petitioner and other caregivers for the Alleged Incapacitated Person to assure her best interests,
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continuing of care, and peace of mind pending the adjudication of her affairs by the Court.
79. Petitioner knows of no available less restrictive alternative to the
establishment of Permanent Guardians of the Person and Estate of the Alleged Incapacitated
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Person to protect the interests of the Alleged Incapacitated Person under the facts alleged in this
Petition.
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80.
The Proposed Guardian, ElderCare Solutions, Inc. has no interest adverse to
the Alleged Incapacitated Person, have agreed to act as Guardian of her Estate and Guardian Ad
Litem if this Court shall so appoint.
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81.
The Proposed Guardian, ElderCare Solutions, Inc., is not related to the
Alleged Incapacitated Person nor does it have an interest in the estate of same.
82. Petitioner is related to the Alleged Incapacitated Person and does have an
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interest in her estate to the extent the interests of his children may have been compromised by
prior and improper actions of her Power of Attorney or the Trustee of the family trust. Under the
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Last Will of the Alleged Incapacitated Person, executed on February 20, 2003, Petitioner is the
Executor appointed by the Alleged Incapacitated Person. A copy of the Last Will is attached as
Exhibit F and incorporated by reference. Petitioner is not aware of any later Will executed by
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the Alleged Incapacitated Person. Petitioner currently lacks sufficient information to know
whether he or his children has any interest in the property in the Valencik Family Irrevocable
Trust dated August 4,2005.
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83. If appointed by this Honorable Court, the Guardians will act in compliance
with regulations promulgated under Court Order in Pennsylvania Bulletin 931, et seq., April 19,
1975.
.
.
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86.
Since the Proposed Guardian of the Estate of the Alleged Incapacitated Person
has liability insurance coverage, there is good cause to dispense with surety requirements in this
case.
.
WHEREFORE, Petitioner respectfully requests this Honorable Court to:
.
.
(1) A ward a Citation directed to BETTY R. V ALENCIK and others as the Court sees
fit to show cause why BETTY R. V ALENCIK should not be declared an incapacitated person
and why Permanent Guardians of her Person and Estate should not be appointed;
(2) Appoint ElderCare Solutions, Inc. as Guardian Ad Litem, if needed, and
Permanent Guardian of the Estate of BETTY R. V ALENCIK and appoint Troy A. Valencik as
Permanent Guardian of the Person of BETTY R. V ALENCIK.
(3) Dispense with the requirement that the Proposed Guardians obtain a bond;
.
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33
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.
(4) Authorize compensation to the Proposed Guardian of the Estate of $100.00 per
month, to be paid from the monthly income of BETTY R. V ALENCIK;
(5) Issue an ORDER to preclude Chester L. Valencik, Jr. and Linda D. Valencik from
exercising any authority under any prior Power of Attorney or other appointment given to him by
the Alleged Incapacitated Person prior to the date of the Order until and unless otherwise
authorized by this Court and to declare such prior powers revoke, null and void;
(6) Issue an ORDER to preclude Chester L. Valencik, Jr. from exercIsmg any
authority as Trustee of the Valencik Family Irrevocable Trust dated August 4, 2005 until and
unless otherwise authorized by this Court;
(7) Award a Citation or Rule directed to Chester L. Valencik, Jr., as Trustee of the
Valencik Family Irrevocable Trust dated August 4, 2005 to Show Cause why he should not be
removed as Trustee and replaced by the Permanent Guardian of the Estate of the Alleged
Incapacitated Person; why he should not be required to produce a copy of the Valencik Family
Irrevocable Trust dated August 4, 2005 for the use and reference of the Trust's beneficiaries;
why he should not be required to provide an accounting of all his transactions as Trustee since
the creation of the Trust; and, why the Alleged Incapacitated Person should not be declared to
have a continuing life interest in the possession of and full management of the residence and
acreage at 73 Lick Run Road, Catawissa, Columbia County, Pennsylvania, including the right to
occupy it free of rent and the right to make improvements thereto to permit and support her
continued residence therein at her own expense; and,
(8) Award a Citation or Rule directed to Charles L. Valencik, Jr. and Linda D.
Valencik, as Durable Power of Attorney appointed by Betty R. Valencik, to Show Cause why
they should not be removed as her Durable Power of Attorney and replaced by Troy A. Valencik
.
.
.
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34
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or a Guardian Ad Litem, why they should not be required to produce copies of all Durable Power
.
of Attorney appointments signed by Betty R. Valencik after February 20,2003, why Chester L.
Valencik, Jr. should not be required to provide an accounting of all his transactions as Power of
Attorney for Betty R. Valencik; and, why Troy A. Valencik should not be declared and
.
substituted as the Durable Power of Attorney for Betty R. Valencik pursuant to the Power of
Attorney on file with AF&L Insurance Company or by Order of this Court; and,
(9) Issue an ORDER to preclude Chester L. Valencik, Jr., from entering onto the
.
property at 73 Lick Run Road, Catawissa, Pennsylvania, including the attached acreage and from
authorizing or directing any other person to do so and from harassing, stalking, or threatening the
.
Alleged Incapacitated Person or Petitioner untiJ and unless otherwise authorized by this Court or
the Guardian for the Alleged Incapacitated Person.
.
Respectfully submitted,
Date: January 7, 2008
~4~
.
Bruce G. Baron, Esquire
Attorney ID No.: 28090
Capozzi & Associates, P.C.
2933 North Front Street
Harrisburg, PA 17110-1250
(717) 233- 410 1 (phone)
(717) 233-4103 (fax)
BruceB@CapozziAssociates.com
Attorneys for Petitioner
.0
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IN THE COURT OF COMMON PLEAS
OF COLUMBIA AND MONTOUR COUNTIES, PENNSYLVANIA
.
INRE: ) ORPHANS' COURT DIVISION
)
BETTYR VALENCIK, ) No.
. )
AN ALLEGED ) PETITION FOR THE APPOINTMENT
INCAP ACIT A TED PERSON ) OF A PERMANENT GUARDIAN
) FOR THE PERSON AND EST A TE OF
AND ) BETTY R V ALENCIK, TO VACATE
) ALL PRIOR POWERS OF ATTORNEY
. CHESTER L. V ALENCIK, JR., ) APPOINTING CHESTER L. V ALENCIK,
INDIVIDUALLY, AND IN HIS CAPACITY ) JR. AND LINDA D. V ALENCIK, FOR AN
AS DURABLE POWER OF ATTORNEY ) ACCOUNTING BY CHESTER L.
FOR BETTY L. V ALENCIK AND IN HIS ) V ALENCIK, JR., AS POWER OF
CAPACITY AS TRUSTEE OF THE ) A TTORNEY FOR BETTY R. V ALENCIK
. V ALENCIK F AMIL Y IRREVOCABLE ) AND AS TRUSTEE OF
TRUST DA TED AUGUST 4, 2005 ) THE V ALENCIK FAMIL Y
) IRREVOCABLE TRUST DATED
AND ) AUGUST 4,2005, AND FOR OTHER
RELIEF
LINDA D. V ALENCIK, IN HER CAPACITY
. AS SUBSTITUTE DURABLE POWER OF
ATTORNEY FOR BETTY L. V ALENCIK
.
VERIFICA TION
I, Troy A. Valencik, the Petitioner, do hereby depose and state that the facts contained in
.
the foregoing Petition are true and correct to the best of my knowledge, information and belief. I
understand that false statements made herein are subject to the penalties of 18 Pa.C.S.A. Section
4094, relating to unsworn falsification to authorities.
.
Date:
Troy A. Valencik
.
36
.
.
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IN RE:
IN THE COURT Of COMMO:S FLEAS
OF COl..,UM8( A AND MONTOUR COUNTIES, PENNSYLVANIA
) ORPHANS' COURT DIVISION
)
) :'\10.
)
) rE'nYlON FOR THE APPOINTMENT
) OF A PERMANENT GUARDIA1~
) FOR l'RE PERSON AND ESTATE OF
) BE1TY R. V ALENCJI(~ TO V ACA TE
} ALL PRIOR POWERS Of ATTORNEY
) APPOINTJ~G CR~STER L. VALi:NCIK,
) JR., FOR AN ACCOUNTINC BY
) CHESTER L. VALENCIK, JR., AS
) POWER OF ATTORNEY fOR BETTY
) R. V ALENCIK AND AS TRUSTEE OF
) THE VALENCIKFA~lLY
) IRREVOCABLE TRUST DATED
) A UGl.:ST 5, 2004, AND FOR RELATED
) INJU"'CTIVE RELIEf"
BETTY R. V ALENe I K,
AN ALLEGED
INCAPACITATED PERSON
.
AND
.
CHESTER L. VALENCrK. JR..
INDIVJDUALL Y. AND IN HIS CAPACITY
AS D'...;RABLE POWER OF ATTORNEY
FOR BETTY L. VALENCIK AND IN [-j[$
CAPACITY AS TRt;STEE OF THE
VALENCIK fAMILY IRREVOCABLE
TRUST OA TED AUGUST 5,1()()4
.
CONS EN,. OF TH E PROPOSED GUARDIAN AD LITEM. GUARDIAN OF THE
.;STATE.ANO SUBSTITUTE TRt.;STEI;
.
I, D<.:b<)rah L. Bel'r1g<ln. Prc..~ident. EldcrCare St)lUlions~ Inc'J P.o. BOX 755,
Willian,spol1, P A ]7703 (Telephone: 570-326-6565), a Registered Guardian by the National
Guardian~hip Foundation: ht:rt':by certifY tnat Eldt..-rCal'c Solution!;, rnc. is wining to act as the
.
Guardian Ad Litcm. PcrmaLlcn~ Guardian ot" lhe Estate of BETrY R. VAlENCIK, and
Substitute Trll~tec of th~ Valcncik Family Irrevocable Trus~ dated Aug'..lSt 5, 2004, if the Court
shall $0 appoint me.
.
Further, I do ht:rcby certify that EldcrCure S()lutions, Inc. and Deborah L, Berrigan have
no interest lIdvcrs~ to the a.lleged tncapacit8tl:d person
.
.
Z.d
ggGG-Zl~OL9
weO':LO BOOl ~ uer
ue6pJae 48Joqao
:pa^!a:J~
B9v:LO eo va Ue('
.
i.
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The tacts and opinions <.:ontalOed herein are true and c~rrect to the best of my knowledge,
inf0n113tion and hclict:
j / if /0 ~
Date
8'd
ggll-ll~OL9
weO~:LO BOOl ~ uer
,~ ~~--
eb"o;ah L. Berrigan, Prc~jdcmt
ElderCare Solutions, Inc.
P.O. Box 755
Williamsport. P A 17703
ueflpJeS 4eJoqeo
:pa^!aOaH
89v:LO eo '170 uer
.
IN THE COURT OF COMMON PLEAS
OF COLUMBIA AND MONTOUR COUNTIES, PENNSYLVANIA
. INRE: ) ORPHANS' COURT DIVISION
)
BETTY R. VALENCIK, ) No.
)
AN ALLEGED ) PETITION FOR THE APPOINTMENT
. INCAP ACIT A TED PERSON ) OF A PERMANENT GUARDIAN
) FOR THE PERSON AND EST A TE OF
AND ) BETTY R. V ALENCIK, TO VACATE
) ALL PRIOR POWERS OF ATTORNEY
CHESTER L. V ALENCIK, JR., ) APPOINTING CHESTER L. V ALENCIK,
. INDIVIDUALLY, AND IN HIS CAPACITY ) JR. AND LINDA D. V ALENCIK, FOR AN
AS DURABLE POWER OF ATTORNEY ) ACCOUNTING BY CHESTER L.
FOR BETTY L. V ALENCIK AND IN HIS ) V ALENCIK, JR., AS POWER OF
CAPACITY AS TRUSTEE OF THE ) ATTORNEY FOR BETTY R. V ALENCIK
V ALENCIK FAMILY IRREVOCABLE ) AND AS TRUSTEE.OF
. TRUST DATED AUGUST 4, 2005 ) THE VALENCIKFAMILY
) IRREVOCABLE TRUST DATED
AND ) AUGUST 4, 2005, AND FOR OTHER
RELIEF
LINDA D. V ALENCIK, IN HER CAPACITY
AS SUBSTITUTE DURABLE POWER OF
. ATTORNEY FOR BETTY L. V ALENCIK
.
CONSENT OF THE PROPOSED GUARDIAN OF THE PERSON AND SUBSTITUTE
DURABLE POWER OF ATTORNEY
I, Troy A. Valencik, 73 Lick Run Road, Catawissa, Columbia County, Pennsylvania
(Telephone: 570-799-0208), the grandson of and current caregiver for the Alleged Incapacitated
.
Person, hereby certify that I am willing to act as the Permanent Guardian of the Person of
BETTY R. V ALENCIK, if the Court shall so appoint me.
.
Further, I do hereby certify that I have no interest adverse to the alleged incapacitated
person.
.
39
.
.
.
The facts and opinions contained herein are true and correct to the best of my knowledge,
information and belief.
Date
Troy A. Valencik
.
.
.
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40
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IN THE COURT OF COMMON PLEAS
OF COLUMBIA AND MONTOUR COUNTIES, PENNSYLVANIA
. INRE: ) ORPHANS' COURT DIVISION
)
BETTY R. V ALENCIK, ) No.
)
AN ALLEGED ) PETITION FOR THE APPOINTMENT
. INCAPACITATED PERSON ) OF A PERMANENT GUARDIAN
) FOR THE PERSON AND EST A TE OF
AND ) BETTY R. V ALENCIK, TO VACATE
) ALL PRIOR POWERS OF ATTORNEY
CHESTER L. V ALENCIK, JR., ) APPOINTING CHESTER L. V ALENCIK,
. INDIVIDUALLY, AND IN HIS CAPACITY ) JR. AND LINDA D. V ALENCIK, FOR AN
AS DURABLE POWER OF ATTORNEY ) ACCOUNTING BY CHESTER L.
FOR BETTY L. V ALENCIK AND IN HIS ) V ALENCIK, JR., AS POWER OF
CAPACITY AS TRUSTEE OF THE ) ATTORNEY FOR BETTY R. V ALENCIK
V ALENCIK F AMIL Y IRREVOCABLE ) AND AS TRUSTEE OF THE V ALENCIK
. TRUST DATED AUGUST 4, 2005 ) FANnLYIRREVOCABLETRUST
) DATED AUGUST 4,2005, AND FOR
AND ) OTHER RELIEF
)
LINDA D. V ALENCIK, IN HER CAPACITY
AS SUBSTITUTE DURABLE POWER OF
. ATTORNEY FOR BETTY L. V ALENCIK
.
ORDER OF COURT
DETERMINING INCAPACITY. APPOINTING
GUARDIANS OF THE PERSON AND ESTATE
AND NOW, this
day of
, 200_ a hearing in this
.
case having been held on
, 200_; and it appearing to the Court that
BETTY R. V ALENCIK, would be harmed by his presence at the hearing, and further fmds from
.
the record that there is clear and convincing evidence:
1. That BETTY R. V ALENCIK suffers from dementia that impairs her capacity to
receive and evaluate information effectively and to make and communicate decisions
.
41
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concerning her management of her personal affairs or to meet essential requirements
for her physical health and safety.
2. That there are insufficient supports available to assist BETTY R. V ALENCIK in
overcoming such limitations and that there exists no less restrictive mechanism for
decision making than the appointment of a Permanent Guardian of her Person and
Estate.
3. That based on the limited incapacity of BETTY R. V ALENCIK, to receive and
evaluate information effectively and to make or communicate decisions, a Guardian
of the Person and Estate is required to assure her continuing health, safety, and
solvency pending the resolution of disputes concerning actions by her Power of
Attorney and Trustee of her Family Irrevocable Trust dated August 4, 2005.
4. Her family agree that the appointment of an Independent Guardian for the Estate of
BETTY R. V ALENCIK is in her best interest and in the interest of a prompt, just and
proper resolution of the disputes concerning the management of her affairs by her
Power of Attorney and Trustee of her Family Irrevocable Trust dated August 4,2005
and consent to the appointment of ElderCare Solutions, Inc., of WiIliamsport,
Pennsylvania as the Permanent Guardian of the Estate of Betty R. Valencik.
5. BETTY R. V ALENCIK appointed her son, Chester L. Valencik, Jr. as her Durable
Power of Attorney and Health Care Agent and her daughter-in-law, Linda D.
Valencik, as Alternative Durable Power of Attorney; and, a dispute has arisen
concerning whether he has exercised that authority in her best interests and with
proper accounting as required by law and his fitness to continue in that capacity and
when Linda D. Valencik is willing to replace her husband; whether BEITY R.
.
.
.
.
.
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42
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V ALENCIK was competent to and did revoke such appointments; and, whether any
substitute or successor Power of Attorney has been appointed and is presently
authorized and willing to exercise such Power on behalf of BETTY L. V ALENCIK.
6. BETTY R. V ALENCIK signed a Deed that transferred property in her Family
Revocable Trust, of which she was the sole surviving Trustee, to the Valencik Family
Irrevocable Trust dated August 4, 2005 on that same date, of which her son, Chester
L. Valencik, Jr., is the sole Trustee, including her residence at 73 Lick Run Road,
Catawissa, Pennsylvania; however, a dispute has arisen concerning whether that
transfer was valid and continued her rights under the Family Revocable Trust to a
continuing life interest in the possession of and full management of the residence and
acreage at 73 Lick Run Road, Catawissa, Columbia County, Pennsylvania, including
the right to occupy it free of rent and the right to make improvements thereto to
permit and support her continued residence therein at her own expense; and, also
whether the Trustee should be replaced by the Permanent Guardian for the Estate of
Betty R. Valencik due to alleged breaches of fiduciary duties and undue influence by
the current Trustee.
7. The rights and person of BETTY L. V ALENCIK would be irreparably harmed if her
occupancy and enjoyment of her home at 73 Lick Run Road, Catawissa,
Pennsylvania, were interfered with pending the resolution of the legal disputes
concerning her effective Durable Power of Attorney and the validity, application and
administration of the Valencik Family Irrevocable Trust dated August 4,2005.
.
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.
.
.
.
..
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43
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NOW THEREFORE, based on the clear and convincing evidence supporting the
foregoing fmdings, it is ORDERED, ADJUDGED and DECREED that BETTY R.
V ALENCIK be and hereby is adjudged a totally incapacitated person. It is further ORDERED,
ADJUDGED and DECREED:
ElderCare Solutions, Inc., by its President, Deborah L. Berrigan, is appointed Permanent
Guardian of the Estate of BETTY R. V ALENCIK; and, shall have the authority and
responsibility to manage and use BETTY R. V ALENCIK's property for her benefit in
accordance with 20 Pa. C.S.A. S 5536(a). The Permanent Guardian for the Estate shall file a
report with the Clerk of the Court about assets, investments, receipts and disbursements, as
required by 20 Pa. C.S.A. S 5521(c) within twelve (12) months of the date of this order, and
annually thereafter. The Guardian of the Estate shall receive compensation of $100.00 per
month, which shall be paid from the income of BETTY R. V ALENCIK, plus reimbursement for
all reasonable costs, including reasonable attorney fees, required to marshal or administer the
assets of the Estate.
Troy A. Valencik is appointed Permanent Guardian of the Person of Betty R. Valencik.
The Guardian of the Person shall have full authority to consent to the general care, maintenance
and custody of BETTY R. V ALENCIK without exception. The Permanent Guardian of the
Person shall have the authority to give and withhold consent for surgical or medical treatment,
taking into account the prior advance directives executed by BETTY R. V ALENCIK. The
Permanent Guardian of the Person shall file with the Clerk of the Court a report on the medical,
social, and other relevant conditions, as required by 20 Pa. C.S.A. 9 5521(c), within twelve (12)
months of this Order, and annually thereafter. The Guardian of the Person shall serve without
compensation, but shall be entitled to reimbursement from the Estate for all reasonable costs,
.
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44
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including reasonable attorney fees, required to enforce and protect the rights of BETTY R.
V ALENCIK, including such costs related to the remaining legal issues in this matter.
All powers of attorney granted by BETTY R. V ALENCIK to Chester 1. Valencik, Jr. and
Linda D. Valencik are hereby specifically revoked and rendered null and void.
The Guardians of the Person and Estate shall assure that BETTY R. V ALENCIK receives
appropriate services and shall assist her in developing self-reliance and independence, as
appropriate.
The Guardians of the Person and Estate shall do nothing to interfere with the relationship
between BETTY R. V ALENCIK and her son, Chester 1. Valencik, Jr., or his wife; provided,
however, that this provision shall not be construed as preventing the Guardians from pursuing
any legal action to enforce or protect the rights of BETTY R. V ALENCIK vis-a.-vis her son or
any other person, including the legal actions still pending in this matter relating to accountings
by the Chester 1. Valencik, Jr., as Durable Power of Attorney and as Trustee of the Valencik
Family Irrevocable Trust dated August 4, 2005, as to the validity, construction, and application
of such Trust, and as to the removal of Chester L. Valencik, Jr. as such Trustee.
Chester 1. Valencik, Jr., along with his wife, shall have the right to visit BETTY R.
V ALENCIK upon 48 hours advance notice to the Guardian of the Person and as long as such
visits include the presence of the Guardian of the Person or his authorized representative; and,
Chester L. Valencik, Jr. shall have the unrestricted right to information about BETTY R.
V ALENCIK'S status, care, and treatment from all care givers. Chester 1. Valencik, Jr. and
Linda D. Valencik shall not enter upon the property at 73 Lick Run Road, Catawissa,
Pennsylvania, including its attached acreage, or authorize or direct any other person to do so
.
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45
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except as permitted by the terms of this Order; and, shall not harass, stalk, or threaten BETTY R.
V ALENCIK or her Guardians.
If there is a safe deposit box in the name of the incapacitated person alone or in the names
of the incapacitated person and another or others, said safe deposit box shall not be entered by
the Guardian of the Estate except in the presence of a representative of the financial institution
where the box is located or in the presence of a representative of the Orphans' Court Division.
The representative present at the time of entry shall make or cause to be made a record of the
incapacitated person's property, and said record shall be filed with the Clerk of the Orphans'
Court Division. None of the incapacitated person's property may be removed until after the
aforesaid inventory is completed.
If the safe deposit box is jointly owned, five (5) days notice of the proposed entry shall be
given to the other owners by the Guardian of the Estate.
An Inventory must be filed within days. A report by the Guardian of the
Estate shall be filed within days and annually thereafter in. a form approved by the
Orphans' Court Divisions.
No Surety Bond is required.
BETTY R. V ALENCIK, an incapacitated person, has the right to appeal this Order of
Court by filing exceptions with the Clerk of the Orphans' Court Division within twenty (20) days
of the date of this Order or to petition this Court for a hearing to review or terminate the
adjudication of incapacity and guardianship herein established.
If BETTY R. V ALENCIK was not present at the hearing on the adjudication of her
incapacity and appointment of a guardian, then Petitioner shall serve upon and read to BETTY
R. V ALENCIK the Statement of Rights attached to this Order of Court and marked as Exhibit
.
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46
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"A." Proof of Service of the Statement of Rights shall be filed by the Guardian with the Clerk of
the Orphans' Court within ten (10) days of the date of this Order.
87. The remaining issues in the matter shall be resolved by the Court after the
completion of the procedures specified below and include the following questions: (1) Whether
the Chester L. Valencik, Sr. and Betty R. Valencik Revocable Living Trust dated February 20,
2003 continues to exists; and, if so, what property is in that Trust, who are the beneficiaries of
that Trust, and who shall exercise authority as Trustee for that Trust; (2) Whether the rights of
the Settlors' of the Chester L. Valencik, Sf. and Betty R. Valencik Revocable Living Trust dated
February 20, 2003 to Pursuant to Section 2.05 (Residence) of the Valencik Family Revocable
Trust dated February 20,2003, to have possession of and full management of the residence at 73
Lick Run Road, Catawissa, Columbia County, Pennsylvania, and the right to occupy it free of
rent has been transferred to the Valencik Family Irrevocable Trust dated August 4, 2005 or
extinguished; (3) Whether the Deed transferring title to the premises at 73 Lick Run Road,
Catawissa, Columbia County, Pennsylvania, from the Chester L. Valencik, Sr. and Betty R.
Valencik Revocable Living Trust dated February 20, 2003 to the Valencik Family Irrevocable
Trust dated August 4, 2005 is valid and an authorized act of the Trustee under the Trust
Agreement dated February 20, 2003; (3) Whether Chester L. Valencik, Jr., individually or as
Durable Power of Attorney for Betty R. Valencik, exerted undue influence over her to have her
change the beneficiaries of her Life Insurance and estate plan to make him and his wife her sole
beneficiaries and to disinherit his grandchildren; (4) Whether Chester L. Valencik, Jr., has
breached his fiduciary duties to the beneficiaries of the Valencik Family Irrevocable Trust dated
August 4, 2005 and should be replaced as Trustee; and, if so, by whom; (5) Whether Chester L.
Valencik, Jr., as Durable Power of Attorney for Betty R. Valencik, has breached his fiduciary
.
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47
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duties to her with respect to his use of her funds; and, (6) Whether Chester L. Valencik, Jr., as
Trustee of the Valencik Family Irrevocable Trust dated August 4, 2005 has breached his
fiduciary duties to the beneficiaries of that Trust with respect to his use of Trust property.
Chester L. Valencik, Jr., as Trustee of the Valencik Family Irrevocable Trust dated
August 4, 2005 and individually is ORDERED and ENJOINED to take no action, until and
unless so Ordered by this Court, to interfere with the Guardians' possession of and full
management of the residence at 73 Lick Run Road, Catawissa, Columbia County, Pennsylvania,
and occupancy of that property free of rent for the benefit of BETTY R. V ALENCIK, with any
expenses arising from the maintenance of the property and from all taxes, liens, assessments, and
insurance payments to be paid by the Trust; provided, however, that any expenses arising from
improvements to the property to accommodate the needs of BETTY R. V ALENCIK shall be
paid from the assets of BETTY R. V ALENCIK or from such other resources or benefits as may
be available. The Guardians are authorized to utilize assets of BETTY R. V ALENCIK to
convert space on the fIrst floor of the residence at 73 Lick Run Road into a second bathroom and
to update the heating system for that floor as they deem appropriate for the safe and proper use of
the premises for the benefIt of BETTY R. V ALENCIK.
The Guardians of the Estate and of the Person of BETTY R. V ALENCIK are hereby
authorized to conduct discovery, including depositions, production of documents, interrogatories
and admissions of Chester L. Valencik, Jr., as Power of Attorney and Trustee of the Valencik
Family Irrevocable Trust dated August 4, 2005, to resolve any remaining issues in this matter,
which discovery shall be completed within ninety (90) days of the date on which Charles L.
Valencik, Jr. provides the Guardians with all of the documents and information Ordered below.
.
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48
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Chester L. Valencik, Jr. is hereby Ordered to provide to the Guardians the following: (a)
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within sixty (60) days of the date of this Order an accounting of all transactions as Durable
Power of Attorney for Betty R. Valencik, individually or for her as Trustee of the Chester L.
Valencik and Betty R. Valencik Revocable Living Trust dated February 20, 2003, from February
.
20, 2003 to the date of this Order; (b) within thirty (30) days of the date of this Order a copy of
all powers of attorney, including Health Care Powers of Attorney, signed after February 20, 2003
.
by Betty R. Valencik appointing Chester L. Valencik, Jr. as her power of attorney; ( c) within
thirty (30) days of the date of this Order a copy of the Valencik Family Irrevocable Trust dated
August 4, 2005, including the beneficiaries thereof and any additional agreements entered into
.
on or after August 4, 2005 relating to distributions by the Trust; (d) within thirty (30) days of the
date of this Order a copy of all competency evaluations on Betty R. Valencik in the possession or
control of Chester L. Valencik, Jr.; (e) within thirty (30) days of the date of this Order a copy of
.
all documents in the possession or control of Chester L. Valencik, Jr. concerning the
beneficiaries and tenns of the Chester L. Valencik Sr. and Betty R. Valencik Revocable Living
.
Trust dated February 20,2003; (f) within thirty (30) days of the date of this Order a copy of all
Wills and Advanced Directives for Health Care executed after February 20, 2003 by Betty R.
Valencik in the possession or control of Chester L. Valencik, Jr.; (g) within thirty (30) days of
.
the date of this Order all documents relating to the substitution of the Columbus Life Insurance
Policy for the Glenbrook Life Insurance Policy in 2004, including those relating to any changes
in the beneficiaries designated in the Glenbrook Life Insurance Policy, in the possession or
.
control of Chester L. Valencik, Jr.; (h) within sixty (60) days of the date of this Order an
accounting of all transactions of the Valencik Family Irrevocable Trust dated August 4, 2005
.
from August 4,2005 to the date of this Order; and, (i) within thirty (30) days of the date of this
,
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.
Order copies in the possession or control of Chester L. Valencik, Jr. of all written notices
provided by Betty R. Valencik after May 5, 2004 through to the date of this Order concerning
any withdrawal of property from or amendment or revocation of the Chester L. Valencik, Sr. and
Betty R. Valencik Revocable Living Trust Agreement dated February 20, 2003 or any
documents signed by Betty R. Valencik terminating that Trust.
Within thirty (30) days after the completion of the discovery authorized above by this
Order or on such. earlier date as the parties may agree, the Guardians and Chester L. Valencik,
Jr., as Trustee of the Valencik Family Irrevocable Trust dated August 4, 2005 and individually,
shall submit a Status Report to the Clerk of the Court in which they shall provide the Court with:
(a) any proposed settlement of the additional issues involved in this matter; (b) any stipulated
facts relevant to the determination of any of the additional issues involved in this matter; ( c) a
statement of any additional issues that require determination by the Court and whether the
determination of such issues requires a hearing or can be determined based on submissions by
the parties; and, (d) if a hearing is requested, the amount of time that the parties believe will- be
required for the hearing, a list of proposed witnesses and their expected testimony, and a list of
exhibits to be entered into evidence.
.
.
.
.
.
BY THE COURT:
.
J.
.
.
50
.
.
.
STATEMENT OF RIGHTS
AN ORDER HAS BEEN ENTERED BY A JUDGE OF THE COURT OF COMMON
PLEAS OF BERKS COUNTY, ORPHANS' COURT DIVISION, WHEREBY YOU HAVE
BEEN ADJUDICATED AN INCAPACITATED PERSON AND UNABLE TO CARE FOR
YOURSELF AND/OR MANAGE YOUR PERSONAL AFFIARS. YOU HAVE THE RIGHT
TO FILE EXCEPTIONS WITHIN TWENTY (20) DAYS OF THE DATE OF THE COURT'S
ORDER WITH THE ORPHANS' COURT OR THE RIGHT TO FILE AN APPEAL WITHIN
THIRTY (30) DAYS OF THE DATE OF THE COURT'S ORDER WITH THE SUPERIOR
COURT. IN THE EVENT THAT YOU FILE EXCEPTIONS AND THEY ARE DENIED OR
ARE DEEMED DENIED PURSUANT TO ORPHANS' COURT LOCAL RULE 7.1, YOU
HAVE A RIGHT TO FILE AN APPEAL TO THE SUPERIOR COURT WITHIN THIRTY (30)
DAYS OF THE DATE OF THE DENIAL OF THE EXCEPTIONS.
IN ADDITION, YOU MAY PETITION THE COURT AT ANY FUTURE TIME TO
MODIFY OR TO TERMINATE THE GUARDIANSIDP IF THERE IS A CHANGE IN YOUR
CAPACITY OR IF YOUR GUARDIAN FAILS TO PERFORM HERlHER DUTIES IN
ACCORDANCE WITH THE COURT'S ORDER.
IF YOU WISH TO APPEAL THE ORDER OR TO PETITION THE COURT TO
MODIFY OR TERMINATE THE GUARDIANSHIP, YOU ARE ENTITLED TO BE
REPRESENTED BY AN ATTORNEY, IF YOU DO NOT HAVE AN ATTORNEY, THE
COURT MAY APPOINT ONE TO REPRESENT YOU. IF YOU CANNOT AFFORD AN
ATTORNEY, THE SERVICES OF AN ATTORNEY WHOM THE COURT MAY APPOINT
FOR YOU WILL BE PROVIDED ATNO COST TO YOU.
.
.
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EXHIBIT A
.
51
.
.
IN THE COURT OF COMMON PLEAS
OF COLUMBIA AND MONTOUR COUNTIES, PENNSYLVANIA
. INRE: ) ORPHANS' COURT DIVISION
)
BETTY R. VALENCIK, ) No.
)
AN ALLEGED ) PETITION FOR THE APPOINTMENT
. INCAP ACIT A TED PERSON ) OF A PERMANENT GUARDIAN
) FOR THE PERSON AND ESTATE OF
AND ) BETTY R. V ALENCIK, TO VACATE
) ALL PRIOR POWERS OF ATTORNEY
CHESTER L. V ALENCIK, JR., ) APPOINTING CHESTER L. V ALENCIK,
. INDIVIDUALLY, AND IN HIS CAPACITY ) JR. AND LINDA D. V ALENCIK, FOR AN
AS DURABLE POWER OF ATTORNEY ) ACCOUNTING BY CHESTER L.
FOR BETTY L. V ALENCIK AND IN HIS ) V ALENCIK, JR., AS POWER OF
CAPACITY AS TRUSTEE OF THE ) ATTORNEY FOR BETTY R V ALENCIK
V ALENCIK F AMIL Y IRREVOCABLE ) AND AS TRUSTEE OF
. TRUST DATED AUGUST 4,2005 ) THE V ALENCIK FAMILY
) IRREVOCABLE TRUST DATED
AND. ) AUGUST 4,2005, AND FOR OTHER
RELIEF
LINDA D. V ALENCIK, IN HER CAPACITY
AS SUBSTITUTE DURABLE POWER OF
. A TTORNEY FOR BETTY L. V ALENCIK
.
AFFIDAVIT OF SERVICE
T,
, an adult individual residing at
.'
.
hereby verify and state as follows:
1. I am a person trained and experienced in evaluating persons with incapacities of
the type alleged in the Petition filed to the above term and number.
.
2.
On , 2008, at _ m., I personally served
a true and correct copy of the said Petition upon the alleged incapacitated person
at her residence at: 73 Lick Run Road, Catawissa, Columbia County,
Pennsylvania 17820.
.
52
.
.
.
.
.
DATE:
.
.
.
.
.
.
.
3.
At the time of service of the Petition, I left a true and correct copy of the Petition
with the alleged incapacitated person. In addition, I explained the contents and
terms of the Petition to the maximum extent possible in language and terms the
alleged incapacitated person is most likely to understand.
4.
I verify that the statements made in this Affidavit are true and correct. I
understand that false statements herein are made subject to the penalties of 18 Pa.
C.S. S 4904 relating to unsworn falsification to authorities.
53
.
ATTACHMENT - INVENTORY
.
BETTY R. V ALENCIK
Monthly Income Social Security
Annuity
Union Pension
$1,100.00 (Direct Deposited)
$ 600.00 ALLIANZ LIFE NUMBER: 70101154
$ 175.00 (Widow's Benefit)
Annual Income
$20,000 (Per information from Chester L. Valencik, Jr. given to
Petitioner however, the source of the income is not known at this
Time; possibly a pension or income from Trust)
.
Other Assets:
.
MEDICARE BENEFICIARY (A&B)
RX Coverage through Express Scripts
.
IRA $7,179.09 (PNC Bank)
IRA $1,500.81 (PNC Bank)
PNC BANK ACCOUNT $2,000
UNION BANK ACCOUNT $8,000
Insurance Assets:
.
MET LIFE
POLICY NO. 638407124MS
FULLY PAID
$1,000
SHE RECEIVES DIVIDENDS AND INCREASED FACE VALUE
AS OF 4/1/2004
FACE VALUE WAS INCREASED TO: $2319.72
.
MET LIFE POLICY WHOLE LIFE FOR $5000
.
AMERICAN INDEPENDENT INSURANCE COMPANY
PRA 1842615 (SPECIFICS UNKNOWN AT THIS TIME)
.
TRUST INTERESTS WITH MET LIFE
Transferred to HERSELF AND her son AS COOWNERS ON 7/30/2004
INVESTOR ill 806788150585
VALUE IN 6/39/3004 STATEMENT = $958.77
.
AF&L INSURANCE CO.
POLICY PLAN HHC-4 (HOME HEALTH CARE)
POLICY NO. 132688 (PAYS $150/DA Y AFTER 1 00 DAYS OF PRIV A TE PAID CARE)
56
.
.
.
COLUMBUS LIFE INS. CO.
POLICY NO. CM5011754U
BENEFICIARY IS CHESTER L. V ALENCIK, JR.
BASE AMOUNT IS $132,632
ADDITIONAL LIFE RIDER IS $132,631
PAYABLE TO AGE 100
CAN RECEIVE ADVANCE OF DEATH BENEFIT TO FINANCE
CRITICAL ILLNESS OR NF CASE = $53,052.40.
CASH SURRENDER VALUE AT AGE 90 OF $215,000+
.
.
ASSETS PLACED IN FAMILY LIVING [REVOCABLE TRUST] IN 2003:
TOTAL FMV AT TIME OF SETTLEMENT PER TAX RETURN = $63,875.46
PNC ACCOUNT NO. 9200326882 ($16,643.64)
SAME ($1.45 ACCRUED INTEREST)
PNC SAVINGS ACCOUNT 9008730332 ($20,342.90)
SAME (5.30 ACCRUED INTEREST)
73 LICK RUN ROAD
CATAWISSA, PA 17820-8716 (FMV OF $35,365.58)
TRUST ASSETS TRANSFERRED TO V ALENCIK FAMILY IRREVOCABLE TRUST:
73 LICK RUN ROAD, CATAWISSA, PA
OTHERS UNKNOWN AT THIS TIME
.
.
THE ACREAGE A TT ACHED TO 73 LICK RUN ROAD HAS BEEN LEASED TO
NEIGHBORING FARMERS FOR TOKEN RENTALS; HOWEVER, ITS CURRENT STATUS
IS UNKNOWN AT THIS TIME.
.
SINCE THE DECEASED HUSBAND OF BETTY R. V ALENCIK WAS A VETERAN,
SHE MAY ALSO BE ELIGIBLE FOR BENEFITS THROUGH THE DEPARTMENT OF
VETERAN AFFAIRS.
.
.
.
57
.
.
Valencik, Betty R (MR # 3104]40)
DOB: 11/05/1922
.
Progress Notes
Note Initiated Bv
Dennis M. Sheehe, MD
S~!Im
Signed
LHtUpd.1ll.Uur
Dennis M. Sheehe, MD
lot UI!!!I!J
12120/200711:21 AM
.
Office visit is being accomplished at the request of Bruce G. Baron.
Apparently this pacient requested that this law firm provoke Powers of
Attorney and the point new health-care agent, grandson Troy [who lives as on
the farm],
When I asked her what is going on she gave some contradictory information,
Claims to have been dumped on the farm by son
Does not want to go back to Harrisburg with him
.
Nephew Troy. wife live with me and are there all of the time
Later said grandson living with her and nephew only there at times
She has regular appointment for blood work and physical in January.
MENTAL STATUS EVALUATION:
.
Appearance: ~ithin ~orrnal limits, age-appropriate, casually dressed and
smells like fireplace smoke.
Eehavior: pleasant, fidgety and hypoactive
Speech: normal pitch, normal rate and normal vclume
Mood: sad and apathetic
Affect: blunted and flat
Thought Process: totally oriented on single goal of living on the farm
Thought Content:
Delusions: No
Haliucinations: No
Obsessions: Yes/ description living on the farm.
Homicidal: No
Suicidal: No
Sensorium: ale=t and oriented to person, does not know me
Cognitio~: impaired due to cerebrovascular disease
Insight: poor
Judgment: poor
.
.
-Jl.SSESSMENT-
.
1. Dementia. Vascular dementia + possible Alzheimer~s dementia.
2. Status post frontotem~oral subdural hemorrhage
3. St2tUS post frontal hemorrhagic cerebrovascular accident
4. Significant deficits in judgment and decision-making dating back to June
2007
5, Generalized cerebral at~ophy
6, Hypertension
Printed 12/20/0711:21 AM
Geisinger
Page 1 of6
.
.
.
.
Valencik, Betty R (MR # 3104140)
DOB: 11/05/1922
.
.
7. History of lymp~oma
8. History of BellIs pa~sy
9. Restless legs synd~ome
10. ::Jepressio:l
11. Gastroesophageal reflux
12. Hyperlipidemia
13. Not compete~t to manage fi~ancial affairs
14. Not com?etent to live independently. Needs 24-hour supervision.
15. Not co~?etent to sign release
16. Not competent to make medical decisions
- PLAN -
Current outpatie~t prescriptions:
.
SYNT~ROID 50 MCG Ort TABS, one tab by mouth daily, Disp: 3 month supply, Rfl:
3
PREVACID 30 MG PO PACK, one daily in the am, Disp: 3 month supply, Rfl: 3
CELEXA 20 MG PO TABS, 1 tab daily, Disp: 90, Rfl: 3
MIRTAZAPINE 15 MG PO TABS, at bedtime, Disp: 90, Rfl: 3
MULTI-VITAMIN PO TABS, 1 tab daily, Disp: , Rfl:
Follow up: Return for re ck in Jan as sched ou a wed am.
.
~ennis M Sheehe, ~.D.
Associate Family Medicine
Geriatrics CAQ
.
Geisinger Medical Group Catawissa
353 Main St.
Catawissa PA, 17820
570-356-2351
Vitals
'::,':BP. '::,
120/58
:';I~u!~.:
72
::':~!~~~~~)';l~::~'~.~1i:1['m;iR'e~F':;~:,,::~:
36.3 oC (97.4 OF) 16 51.256 kg (113 Ibs)
(Oral)
i+':~~:;:;:~::=l:;F -:
... ,,:LJ./lR:.,: ", :,.::,.'0.
Postmenopausal
.
Vitals Historv Recorded
ENC VITALS
:~'1~~~~~~~~~IIIIiIIi~:.f~i~i:~~fj~lf#:it~~rtf~~11i~~~if;,fRf\~~~~~~~~~~~~]~1iJ~~~~ijl~~1i;i':
Pulse 72 -CL
h.~.~~m~~~~W~m;~~~~~~!J1~~~t~~~t~~~[-I~~il~]!1!~~~~~~~~'~~~~W~l~~i~1mj;~~1~t~m~~j~~~t~1~~~~ii~~m~!~J~~-~~!~~~!lili~~~~~~1t~~~j~~~~~~
Temp 36.3 'C (97.4
.
Printed 12/20107 11:21 AM
Geisinger
Page 2 of 6
.
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.
Valencik, Betty R (MR # 3104140)
DOB: 11/05/1922
.
~JI_~~~iG~~~~~~f.~~~~~~\~~_~Stj~~~~l[ij~lit~~~~?ml[Jm!mire!~~~~~i~~;~~~~;!1~~~~~rJn~;~~Z~[f:m~~~~~~~~~\~~_~(
Sp02
.
1mQtgl
LaSllipdate: .
12120!0T1121 .
------;
.
.
.
.
Return for re ck in
as sched on a wed am.
.
Referra I
_~!te.r~!Il.~ ~r~\,!~!,!..
Self
""
Patient Instructions
Printed 12/20/07 11:21 AM
Geisinger
Page 3 of6
.
.
.
.
Valencik, Betty R (MR # 3104140)
DOB: 11105/1922
.
None
.
Problem List as of 12/20/2007
'::,:':i"r~~letI')"""" ,,' "Ci, ',"'rH:: "" ""'" :::,''l'\iQled,L:,,' :,ce"":;,,,
ROTATOR CUFF SYND NOS[726.10) 10/23/2000
:!I~.~D=~~!~~E8.:~~'~9.:~~~~i[~~!~9.L::=:=_._.. ,,"., ...._.=12?!1f~~~:==~=:::=::::~-,:~~:_..... .." '
.L 'r:~!:'J:lQ~~!:J,~C2..~!:J.~~.~~_ SI~!2_g,~~~L___.. "'" ._____'~~~~~~,_.,""..___.__..___n_.._.."
.S~C)~L~~F3.I!v1~~C?E~~.~!!~~_~~L..___'m___ .... ._~!!.~2~~~_..__. _..n_____.._m..'
ADVANCE DIRECTIVE INFORMATION[EP888] 10/27/2005
Comment: Yes, Patient instrLJcled to provide copy of advance directive for provider 10 review and to be
scanned into Eiectronic Medical Record
, ....... ,__u._____..__..... __._~.._~__~..__U_.__h___.._.__,___._._. ._. ._. ",_...__...0.._..,___. ...h..___n'__'___.. _...m._'.._...._..._.__._...__..___.__.~.....___
spinaIOSA[715.00]
_.__g<?~~~n~:.~pir1.e.~r1.~_~~~El... "
MY AL9.1~.!'-~g.~.Y_C?~I:r.lS..~().~!?~:.1J..._.._. '.n.___._______._______n'
hip ,pain~.t:~.~9_<:'I!?_~jr1.111 ~i~.~.Il~ElE~.~:~~.n'._.' '" .__..__.______mnn.
, g~!ES~F'g"'g.~.I.~..N..Q~[!.~3.'O~] ..... .____._____ ____________.______..
_g~~~!3TI~LJ~I!!~.Q!..9.Q~9.~J?~~.:.1_!L...... n', __... .__._.______ ..__.....
_!:t~!:~.'3:LIPI9.E~JI\__~C.~l?~l2!2~4L. .. 'n________._____.'.n.
.. F__t1..~:~.~!.s:~J~~F.!?L,....,_________n.__.....__.._..._.,.. __ ._n_'_' .... ....____.. __. .
..!".e.~!!,,~~.I.Elg!l}'.~~.rg.r1l.El!y~9.:~L___..... .
.gl~~_~l::l.~~:.<'!:lce W~!I<W~!.:~~L... .._.... . '" ______. "'___"__"_"'" "'__n.._
[)~~~~~~!~~~I~!'lD~~_~~~[~~!L.._,__..n__._.._ . _ ,_____.__ .._._ ._..._.___
~~_O!~y!3gl_~..!..~~_~g~J2,~~:~.._.________.____________.__.._____ ___ _______________..___.....
MEMORY LOSS[780.93] 1/19/2007
~~Al?:i_~~Vj~i5~~~ST7_8_~.-~~L_:: ~.:'.--'-----'---- . . '----------11'1912'0'07. ..,:~:,:~.--'---'------ --
CVA[436] 9/18/200i'-''''
.
.
.
Allergies as of 12/20/2007
.. ""'C"", :"., ',' ~':'I!:Ii:)re\'l";';:":":" 'rYP!1!',.-,,""
Aspirin 1/2411998
stoma.c~_:__~v.~~~it~..::Y~totec__ .,__..______._._____. .__.u __...__
Date Reviewed: 12/20(2007
J~-:eii(:t]bb':S
(Not Noted)
._,..__,.__..~.___.,_n __.__. _ _ _ ..._._~.__..__ ~'~"___"___"__._~~.._._n. h....____......____._._... .. .~. .~..h.._,._.____~_._ .._
...~~Ifa .Dr.ll9"!.________... .. .. ._.,..!L2~!!_~~~________.__......__.1~gt,.t;lo.!e~ L. '... _.______.___._.." .
Ibuprofen
,n.:S!~.r!l~~_~ramps
2/26/1998
(Not Noted)
.
Nsalds 6/10/1998 (Not Noted)
R.Ellll~1"! .:.stor1l~~h.. ~~IT1P~..~.~_e~i~~~if.1..~':!!!:~~.~~.rl.!~~~__,.__________. '.' ..... .__.._________,__...
CeJecoxib 9/22/1999 (Not Noted)
.__. ,????.7?!:Il~.~~~.!l~o.HenJjps a.~~.!o"-gLJe
Codeine
6/5/2000
(Not Noted)
nausea
.
Percocet
. .._~()rnith"!g.
... .--.--' --------6I"5i2'ooo------------------.--(Not Noted)
Printed 12/20/0711:21 AM
Geisinger
Page 4 of 6
.
.
.
.
Valencik, Betty R (MR # 3104140)
DOB: 11/05/1922
.
Vioxx
__.!!1.9L1t~ .~f1~!Ip' swell!~~_.
1 0/6/2000
(Not Noted)
f'!:..o~()nPumplnhill.l!or~
919/2004
J~~~_~ot~)__.____. _ .
.
Outpatient Meds as of ~ .2/20/2007
. ..-. '.j.. ., "':",-,,+-, .' :..;;7' ..':::,."",~..
, I~\:;~~ ,,-.
. . ',pisp'
3 month
supply
R~fi!llf" 'S'tart::'~:
3 10/17/2007
'fifd-,.. '
SYNTHROID 50 MCG OR TABS (Taking)
5ig: one tab by mouth daily
Route: Oral
." ~. .",," .~. __~__._.____._..__U.___^'d_____'
PREVACID 30 MG PO PACK (Taking)
3 month
supply
3
10/17/2007
.
5ig: one daily in the am
Route: PEG Tube
._..___."._____....___.___u.. _,_'___'. ",' __....____._.... . ._.__._ .". _.......___...__..._....
CELEXA 20 MG PO TABS (Taking) 90 3
Sig: 1 tab daily
Route: Oral
._. .~.._.___.,~_.___~.________~. "...".w.'.._...._.__. _ __.,. _"..__._.-__..__
MIRTAZAPINE 15 MG PO TABS (Taking) 90 3
5ig: at bedtime
Route: Oral
_"'_'___~_"~"___"'._'."__'___"_" .'. ....N._______
MULTI-VITAMIN PO TABS (Taking)
Sig: 1 tab daily
Class: Historical
10/17/2007
10/17/2007
.
Meds Comments as of 12/20/2007
.
,,,-, ,-.-..,"' . "-."'-""','-'"
Patient cannot verbalize medications they are on at todays visit.pt states that she takes 4pllss in the am
and 1 at bedtime.
Christine Letterman, LPN
12/20/2007
10:55 AM
George J. R~t1e RN
[88Cl]
.
Peds Hem/One Med Admin Hx:
,::,~' ,If;t<ppli~1:11e~r H'C..' ,,'
No administration data available
.. .". ._~ r.. ",,,.
';i.:-,(;'
MEMORY LOSS [780.93]
.
Nursing Notes
CHRISTINE LETTERMAN LPN Thu Dec 20, 2007 10:59 AM
pt here for eval of mental status with DS.pt states tha~ she dosen't want to
Printed 12/20/07 11 :21 AM
Geisinger
Page 5 of 6
.
.
.
I
.
Valencik, Betty R (MR # 3104140)
DOB: 11/05/1922
.
go home with her son.pt states that she wants to stay at her home.pt states
that she has family with her at home.
Reason for Visit
EVALUATION
mental status
Patient Information
.
,,-'-'-"'.-,', "CO",
..~~!1..<?,~~!~,~!tt.,'3,l~2~1..~o.)".._
73 LICK RUN RD
. ""'_~__.'._._M___".~_"~'__"U"__"'" 4_'
CATAWISSA, PA 17820
DOB 11/05/1922 Female
,.. .-. .___._.__~."'___,.__... "" '~.'.. . ____.__ .......~~~M_____.__....__..
Home Phone 570-799-0208
_____,_..____,_'. u._ ,.~..~. ...__._.__...._.. ,_._,_,_~~_... ,.".."........,.,,,...,, ....,......~.._..____...___...._~_~_._.....'.
Work Phone
Visit Information
::Oafee&Tlme" ,'~ !"p'r~~ipf;f,;,';: ,
12/20/200711 :00 AM Dennis M. Sheehe,
MD
:~~~~,lillil,: .~' .~, '::'.
Farn Prac Catawissa
"rf?~cl)t,Jflfur'#' " ; ',' ,
70801306
.
Appointment Notes
eval fDr mental statis
PCP and Practice
::::f>::t;f:'ri~llM~~'~qYJ.(j~~1:j,,~;j:1f;iii,t:.l::i;;';:~'ll1te:iit~~iR!,!~::..:~":;:;'i,.. .c'"
Dennis M Sheehe [1214] Catawissa Geis Med Grp
.,i
""-"-""',",'_:.!-;:;.;>:,,'"
","','phqpiV,:."
570-356-
2351
.
Administrative Information
',!'j;:i1~Qti~~Elf~I~~\f.i!i@,~qgl~!;iS:":1:" :i:',:;~r.~@9'f,~.~1(1&f:. ....'i,.::., ",.~.r;~lfrriqThf.if(W.'" ". , ..'.'
None SELF Medicare
. -_._-~_._-._-- .__......,..w .~. 'w _...,. ._ .~___..._.__.._.__.______._ ~__~_~____...._~___.~. k_ ~..__._~..~_,.. W'_'..,~_.~.."_._______~._, ____.
Indicator Date:
.~".,."_.,, -n
;'.,;,.;,:
.
Advance Directives
, , :::~V;~i>~.!:j!~ij~e~'i;!:;r'l!::;:i~i!~titS,,::t:.ffl!~T:'i1[@~miily",,:'*'" .,. ' '
On File? Yes On File? Yes
__~.._...h._____._._".____________...._ _ ,".,~,_..~..__~"_...___~__,,...~,...,.......,._..~_.______.
Date Asked: 12/18/07 Date Asked: 2/26/03
..
..
Level Of Service
E4 OFFICE VISIT,EST,LEVEL4 MOD [99214]
Authorizing Provider
Dennis M Sheehe [1214]
.
Encounter Information
. ", ",-,..-,... '''..
Encounter Number: 70801306
Status: Closed by SHEEHE MD, DENNIS Dn 12/20/07 at 11 :21 AM
.
Printed 12/20/07 11 :21 A1\1
Geisinger
Page 6 0[6
.
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.
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.
PART II. ATTENDING f'IIYSICIAN'S STA TEMENT
Thil section tnUR be compltled and si;.ned 'by1he pbYJidan orderit\& honae health services.
Plejen! Nome~:ffi(; 1 / C-t I ~ G . r
HospitaVSNFJReh admissi n in past 6 mont s: '
In~itUliDn City/StIle
Policy Nvmba
Date ^dmitt~d
DaleDiSChar&ed
,I
Diagnosis for hOsp\talizaliOfl or admission:
.
Past Medical histQf)' including diagnosis with dale of onset:
Has tbe p.u.icnl been lJ~lucd for and/or diagnosed w~h M)' mental/nervous conditions! Yes _ No
If yes., please suppiy fbe dtatnosis,. lC09 code and date oflhc diagnosr:s;
.
FUNCTlONA LABILITIES
Indicate the revel o{ assistance' your palrel'tt re-quires ...~ the foJlowillC 4Cliva;f:s:
}mtNmenlal Activities ofOailv livin2
No N~ed5
Assistance Assistance
o
o
o
o
o
o
TOI.t
AssiS:/
o
0/
~
~
A:ctiviLies. ofDai'~iJ)~
No N ecds Total
. 1\f~~ASSI~ace Assistance Assistance
Eahng . ~f'r(f(~ 0 0 Housekeeping
Toile.;ne iY 0./ 0 M,.l Preparalion
. Oressiog (3 !I' 0 Shopping
Balhing 0 ~ 0 Tr.nsportadon
Ambuloling i)/b....~ 0 a MDR1l&ingMedieinc.s
Transfer (i"- 0 0 'Laundl)'
BoweL'Btadder: Continent r;rj lnoonlinent b ~ fotey Catheter
Vision; Normallcorrcclcd ~ / Impaired n Blind
Ilcaring: NUfmal/Gorrccrcd cY / Impaired 0 / Oe.f
Me-ole1 Slalus: Alert &. Orienled [JI" Forgclful. ~ Conruscd.
Wb,ll equipmenr does th;s patient use'? Cane / Walker gI'.Btdsidc Commode 0
St., Lift: Chait 0 Hoyer ~ift 0
Place ~ Time 0
Imp.ired O<:casiOllolly O/'
Impaired Occasionally Il'
~
o
o
o
o
OStomy a
.
o
o
~ ~t ftfl,t-S
,;
Wheel Chair ~ J-J~jr.J Bed 0
Raised ToiSd Seat 0
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No -X-1fyes, please attach copies cf.hc diagnostic leSl results.
Family 0 C:aregive9 0
Impaired Continuously V
lmpa;red Continuously 0
HOHE HEALTII PLAN OF CARE
Certir.calionO"e IO-n-D7 To u/{t:~"rr?
Wha';'lh'1',imarydi.gno,i<ro,homeheollhcare7 f'?el?'tc<1i' L6s;c c,vll ""!>p I/I"'l.$.,...v~ Vr<:"ortIff
r .... f ,
Is this achtOl'lie condition? Yes.(1... No _ What is the lnticipateddumtion of.he: need for services? "-6C:)
Reeommended Level of C.a~;
.
Skilled services RN 0
LVN 0 PT 0
5T 0
OT 0
LPN 0
r/
HOmeRl8kcr or Compaoion 0
InrormBl Caregiver 0
Home Health Aide Dr CNA
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, Attending Pbysltlan's Cerlllitation . .
I certify that me Home Health SCrv1(;C$ 'indicated abow are medkaUy necessary and ~ IIUlthoriud by me with a 'Nrhler\ plan of cace wbkb win
periodically be reviewed. This patient U undCl my care and i$ in need of the .serviceS' spc:cifted. , give pcnnissicn [or an in-home &ucssmenl by a
horn' health pror"'iona~palient.~
Phyoid.. Sil..lu~ . j",I:.. lll_ k-- D... . i [) -1/ -6')
PhysicianN.me h /I,." ~ ~ .fJp ToxIO.
Addre...__J?6"3 (Ylvin S+-. . Telcph""e.lLl.Q>. ;tir2."SS1
Cl'Y~ 51..e f'A Zip 17&').OFaxlll!DQ) 1,g:p-)-{,lj7,
CLM-MC.Hl-lC-PC. ".
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VALENCIK,BETTY R [3104140] Page 1 of2
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Outpatient Clinic Note Id: GMC3848430
Author: SHEEHE, DENNIS M
Document text:
6/5/2007
10:23 AM
CLINIC NOTES
Geisinger Medical Group
Central Region
.
Valencik, Betty R
MR #03-10-41-40
Page 1 of 1
GEISINGER MEDICAL GRODP - CATAWISSA
FAHILY PRACTICE
NURSING HOME NOTES
06/05/2007
.
SUBJECTIVE: Betty was admitted ~o Geisinger recently with a stroke. It ended up
being an intracerebral hemorrhage.
After supportive care and multiple Physical Therapy, Occupational and Speech
Therapy evaluations, as well as a gastric tube the patient was transferred to the
nursing home for cngoing care.
.
I am not sure if she is supposed to be a full code or not at this point because of
the feeding tube and the fact that the code status in the hospital was a full code.
T will need to talk to her son.
In any event, si~ce admission her only complaint has been left heel pain.
The nurses report some apathy to her environment. Otherwise, she has not had any
specific rre~tal status issues.
She cannot move her left side.
.
She has been tolerating her feedings well, 18 hours of oontinuous feedings daily,
approximately 1,400 calories.
The patient denies chese pain, abdominal pain, shortness of
breath, nausea, headache! or other symptams.
.
EXAMINATION reveals acceptable vital signs as documented. Clear lungs. Regular
heart rhythm withcut murmur. Soft abdomen, noninfected gastrostomy site. Foley
catheter in place. No leg edema. No rashes. No signs of anemia or
jaundice. Neurologic exam reveals an apathetic but communicative elderly female
who looks her stated age, is only oriented to person. She doesn't know where she
is and she doesn't know my name even though she has known me for a long time. Her
left side doesn't move at all. She has a right facial droop.
Although there is no open area on her left heel, it is very soft and slightly
red. She has a footdrop/functional on the left. There is direct pressure of the
heel on her padded boot, which is in place securely.
.
ASSESSMO:NT:
1. Unfortunate sequelae of spontaneous right subdural hematoma with some
intraparenchymal hemorrhage.
2. Hypertension.
Printed on 12/20/2007 at 10:24:55 AM
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VALENCIK,BEITY R [3104140] Page 2 of2
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3. History of lymphoma.
4. :nability to swallow safely.
5. Gastrostomy tube.
6. High risk left heel secondary to pressure from left footdrop and basic
pressure mechanics on her heel.
7. Hyperlipidemia.
8. Past dementia, vas=ular.
9. Right Bell's palsy, whict is an old problem.
10. Restless leg syndrome.
11. Depressl.on.
12. Hypothyroidism.
13. Gastroesophageal reflux disease.
.
.
PLAN:
1. Speech, occupational and physical therapy.
2, Keep Foley in place, at least for now.
3. :ommunicate with son regarding prognosis and future aggressiveness
issues.
4. Continue feedings as ordered in the hospital.
5. Prevacid 30 mg via NG tube daily.
6. Levoxyl 50 mcg via NG tube daily.
7. Citalopram 20 mg via NG tube daily.
8. Mirtazapine 15 mg via KG tube nightly.
9. Code status needs to be established.
10. Follow chyroid studies long term.
11. Foley precauLions with ultimate decision as to whether to discontin~e
the Foley after we see how things are going.
.
Dennis M Sheehe, MD
.
DMS/ra; D: 06/05/2007 10:23 A; T: 06/05/2007 5:59 P; Doc #: 3848430 CC: Nursing
Home
Authenticated by SHEEHE, DENNIS M MD on 6/12/2007 at 9:16 AM
.
A copy was distributed on 6/12/07 to the following:
I; BLOOMSBURG HEALTH, CARE CENTER[10770]-BLOOMSBURG(Fax)
.
Printed on 12/20/2007 at 10:24:55 AM
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Valencik, Betty R (MR # 3104140)
DOB: 11105/1922
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Results
MRI.BRAIN WNVO CONTRAST [70563] (Order# 95073927) (Spec. #5319113)
Result Ittatus
Information Final result (5/2512007 5:30 AM)
.
iSlte PACS Imoo.
Collection l;llllecU.on.Pil~
Information 512312007
C!!ll.JiliOD. Tim,
5:20 PM
Transcription !YJa
Diagnostic imaging
1.0 Oalllllod TiIM
R5319113 5/2412007 1:09 PM
Author
ARIBANDI. MANOHAR
.
Authenticated by ARIBANDI, MANOHAR MD on 5/2512007 at 8:30 AM
D.oJ;.1I!:!lI!llIn1
MRI BRAIN WITH AND WITHOUT CONTRAST, MRA OF TE8 H8~.D "ITHOUT CONTRAST AND MRV OF
THE HEAD WITHOUT CONTRAST - 5123/07
HISTORY: Stroke. acute right subdural hemo:rrhage and subarachnoid hemorrhage on
the previous CT .scan done ear lier on the .same day.
.
TEc:.nUQUE: Multiplanar, multisequential images of the brain were obtdined
wit~'1out and with intravenous contrast using stt.ndard protocol. MRA of the circle
of wil11s was done without con't.rast using time-af-flight technique. MRV waa also
done without IV contrast I.:.sinq time-of-flight techniq"J.e.
?INDINGS: Comparison is made to a previous CT scan done 5/23/07 at 1226 hours.
Acute subdural hemorrhage is noted over the right frontotemporal convexity
extending 1.nto the occ1pi tal and parietal area. There io! also evidence for acute
subarachnoid hemorrhage in the right frontal lobe near the vertex corresponding to
the findings on the C'l' scan. SurrQunding this area of ~ubalachnoid hemorrhage, in
the right frontal lobe, there is evidenCli for some cytotoxic edema.
.
A separate focus of s1.i.bacute hemorrhage is noted in the riqht frontal lobe just
abovE' the sylvia.n fissure with surround:.r,g heIf\osiderin rim. The central portion
appears hyperintense on Tl and T2-weighted images. This is consistent with a
subacute herr,orrhage and appea=s hypode:lse 0:10 the CT scar:..
There is mass effect with midline sh.1.ft to the left side. Right ventricle is
slightly effaced. Ther~ is prominence of both temporal horns especially on the
lett side.
.
There is generalized cerebral atrophy. I?atchy extensi.ve T2 hyperintensity is
noted in the _hi te matter of both cerabz:al hemispheree. predominant in the
pe=iventri.cDlar regi:m which may be due to small vessel chronic ischemc changes.
Some of the hyperintensi ty in t~e right frontal lobe could be secondary to edema
frem the above-described hemorrhages.
The brainstem, sellG. turcica, other midlines, are unremarkable. On the sagittal.
post contrast images, there is .suggestion of some leptomeningl!!:l!I.l/vasc:ular
enhancement in the sulci of the right temporal lobe as well as the posterior
portior: o~ the sylvian fissure and also in the adJacent portions of the right
frontal lobe.
.
MRA OF THE CIRCLE OF WILLIS; Bilateral carotid arteries .show normal caliber and
branching pattern. No significant steno~i.s ilS noted. There is mild irregulari-::y
and sonewhat decrease~ vi~ualization of the right N:CA branches which may be
artifactual or due to vasculitis. No aneurysm i5 detected. There is bilateral
fetal origin of the posterior ce=ebral arteries. Left Pl seqment of peA is
Printed 12120/07 10:00 AM
Geisinger
Page 1 00
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Va1encik, Betty R (MR # 3104140)
DOB: 11/05/1922
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r.ypoplastic. A prominent infundibulum is noted at the origin of the left $uperior
cerebellar artery; however, please note that it is difflcult to exclude a subtle
aneurysm. Beth vertebral arteries are codominant.
MRV: The bilateral dural venou~ Binuse!!l including the superior sagittal sinus,
bilaterai. transverse sinuses, siqro-oid sinuses are patent. Deep VenOU3 system
lncluding the straight sinus, great cerebral brain, and internal cerebral veins
are patent. There lS paucity of "the cortical veins in the right frontal area and
in t.he right te1nporal area. This may be due to p::essure effect fro;n the adjacent
subdural hemorrhage or could represent sequela of recent or previou9 cortical
venous thromCosis.
.
:MPRES SION ,
1. Acute subdural hemorrhage over the riQht cerebral convexity.
"'. Acute 5ubarachnoicL hemorrhage in the right frontal lobe ~ulci near the
vertex laterally. There is cytotoxic edema and vasoqenic edema in the adjacent
portion of tbt! right frontal lobe in the cortical and white matter areas.
3. Late subacute hemorrhage in the right frontal lobe just above the anterior
portion of the sylvian fissure.
4. Mild midline shift. to the left side with slight effal':ement of th~ ri9ht
lateral ventricle. Mild prominence of the temporal horns is also noted especially
on the left side. 5. Poor visualization of the cortical veins in the rIght
frontal lobe and right temporal lobe, which I\'J.ay be secondary to either mass effect
from the subdura 1 hemorrhage or thi!l could repre sent sequela of recent or old
cortical venous thrombosis. Correlation is suggested '...ith clinical findings and
clinica.l history. 6. MAA. of the l':ircle of Willis: There is diminished caliber
and subtle irregulari ty of the right MCA branches which could be art=.factual or
could represent vasculitis. Correlation is suggested with cerebral angiography.
7. MRV: No ~vidence for thrombosis of the dural venous ~inuses. There is
paucity of the cortical veins over the right frontal and right temporal convexity
which may be due to mass effect from the subdural hemorrhage cr could represent
seque2.a of re-cent 0::: old cortical venous thrombosis. Findings were discussed with
Or. vi vino on 5/23/07 at a.pproximately 7: 00 PM.
.
.
Ql,olav transcriotiQn (R53191131 on ~.1;Q9EM..1l:l.P.RIBAND.I. MANOH.~
Status of other \lillY/ Slll.lus of Other On~el];
Orders
Order
MRI.BRAIN WIWO CONTRAST [70553) (Order# 95073927) (Spec. #5319113)
.
~e PAC.SJm~
Order o~
Information 512312007
QrarinsJ!m
TllInscriplion Interface [999971
DeI!l.!1muli
Agp5 Ip[300009]
.
Order Providers ~[i~in~
John W Randolph [1oo202J
Result SlB1U
Information Final resull (5/2512007 8:30 AM)
.
Collection ldlIJJ.ctj~
Infonnation 5/2312007
~c1ilm..Ilme
5:20 PM
Priority and
Printed 12120/07 10:00 AM
Geisinger
Page 2 00
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Valellcik, Betty R (MR # 3104140)
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Order Details
Status 06~~~~ View l;itatYe otQlber.Q(d~!lt
Encounter View Encounter
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Printed 12/20/07 10;00 AM
Geisinger
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DOB; 11/05/1922
Page 3 of3
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Recording Requested by:
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Bohmueller Law Offices
900 East Eighth Avenue, Suite 300
King of Prussia, Pennsylvania 19406
RECORD AND RETURN TO:
.
And When Recorded Mail to:
BETTY R. V ALENCIK, Principal, to CHESTER L. V ALENCIK, SR., Agent:
.
DURABLE GENERAL POWER OF ATTORNEY
NOTICE
THE PURPOSE OF THIS POWER OF ATTORNEY IS TO GIVE THE PERSON YOU DESIGNATE
. (YOUR"AGENT") BROAD POWERS TO HANDLE YOUR PROPERTY, WHICH MAY INCLUDE
POWERS TO SELL OR OTHERWISE DISPOSE OF ANY REAL OR PERSONAL PROPERTY
WITHOUT ADVANCE NOTICE TO YOU, OR APPROVAL BY YOu.
THIS POWER OF ATTORNEY DOES NOT IMPOSE A DUTY ON YOUR AGENT TO EXERCISE
GRANTED POWERS, BUT WHEN POWERS ARE EXERCISED, YOUR AGENT MUST USE DUE
. CARE TO ACT FOR YOUR BENEFIT AND IN ACCORDANCE WITH THIS POWER OF
ATTORNEY.
YOUR AGENT MAY EXERCISE THE POWERS GIVEN HERE THROUGHOUT YOUR LIFETIME,
EVEN AFTER YOU BECOME INCAPACITATED, UNLESS YOU EXPRESSLY LIMIT THE
DURATION OF THESE POWERS OR YOU REVOKE THESE POWERS OR A COURT ACTING ON
. YOUR BEHALF TERMINATES YOUR AGENT'S AUTHORITY.
YOUR AGENT MUST KEEP YOUR FUNDS SEPARATE FROM YOUR AGENT'S FUNDS.
.
A COURT CAN TAKE AWAY THE POWERS OF YOUR AGENT IF IT FINDS YOUR AGENT IS
NOT ACTING PROPERLY.
THE POWERS AND DUTIES OF AN AGENT UNDER A POWER OF ATTORNEY ARE
EXPLAINED MORE FULLY IN 20 PA.C.S. Ch. 56.
.
IF THERE IS ANYTHING ABOUT THIS FORM THAT YOU DO NOT UNDERSTAND, YOU
SHOULD CALL OUR OFFICE AND HAVE US EXPLAIN IT TO YOu.
I HAVE READ OR HAD EXPLAINED TO ME THIS NOTICE AND I UNDERSTAND ITS
CONTENTS.
.
g~..f~
BETT . V ALENCIK
4r' ~~
Date
.
EXHIBIT
DURABLE GENERAL POWER OF ATTORNEY
Page 1
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DURABLE POWER OF ATTORNEY
KNOW ALL MEN BY THESE PRESENTS, that I, BETTY R. V ALENCIK of Columbia
County, Pennsylvania, hereby revoke any general power of attorney that I have heretofore given to any
person, and by these Presents do constitute, make and appoint Chester L. Valencik, Sr., my true and
lawful agent. If Chester L. Valencik, Sr. is unable or unwilling to serve, then I appoint Chester L.
Valencik, Jr., my true and lawful agent.
Anyone dealing with the agent(s) shall incur no liability for any dealings with any designated
agent(s) in good faith reliance on the original Power of Attorney document. This provision is inserted in
this document to encourage third parties to deal with my agent(s) without the need for court proceedings.
1.
A power to "make limited gifts" shall mean that the agent may make only gifts for or on behalf of
the principal which are limited as follows:
(a) The class of permissible donees shall consist solely of the principal's spouse, issue and a
spouse of the principal's issue (including the agent if a member of any such class), or any
of them. .
(b) During each calendar year, the gifts made to any permissible donee, pursuant to such
power, shall have an aggregate value not in excess of, and shall be made in such manner
as to qualify in their entirety for, the annual exclusion from the Federal gift tax permitted
under section 2503(b) of the Internal Revenue Code of 1986 (public Law 99-514, 26
V.S.C. Section 1 et. seq.) for the principal and, if applicable, the principal's spouse.
(c) In addition to the gifts authorized by subparagraphs (i) and (ii), a gift made pursuant to
such power may be for the tuition or medical care of any permissible donee to the extent
that the gifts is excluded from the Federal gift tax under section 2503(e) of the Internal
Revenue Code of 1986 as qualified transfer.
(d) The agent may consent, pursuant to section 2513(a) of the Internal Revenue Code of
1986, to the splitting of gifts made by the principal's spouse to the principal's issue or a
spouse of the principal's issue in any amount and to the splitting of gifts made by the
principle's spouse to any other person in amounts not exceeding the aggregate annual gift
tax exclusions for both spouses under section 2503(b) of the Internal Revenue Code of
19'86.
2.
A power to "create a trust for my benefit" shall mean that the agent may execute a deed of trust,
designating one or more persons (including the agent) as original or successor trustees and
transfer to the trust any or all property owned by the principal as the agent may decide, subject to
the following conditions:
(a) The income and corpus of the trust shall either be distributable to the principal or to the
guardian of the estate, or be applied for the principal's benefit, and upon the principal's
death, any remaining balance or corpus and unexpected income of the trust shall be
distributed to the deceased principal's estate.
(b) The deed of trust may be amended or revoked at any time and from time to time, in
whole or in part, by the principal or the agent, provided that any such amendment by the
agent shall not include any provision which could not be included in the original deed.
3.
A power to "make additions to an existing trust for my benefit" shall mean that the agent, at any
time or times, may add any or all of the property owned by the principal to any trust in existence
when the power was created, provided that the terms of such trust relating to the disposition of the
income and corpus during the lifetime of the principal are the same as those set forth in
subsection (b). The agent and the trust and its beneficiaries shall be answerable as equity and
DURABLE GENERAL POWER OF ATTORNEY
Page 2
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justice may require to the extent that an addition to a trust is inconsistent with prudent estate
planning or financial management for the principal or with the known or probable intent of the
principal with respect to disposition of his estate.
A power to "claim an elective share of the estate of my deceased spouse" shall mean that the
agent may elect to take against the will conveyances of the principal's deceased spouse, disclaim
any interest in property which the principal is required to disclaim as a result of such election,
retain any property which the principal has the right to elect to retain, file petitions pertaining to
the election, including petitions to extend the time for electing and petitions for orders, decrees
and judgments in accordance with section 2211(c) and (d) (relating to determination of effect of
election; enforcement), and take all other actions which the agent deems appropriate in order to
effectuate the election: provided, however, that the election shall be made only upon the approval
of the court having jurisdiction of the principal's estate in accordance with section 2206 (relating
to right of election personal to surviving spouse) in the case of a principal who has been
adjudicated an incapacitated person, or upon the approval of the court having jurisdiction of the
deceased spouse's estate in the case of a principal who has not been adjudicated an incapacitated
person.
4.
A power to "disclaim any interest in property" shall mean that the agent may release or disclaim
any interest in property on behalf of the principal in accordance with Chapter 62 (relating to
disclaimers) or section 6103 (relating to release or disclaimer of powers or interests), provided
that any disclaimer lUlder Chapter 62 shall be in accordance with the provisions of section 6202
(relating to disclaimers by fiduciaries or agents) in the case of a principal who shall have been
adjudicated an incapacitated person at the time of the execution of the disclaimer.
5.
.
6. A Power to "renounce fiduciary positions" shall mean that the agent may:
.
(a)
(b)
renolUlce any fiduciary position to which the principal has been appointed; and
resign any fiduciary position in which the principal is then serving, and either file an
accounting with a court of competent jurisdiction or settle on receipt and release or other
informal method as the agent deems advisable.
The term "fiduciary" shall be deemed to include, without limitation, an executor,
administrator, trustee, guardian, agent or officer or director of a corporation.
7. A power to "withdraw and receive the income or corpus of a trust" shall mean that the agent
may:
.
.
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8.
(a)
demand, withdraw and receive the income or corpus of any trust over which the principal
has the power to make withdrawals;
request and receive the income or corpus of any trust with respect to which the trustee
thereof has the discretionary power to make distribution to or on behalf of the principal;
and
execute a receipt and release or similar document for the property received under
paragraphs (1) and (2).
(b)
(c)
A Power to "authorize admission to medical facility and power to authorize medical
procedures" shall mean that the agent may:
(a) apply for the admission of the principal to a medical, nursing, residential or other similar
facility, execute any consent or admission forms required by such facility which are
consistent with this paragraph, and enter into agreements for the care of the principal by
such facility or elsewhere during the lifetime or for such lesser period of time as the agent
may designate, including the retention of nurses for the principal; and
DURABLE GENERAL POWER OF ATTORNEY
Page 3
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(b) arrange for and consent to medical, therapeutical and surgical procedures for the
principal, including the administration of drugs.
A power to "engage in real property transactions" shall mean that the agent may:
(a) Acquire or dispose of real property (including the principal's residence) or any interest
therein, including, but not limited to, the power to buy or sell at public or private sale for
cash or credit or partly for each; exchange, mortgage, encumber, lease for any period of
time; give or acquire options for sales, purchases, exchanges or leases; buy at judicial sale
any property on which the principal holds a mortgage.
(b) Manage, repair, improve, maintain, restore, alter, build, protect or insure real property;
demolish structures or develop real estate or any interest in real estate.
(c) Collect rent, sale proceeds and earnings from real estate; pay, contest, protest and
compromise real estate taxes and assessments.
(d) Release in whole or in part, assign the whole or a part of, satisfy in whole or in part and
enforce any mortgage, encumbrance, lien or other claim to real property.
(e) Grant easements, dedicate real estate, partition and subdivide real estate and file plans,
applications or other documents in connection therewith.
(f) In general, exercise all powers with respect to real property that the principal could if
present.
10.
A power to "engage in tangible personal property transactions" shall mean that the agent may:
(a) Buy, sell, lease, exchange, collect, posses and take title to tangible personal property.
(b) Move, store, ship, restore, maintain, repair, improve, manage, preserve and insure
tangible personal property.
(c) In general, exercise all powers with respect to tangible personal property that the
principal could if present.
11.
A power to "engage in stock, bond and other securities transactions" shall mean that the agent
may:
(a)
(b)
(c)
Buy or sell (including short sales) at public or private sale for cash or credit or partly for
cash all types of stocks, bonds and securities; exchange, transfer, hypothecate, pledge or
otherwise dispose of any stock, bond or other security.
Collect dividends, interest and other distributions.
Vote in person or by proxy, with or without power of substitution, either discretionary,
general or otherwise, at any meeting.
Join in any merger, reorganization, voting-trust plan or other concerted action of security
holders and make payments in connection therewith. .
Hold any evidence of the ownership of any stock, bond or other security belonging to the
principal in the name of a nominee selected by the agent.
Deposit or arrange for the deposit of securities in a clearing corporation as defined in
Division 8 of Title 13 (relating to investment securities).
Receive, hold or transfer securities in book-entity form.
In general, excise all powers with respect to stocks, bonds and securities that the principal
could if present.
(d)
(e)
(f)
(g)
(h)
12.
A power to "engage in commodity and option transactions" shall mean that the agent may:
(a) Buy, sell exchange, assign, convey, settle and exercise commodities future contracts and
call and put options on stocks and stock indices traded on a regulated options exchange
and collect and receipt for all proceeds of any such transactions.
(b) Establish or continue option accounts for the principal with any securities of a futures
broker.
DURABLE GENERAL POWER OF ATTORNEY
Page 4
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(c) ill general, exercise all powers with respect to commodity and option transactions that the
principal could if present.
A power to "engage in banking and financial transactions" shall mean that the agent may:
(a) Sign checks, drafts, orders, notes, bills of exchange and other instruments ("items") or
otherwise make withdrawals from checking, savings, transactions, deposit, loan or other
accounts in the name of the principal and endorse items payable to the principal and
receive the proceeds in cash or otherwise.
(b) Open and close such accounts in the name of the principal, purchase and redeem savings
certificates, certificates of deposit or similar instruments in the name of the principal and
execute and deliver receipts for any funds withdrawn or certificates redeemed.
(c) Deposit any funds received for the principal in accounts of the principal.
(d) Do all acts regarding checking, savings, transaction, deposit, loan or other accounts,
savings, certificates, certificates of deposit or similar instruments, the same as the
principal could do if personally present.
(e) Sign any tax information or reporting form required by Federal, State or local taxing
authorities, including but not limited to, any Form W-9 or similar form.
(f) ill general, transact any business with a banking or financial institution that the principal
could if present.
14.
A power to "borrow money" shall mean that the agent may borrow money and pledge or
mortgage any properties that the principal owns as a security therefor.
15. A power to "enter safe deposit boxes" shall mean that the agent may enter any safe deposit box
in the name of the principal; add to or remove the contents of such box, open and close safe
deposit boxes in the name of the principal; however, the agent shall not deposit or keep in any
safe deposit box of the principal any property in which the agent has a personal interest.
16.
A power to "engage in insurance transactions" shall mean that the agent may:
(a) Purchase, continue, renew, convert or terminate any type of insurance (including, but not
limited to, life, accident, health, disability or liability insurance) and pay premiums and
collect benefits and proceeds under insurance policies.
(b) Exercise nonforfeiture provisions under insurance policies.
(c) ill general, exercise all powers with respect to insurance that the principal could if
present; however, the agent cannot designate himself beneficiary of a life insurance
policy unless the agent is the spouse, child, grandchild, parent, brother or sister of the
principal.
17.
A power to "engage in retirement plan transactiohs" shall mean that the agent may contribute
to, withdraw from and deposit funds in any type ofretirement plan (including, but not limited to,
any tax qualified or nonqualified pension, profit sharing, stock bonus employee savings and
retirement plan, deferred compensation plan or individual retirement account), select and change
payment options for the principal, make roll-over contributions from any retirement plan to other
retirement plans and, in general, exercise all powers with respect to retirement plans that the
principal could if present.
18.
A power to "handle interests in estates and trusts" shall mean that the agent may receive a
bequest, devise, gift or other transfer of real or personal property to the principal in the principal's
own right or as a fiduciary for another and give full receipt and acquittance therefor or a
refunding bond therefor; approve accounts of any estate, trust, partnership or other transaction in
which the principal may have an interest; and enter into any release in regard thereto.
DURABLE GENERAL POWER OF ATTORNEY
Page 5
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19.
A power to "pursue claims and litigation" shall mean that the agent may:
(a) Institute, prosecute, defend, abandon, arbitrate, compromise, settle or otherwise dispose
of, and appear for the principal in, any legal proceedings before any tribunal regarding
any claim relating to the principal or to any property interest of the principal.
(b) Collect and receipt for any claim or settlement proceeds; waive or release rights of the
principal; employ and discharge attorneys and others on such terms (including contingent
fee arrangements) as the agent deems appropriate.
(c) In general, exercise all powers with respect to claims and litigation that the principal
could if present.
20.
A power to "receive government benefits" shall mean that the agent may prepare, sign and file
any claim or application for Social Security, unemployment, military service or other government
benefits; collect and receipt for all government benefits or assistance; and, in general, exercise all
powers with respect to government benefits that the principal could if present.
21.
A power to "pursue tax matters" shall mean that the agent may:
(a) Prepare, sign, verify and file any tax return on behalf of the principal, including, but not
limited to, joint returns and declarations of estimated tax; examine and copy all the
principal's tax returns and tax records.
(b) Sign an Internal Revenue Service power of attorney forms
(c) Represent the principal before any taxing authority; protest and litigate tax assessments;
claim, sue for and collect tax refunds; waive rights and sign all documents required to
settle, pay and determine tax liabilities; sign waivers and extending the period of time for
the assessment of taxes or tax deficiencies.
(d) In general, exercise all powers with respect to tax matters that the principal could if
present.
22.
A power to "make an anatomical gift, of all or part of my body" shall mean that the agent may
arrange and consent, either before or after the death of the principal, to procedures to make an
anatomical gift in accordance with Chapter 86 (relating to anatomical gifts).
23.
Powers generally - All powers described in this section shall be exercisable with respect to any
matter in which the principal is in any way interested at the giving of the power of attorney or
thereafter and whether arising in this Commonwealth or elsewhere.
DURABLE GENERAL POWER OF ATTORNEY
Page 6
.
~ES~OF have hereunto set my hand this ~ay of
.
B~~))~
BETTY . V ALENCIK
.
The Principal is personally known to me and I believe Principal to be of sound mind.
.
J;dL 6-~
Witness
MIv~e.~
Print Name
g/~ tl-. L~
WItness
Jj/hff1/4 k/l?
7fYr4y~~
Address Y
()-//W'#~.1 /~~
City, State, Zip
Z~~~~
td$&l~~ f7fW
City, State, Zip
.
Print Name
.
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF COLUMBIA
.
BEFORE ME, THE UNDERSIGNED, A NOTARY PUBLIC WITHIN AND FOR THE
COUNTY OF COLUMBIA, COMMONWEALTH OF PENNSYL VANIA, PERSONALLY APPEARED
Betty R. Valencik KNOWN TO ME TO BE THE PERSON WHOSE NAME IS SUBSCRIBED TO THE
WITHIN INSTRUMENT, AND ACKNOWLEDGED UNDER OATH, TO MY SATISFACTION THAT
SHE IS THE MAKER OF THIS DURABLE POWER OF ATTORNEY AND EXECUTED THE SAME
FOR THE PURPOSES THEREIN CONTAINED. ~
~ WITNESS ~F. I have hereunto set my hand and official seal this J day of
~ ' .
.
.
My Crissi~})pires:
/f'f'/;;'#/
4~
Notary Public
TooD ~TARlAL SEAL
lowtl Sou . GARRy, ~ Public
-MY~~~County
. 3, 2004
.
DURABLE GENERAL POWER OF ATTORNEY
Page 7
.
.
ACKNOWLEDGMENT OF AGENT*
.
Principal: Betty R. Va1encik
73 Lick Run Road
Catawissa, Pennsylvania 17820
Agent:
Chester L. Va1encik, Sr.
73 Lick Run Road
Catawissa, Pennsylvania 17820
.
I, Chester L. Valencik, Sr., have read the attached power of attorney and am the person identified as
the agent for the principal. I hereby acknowledge that in the absence of a specific provision to the contrary in
the power of attorney or in 20 P A.C.s. when I act as agent:
I shall exercise the powers for the benefit of the principal.
I shall keep the assets of the principal separate from my assets.
.
I shall exercise reasonable caution and prudence.
I shall keep a full and accurate record of all actions, receipts and disbursements on behalf of the
principal.
.
~
Date
.
COMMONWEALTH OF PENNSYL V ANlA
.
COUNTY ,.9LUMBIA
On the day o~./1I , 20~ before me, the undersigned Notary Public,
personally appeared the above named Affiant who acknowledged before me to be the individual named above
and executed the foregoing instrument and acknowledged that he/she executed the same as his/her free act
and deed.
.
~
.
M4;;r;;S
TOOt> ~OTARIAL SEAL
Lower Soo~Y. Not~ Public
f"~~;:' r:!.WP" BUeIls County
~"'~........res M 3,2004
*In order for the Power of Attorney to be effective, this Notice must be signed and returned to Mrs. Valencik.
.
DURABLE GENERAL POWER OF ATTORNEY
.
.
Recording Requested by:
}
}
}
}
}
Bohmueller Law Offices
900 East Eighth Avenue, Suite 300
King of Prussia, Pennsylvania 19406
RECORD AND RETURN TO:
.
And When Recorded Mail to:
BETTY R. V ALENCIK, Principal, to CHESTER L. V ALENCIK, SR., Agent:
.
DURABLE GENERAL POWER OF ATTORNEY
NOTICE
.
THE PURPOSE OF TillS POWER OF ATTORNEY IS TO GIVE TIIE PERSON YOU DESIGNATE
(YOUR"AGENT") BROAD POWERS TO HANDLE YOUR PROPERTY, WHICH MAY INCLUDE
POWERS TO SELL OR OTHERWISE DISPOSE OF ANY REAL OR PERSONAL PROPERTY
WITHQUT ADVANCE NOTICE TO YOU, OR APPROVAL BY YOU.
.
THIS POWER OF ATTORNEY DOES NOT IMPOSE A DUTY ON YOUR AGENT TO EXERCISE
GRANTED POWERS, BUT WHEN POWERS ARE EXERCISED, YOUR AGENT MUST USE DUE
CARE TO ACT FOR YOUR BENEFIT AND IN ACCORDANCE WITH THIS POWER OF
ATTORNEY.
.
YOUR AGENT MAY EXERCISE THE POWERS GIVEN HERE THROUGHOUT YOUR LIFETIME,
EVEN AFTER YOU BECOME INCAPACITATED, UNLESS YOU EXPRESSLY LIMIT THE
DURATION OF THESE POWERS OR YOU REVOKE THESE POWERS OR A COURT ACTING ON
YOUR BEHALF TERMINATES YOUR AGENT'S AUTHORITY.
YOUR AGENT MUST KEEP YOUR FUNDS SEPARATE FROM YOUR AGENT'S FUNDS.
.
A COURT CAN TAKE AWAY THE POWERS OF YOUR AGENT IF IT FINDS YOUR AGENT IS
NOT ACTING PROPERLY.
THE POWERS AND DUTIES OF AN AGENT UNDER A POWER OF ATTORNEY ARE
EXPLAINED MORE FULLY IN 20 PA.C.S. Ch. 56.
.
IF THERE IS ANYTIllNG ABOUT THIS FORM THAT YOU DO NOT UNDERSTAND, YOU
SHOULD CALL OUR OFFICE AND HAVE US EXPLAIN IT TO YOU.
I HAVE READ OR HAD EXPLAINED TO ME THIS NOTICE AND I UNDERSTAND ITS
CONTENTS.
.
Btf~~
~o/' ~Jj~
Date
.
DURABLE GENERAL POWER OF ATTORNEY
pa*17
.
.
.
.
01/311200112:38 PM ArBS1 82225
~.~.?(~.l!.? f2:~~___?177?1f>634
VALEN::IK
PAGE Ell
. ---..-' NOTICE
THE PURPOSE OF TIllS POWER OF ATTORNEY IS TO GIVE THE PEll.SON YOU
DESIGNATE (YOUR "AOENT'') BROAD POWERS TO HANDLE YOUR PROPERTY,
WHICH MAY INCLUDE FOWERS TO SELL OR OTHERWISE DISPOSE OF ANY REAL
OR PERSONAL PROPERTY WITHOUf ADVANCE NOTICE TO YOU OR APPROVAL 13Y
. YOU.
TIllS POWER OF AITORNEY DOES NOT IMPOSE A DUTY ON YOUR AGENT
TO EXERCISE GRANTED POWERS, BUT WHEN POWERS ARE EXERCISED, YOUR
AGENT MUST uSE DUE CARE TO ACT FOR YOUR B:eNEF1T AND IN ACCORDANCE
WITH THIS POWER OF AITORNEY.
YOUR AGENT MAY EXERCISE THE POWERS GIVEN HERE THROUGHOUT
. YOUR LIFETIME. EVEN AFTER YOU BECOME INCAPACITATED, UNLESS YOU
EXPRESSLY LIMIT 1HE DURATION OF THESE POWERS OR YOU REVOKE THESE
POWERS OR A COURT ACTING ON YOUR BEHALF TERMINATES YOUR AGENT'S
AUTHORITY .
'-' YOUR AGENT MUST KEE.P YOUR FUNDS SEPARATE FROM YOUR AGENT'S
FUNDS.
. A COURT CAN TAKE AWAY TIIE POWERS OF YOUR AGENT IF IT FINDS
YOUR AGENT IS NOT ACTING PROPERLY.
THE POWERS AND DUflES OF AN AGENT UNDER A POWER OF ATTORNEY
ARE EXPLAINED MORE FUIL Y IN 20 PA.C.S. CH. 56.
IF THERE IS ANYTHING ABOUf TInS FORM TIIAT YOU DO NOT
UNDERSTAND, YOU SHOULD ASK A LAWYER OF YOUR OWN CHOOSING TO
. EXPLAlN IT TO YOU~
I HAVE READ OR HAD EXPLAINED TO ME THIS NOTICE AND I UNDERSTAND
ITS CONTENTS.
AUG 0 4 2005 At#( y ~ ~.(
DATE BETTY . V ALENC~
.
-----
.
EXHIBIT
I A-I
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.
071311200712:38 Pt;I A7B87 82225
B6/25/2ea7 1~:a7
717761663~
VALENCIK
PAGE e:z
.
POWER OF ATIORNEY
'--"
KNOW ALL MEN BY THESE PRESENTS:
.
That I. BE'ITY R. VALENCIK, having my legal residence ~o Chester L. Valenc:ik, Ir.,
S I 08 Inverness Drive, Mechanicsburg. Cumberland County, Pennsylvania, have made, collBtituted
and appointed, and by mese presents do make, constitute lI!ld appoinl my BOIl, CHESTER L.
VALENCIK, JR., my true and lawful agent, or, if he is unable or unwilling to serve, my son's
spouse, UNDA V ALENClK. my true and lawf\Jl agent, or. if she is unable or unwilling to serve,
my grandson, TROY V ALENCIK. my true and lawf\Jl agent, 10 act as fOllows. !hat is to say:
.
GNlNG AND GRANTING Wlto my said agent full power to buy, receive, lease, accept or
otberwise acquire; to sell, convey, mortgage, hypothecate, pledge, quitclaim or otheJWise encumber
or dispose of; to contl1lCt or agree to the acquisition, dispoSllI or encwnbrance of any pn>perty
whatsoever and wheresoever situate, be it real, penollll1 or me(\, or lIIIY custody, possession,
\metm. or Tight thereon <:If pert2Wling th..e'eo, upon SllCh terms as my said agent shall think proper,
that is \0 say:
I. To engage in tangible petSOllIll property transaction&.
.
2. To engage in ",a1 property lransactions including the power to make, execute,
acknowledge and deli VCll" good and sufficient deeds llIId convgyances for the: same, either with or
wilbou! oovenants ofwarrsnty.
3. To et\glLge in stock, bond and olbcr securities transacliOllll.
4. To engag~ in commodity and option ttanaactions.
.s.
T 0 cnga&~ in banking and financial trIlnJal;tions.
.
6. To borrow money.
7. To enter safe deposit boxes.
8. To engage in insurance transactions.
9. To engage in retirement plan 1IlIIlsaCllons.
.
10.
To handle interests in estates and trUSts.
11. T (j pursue olaims and litigation.
12. To receive government b~nefits.
2
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.
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.
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07'311200712:38 PM A1B87 82225
. .....~/2.5/2B.fl7. f2: fl7
1177616634
VALENCIK
PAGE 83
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13. To pursue tax matters.
.
14. To make limited gifts and, further, such other gifts, ofwh~ nature and in such
atnOWlts as my agent, in my agent's sole discretion. dctc:rmines appropriate. t authoriz;o my agent to
make such gifts even if oonlrUy to the provisions of 20 Pa.C.s. Section 5601(e). The foregoing
gifts may be made for and on my behaJfto my son. CHESTER L. V ALENCIK, 1R.
IS. To create a trud for my benefit, including the power to elCocute a deed of tr\ISt,
designating one or more pc:rllOns (including my agent) as originlll or successor ttustees and U1lnsrer
Ie the trust any or all property owned by me as my agmt may decide, subject to the following
conditions:
.
A. The income and GOrpUS of the trust shall be distributable to me or the
guardillD of my estate, or be applied for my \:Jen8fit, and npon my death. any remaining
balance of COrpllS and unellpcnded income of the trust shall be distn"butcd to my esbde.
B. The deed of \rUSt may be amended or ~oIced at any time and ftom time to
time, in whole or in pan, by my agent, provided that any such amendment by my ssent shall
not include any provisi ons which could not be included ill the original deed.
.
16.
To make additions to an existing trust for my b_fit.
17. To claim an dclCtive share of the estate of my deceased spouse.
18. To disclaim any intt$Wl5t in property.
19. To renounce fiduciary positions.
.
20.
To withdraw and te1;cive 1he; income; or colpus of a trust. including the power to:
A. Demlllld, withdraw and teeeive the income or corpus of any trust over which
J have the power to make withdrawals;
B. Request and receive the income or corpus of any 1nlst with respect to which
the tnIstec thereof has the: discretionary power to make distn'bution to me: (J[ on my behalf;
and
.
C. ElIocute a n:ceipt and release or similar document for the property rcccived
Wlder paragraphs A lIlId B.
3
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.
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.
.
07131/20~Wl~f~~~B87d~2€1
71 77616634
VALENCIK
PAGE 1:14
.
--'
21. To authorize my admi&Sion to a medical, nUl'8ina, residential or simi.Iar facility, and
to enta" into agr=~u for my care, including the power to apply for my admission to a medical,
nursing, residential or other Gimilar facility, execute any COllStmt or admission forms IUluired by
such facility which ~ consistent with this paragraph, and enter into ~ents for my ClIl"e by
such facility or elsewhere during my lifetime or for such lesser period of time as my said agent may
desi gnatc, including the retention of nurses for me.
.
22. Subject to my desires set forth in a living will, if any, lOauthorize medical and
surgical procedures, ineluding the power to lIITNIge for and consent to medical, therapeutical 81Jd
surgical pro<;edures for me, as well as the administration of chugs.
23. To appoint successor agent(s) if all of the agents' in this Power of Attorney -
lUlable or unwilling to serve.
.
24.
To make an 1lJIat0mieal gift of all or part of my body.
25. My agent shall be entitled to eharge reasonable Compensation for servi..es rendered
and expcnSClS incurred &om time to time and at any time during the term of this Power of Attorney.
.
26. It is my intent thai the authority gIlIIlted above extend to records, including
records considered "Protected Health Information", as tI!lIt term is dl:fined by tho Health
lnsurance Portability and Accountability Act and the regulations promulgated thereunder
(collectively, "HIPAA"). I further intend that my agent be treated as a "Pasonal Representative"
as that term i& used in HIPAA, and that my medical and health cue pIOVidera diaclOIIe neh
Protected Health Information to my agent, consistent with the authority which has been eranted
above. For purpoSl:S of such information and records covered by HIPAA, my agont's po....er to
act on my behalf shall be effective immediately regardless of my ability to make my own medical
or health care decisions. This authorization is intended to comply witll HIP AA and all other
fcderal, state, and local laws, regulations, statutes, and codes related to privacy an<! the release of
medical and health care information. I intend that my agent shall have full authority to accen
such information on my behalf I:ff'l:Ctivo immediall:ly.
.
27. This Power of Attorney sball not be affected by my subsequent disability,
incapacity, or incompelenl:e, since it is my desire lhat my son, CHESTER 1-. V ALENCIK, JR. , or,
ifhe is unable or unwilling to SCIVIl, my son's spouse, LINDA VALENCDC, or, ifahe is unable or
lUlWilling 10 serve, my gnmdson, TROY V ALENCIK, has the power to act on my behalf lIB my true
and lawful agent should I become disabled, incapacitated Or incompetclnt.
.
28.
by me.
This Power of Attorney shall revoke all other Powers of Attorney h8l'etofolll made
GIVING AND GRANTING unto my said agent full power and autJ:lOOty to do and perform
all and every act, deed, malter, and tbing whatsoever in and about my estate, property, and affairs as
fully and effectually 10 all Intents and purpo.... as 1 migIU or could do in Ill)' own proper penon If
4
.
.
.
.
.
071311Z~~:~~~7~~B~~_ _ 'V _____ 'V _____ 'V _____ \! _____ \/_____ 'V -----
.
personally present, the above specially enumerated powers being in aid and c:xemplificlUion of the
fuU, complete, and genenl power hemn granted and not in limitation or definition thereof, and
hereby ratifying all that my 5llid agent dJall lawfully do or cause to be done by virtue of Ibese
p=enls.
.
AND, I hereby declare that any act or thing lawfully done hemmder by my said agent shall
be binding on m}'$elf, and my heirs, legal and plltSonal represmtativ~ and assigns; whother the
same shall have been done before or after my death. OT other rovocation of Ibis instrument, unless
and until reliable intelligence or notice thereof shall have been received by my said agent.
IN WITNESS WHEREOF. I. BE'ITY R. V ALENCIK. have hereunto set my hand 8IId seal
this Alii, n It 7~
.
WITNESS:
gIft Y&~
BErrY .V ALENCIK
rr:~~/
.
ACKNOWLEDGEMENT
"--'
.
COMMONWEALTH OF PE.NNSYLV ANlA
COUNTY OF DAUPHIN
On this AUG 0 ~ 2005 , before me a notary public, the undellligncd officer,
penonallyappear.ed BETTY R VALENCIK, known to me (or satisfactorily proven) to be the
person whose name is sub6Cribed to the within instrument, and acknowledged that she executed the
same for the purposC$ therein contained.
:ss
IN WITNESS WHEREOF, I hereunto set my hand and official seal
.
~ _'U'
5
~L.=- "-
--~~-
-.""'----.......
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-./
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07/311200712:38 PM A7B87 82225
06/25/2097 1~:07 7177616634
VALEN::IK
PAGE 0S
..--
.
'-----
I, CHESTER L, V ALENCIK, JR, bave ll:ad the atlachccl power of attorney lIIld am the
person identified as the agent for the principal. 1 hereby acknowledge that in the .b5CJ\ce of a
5p\l\:i1ic provision to the contrary in the power of attorney or in 20 Pa.C$. wben I act as agent:
.
! shall exercise the powers for the benefit of the principal.
! shall keep the assets of the principal separate from my assets.
[ shall exen:.ise tellSO\llIble caution and llJ\ldence.
.
I shall keep a fun and aocurale record. of all actions, receipts and disbunements on behalf of
... -;pol AUG 0 \ 20!5 I!lu/... ~ 0
Date CHESTER L. V elK. JR. I
.
---'
!, LINDA V AL.ENCIK. have read the artached pOWI!l' of attorney and am the person
ider'ltified as the ag<:nt for the principal. I hereby acknowledge that in the absence of a specific
provision to the conl!1ll')'in the power ofattomcy or in 20 Pa.CS. when I act as agent:
.
1 shall exercise !he powefS tbr the benefit ofthe principal.
I shall keep the assets of the prin<:ipal separate from MY lIS80ts.
I shall exercise reasonable caution and prudence:.
I shall keep a full and BOCW'lIte record of all actions, receipts and disburscml:nts on behalf of
the principal.
.
Date
AUll 0 ~ ~05
~
LJNDAVAU.N~
6
.
.
.
.
.
.-
07/31I2otgb~~7p87t'lta~
71 77G1 ..634
VAlENCIK
PAGE__~
.
T, TROY V ALENCIK, have read the attached power of attorney and am the parson
identified as the agent for the principal. I hr::n=by acknowledge thal in the absence of a specific
provision to the contrary in the powerofattomey or in 20 Pa.C.S. whe:n I act as agent:
.
I shall exercise the powerx for the benefit of the principal.
I shall keep the usets of the principal sepllnlte from my assets_
I shall exercise reasonable cantion and prudence.
.
T shall keep a full and accurate record of all actions. receipts and disbllISements on-behalf of
tJie principal.
12-2.s-oS
Date
~
.
.
.
7
.
.
.
I.
.
.
DURABLE POWER OF ATTORNEY
KNOW ALL MEN BY THESE PRESENTS, that I, BETTY R. V ALENCIK of Columbia
County, Pennsylvania, hereby revoke any general power of attorney that I have heretofore given to any
person, and by these Presents do constitute, make and appoint Chester L. Valencik, Sr., my true and
lawful agent. If Chester L. Valencik, Sr. is unable or unwilling to serve, then I appoint Chester L.
Valencik, Jr., my true and lawful agent.
.
.
.
.
.
.
.
I
.
I.
Anyone dealing with the agent(s) shall incur no liability for any dealings with any designated
agent(s) in good faith reliance on the original Power of Attorney document. This provision is inserted in
this document to encourage third parties to deal with my agent(s) without the need for court proceedings.
1.
2.
3.
4.
5.
6.
7.
8.
A power to "make limited gifts"
A power to "create a trust for my benefit"
A power to "make additions to an existing trust for my benefit"
A power to "claim an elective share of the estate of my deceased spouse"
A power to "disclaim any interest in property"
A Power to "renounce fiduciary positions"
A power to "withdraw and receive the income or corpus of a trust"
A Power to "authorize admission to medical facility and power to authorize medical
procedures"
A power to "engage in real property transactions"
A power to "engage in tangible personal property transactions"
A power to "engage in stock, bond and other securities transactions" .
A power to "engage in commodity and option transactions"
A power to "engage in banking and financial transactions"
A power to "borrow money"
A power to "enter safe deposit boxes"
A power to "engage in insurance transactions"
A power to "engage in retirement plan transactions"
A power to "handle interests in estates and trusts"
A power to "pursue claims and litigation"
A power to "receive government benefits"
A power to "pursue tax matters"
A power to "make an anatomical gift, of all or part of my body"
Powers generally to "any matter in which the principal is in any way interested"
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
~~S~OF have hereunto set my hand this J!I" day of
~{y~
DURABLE GENERAL POWER OF ATTORNEY
~
Pa~~i
.
The Principal is personally known to me and I believe Principal to be of sound mind.
.
'};. ~;~ c ~
Witness
UUI,I--t5. ~/
Print Name
?IY /~~4'"r~
Address
&4p1/.I/-')I/U /7tw
City, State, Zip /"
.
~~aL~
j/,H'i/ ,4. ~
Print Name
JI(dt~~/LJ
Address .V'
~~~.11TY
City, State, Zip /
.
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF COLUMBIA
.
.
BEFORE ME, THE UNDERSIGNED, A NOTARY PUBLIC WITHIN AND FOR THE
COUNTY OF COLUMBIA, COMMONWEALTH OF PENNSYLVANIA, PERSONALLY APPEARED
Betty R. Valencik KNOWN TO ME TO BE THE PERSON WHOSE NAME IS SUBSCRIBED TO THE
WITHIN INSTRUMENT, AND ACKNOWLEDGED UNDER OATH, TO MY SATISFACTION THAT
SHE IS THIS MAKER OF THIS DURABLE POWER OF ATTORNEY AND EXECUTED THE SAME
FOR THE PURPOSES THEREIN CONTAINED. "'" ~
~~~SS ~E~ ha~e hereunto set my hand and official seal thi?-/'- day of
.
~~~
Notary Ie
.
My Commission Expires:
~GLl~j/0
. NOTARIAL SEAL
L TOOD B. GAAA.V, ~..... Public
OW8(~r~~ .
--Mi~-~~iii;;l.~
.
.
DURABLE GENERAL POWER OF ATTORNEY
Page;
.
.
ACKNOWLEDGMENT OF AGENT*
.
Principal:
Betty R. Valencik
73 Lick Run Road
Catawissa, Pennsylvania 17820
Agent:
Chester L. Valerwik, Sr.
73 Lick Run Road
Catawissa, Pennsylvania 17820
.
I, Chester L. Valencik, Sr., have read the attached power of attorney and am the person identified as
the agent for the principal. I hereby acknowledge that in the absence of a specific provision to the contrary in
the power of attorney or in 20 P A.C.S. when I act as agent:
I shall exercise the powers for the benefit of the principal.
.
I shall keep the assets of the principal separate from my assets.
I shall exercise reasonable caution and prudence.
I.
I shall keep a full and accurate record of all actions, receipts and disbursements on behalf of the
principal.
.
,
~/tJ
Date
COMMONWEALTH OF PENNSYLVANIA
.
COUNTY OF COLUMBIA __
On the ~ day Of~# . , 20 G before me, the undersigned Notary Public,
personally appeared the above named Affiant who acknowledged before me to be the individual named above
and executed the foregoing instrument and acknowledged that helshe executed the same as his/her free act and
deed.
.
.~.
Notary Public
.
My commissi~es:
/f~ ~JP//jt:7
. NOTARIAL SEAL
TOOD B. GARRY, Notary Public
~~ Twp., BUcks County
~J.JIlllIIOft 3,2004
*In order for the Power of Attorney to be effective, this Notice must be signed and returned to Mrs. Valencik.
.
(DURABLE GENERAL POWER OF ATTORNE~
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IKFMIIIL Y LIVING tRUST
eft .. . .. . ..'(VA.LE~CIK TTEE
aErtYa,VALl;NcIi< TTEE
73UCI(,l\UNf\D
cA"AWtSSA.P~ .
Pay to tile
Order' f
579
.
Date
fi}/q/O{
I (
60-1/313
. 532
$
3000 .60
Dollars fD ==:;
.
~ n......:1l2B BriNl€Ched Caa;hed Bi $3 ~OOO .0c! PD
Q..:Fl"l ~U/"'\.I'''~0326.~~2 e.[>I::C2004 124
~C . )5::fflJi ~1.IY!St-'lS~r('i6b03(12 .~
:7030300;:92,: q 2003 2baa 2"f3~-;Z~~~O~:
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C~.,.q~lc~u,
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EXHIBIT
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DEED
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Parcel #: 20,07-028-00,000
This indenture, made the ~ day of ~~I TI- , in the year two thousand five
(2005),
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Between
Betty R. Valencik, Trustee of the Chester L. Valencik, Sr. and Betty R. Valencik
Revocable Living Trust dated February 20,2003, Grantor
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and
Chester L. Valencik, Jr., Trustee ofthe Valencik Family Irrevocable Trust dated
AUG 0 4 2005 , Grantee
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Witnesseth, that the Grantor, for and in consideration of the sum of One and
NollOO ($1.00) Dollars, lawful money of the United States of America, unto her well and
truly paid by the Grantee at or before the sealing and delivery hereof, the receipt whereof
is hereby acknowledged, have granted, bargained and sold, released and confirmed, and
by these presents do grant, bargain and sell, release and confirm unto the Grantee, his
successors and assigns.
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ALL THOSE CERTAIN tracts of land situate in the Township of Locust,
Columbia County, and Commonwealth of Pennsylvania, more particularly bounded and
described as follows, to wit:
TRACT NO.1:
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BEGINNING at a stone and running thence by land formerly of Samuel Flemings
north 45 degrees west 32 perches to a stone; thence by land formerly of John Leenorth
north 41.25 degrees east 10 perches to a stone; thence by the same south 54.75 degrees
east 32 perches to a stone thence by the same south 44.75 degrees west 10 perches to the
place of beginning. CONTAINING two acres be the same more or less.
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TRACT NO. 2:
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Lying adjacent to the first mentioned and described as follows, to wit"
BEGINNING at a stone comer of land formerly of Mary M. Keller and running thence by
the same north 45.5 degrees east 32 perches to a stone, thence by the same south 45
degrees west 10 perches to a stone, thence by land formerly of Samuel Flemings north
45.5 degrees east 10 perches to a stone, thence by land formerly of Lewis Lee north 44.5
degrees east 23 perches to a stone; thence by land formerly of Josiah Rhoades south 45.5
degrees west 42 perches to a stone; thence by the same south 44.5 degrees west 13
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EXHIBIT
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perches to the place of beginning. CONTAINING four acres be the same more or less.
Wherein is erected a two and one-half story frame dwelling, barn and outbuildings.
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TRACT NO. 3:
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BEGINNING at the public road leading through other land above described, and
extending along the above and the Wesley Lindemuth farm from said public road to the
first described tracts one rod wide, this is understood is for a road from the public road in
and through and over the land fonnerly of Elias W. Stine.
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BEING the same premises which Chester L. Valencik (a/k/a Chester L. Valencik,
Sr.) and Betty R. Valencik, husband and wife, by Deed dated February 20, 2003, and
recorded on March 24, 2003, as Instrument Number 200303424, in the Office of the
Recorder of Deeds in and for Columbia County, Pennsylvania, granted and conveyed
unto Chester L. Valencik, Sr. and Betty R. Valencik, Trustees oftbe Chester L. Valencik,
Sr. and Betty R. Valencik Revocable Living Trust dated February 20,2003. Chester L.
Valencik died on May 5, 2004, thereby vesting title to Betty R. Valencik as sole Trustee,
the Grantor herein.
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UNDER AND SUBJECT to all restrictions, easements, covenants, conditions and
agreements of record.
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TOGETHER with all and singular the buildings and improvements, ways, streets,
alleys, passages, waters, water-courses, rights, liberties, privileges, hereditaments and
appurtenances, whatsoever unto the hereby granted premises belonging, or in any wise
appertaining, and the reversions and remainders, rents, issues and profits thereof; and all
the estate, right, title interest, property, claim and demand whatsoever of her, the Grantor,
as well at law as in equity, of, in and to the same.
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TO HA VB AND TO HOLD the said lot or piece of ground above described, with
the messuage or tenement thereon erected, hereditaments and premises hereby granted, or
mentioned and intended so to be, with the appurtenances, unto the Grantee, his successors
and assigns, to and for the only proper use and behoof of the Grantee, his successors and
assigns, forever.
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AND the Grantor, for her successors and assigns, does covenant, promise and
agree, to and with the Grantee, his successors and assigns, by these presents, that she, the
Grantor, her successors and assigns, all and singular the hereditaments and premises
hereby granted or mentioned and intended so to be, with the appurtenances, unto tbe
Grantee, his successors and assigns, against them, the Grantor, her successors and
assigns, and against all and every person and persons whomsoever lawfully claiming or
to claim the same or any part thereof, by, from or under him, her, them or any of them,
shall and will, Subject as aforesaid, WARRANT and forever DEFEND.
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111111111111'111' 1
00173E
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COUNTY OF COLUMBIA
RECORDER OF DEEDS
Beverly J. Michael, Recorder
35 West Main Street
Bloomsburg, P A 17815
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Instrument Number - 200508513
Recorded On 8/12/2005 At 11:07:23 AM * Total Pages - 6
* Instrument Type - DEED
Invoice Number - 84508
* Grantor - CHESTER L V ALENCIK SR AND BETTY R V ALENCIK REVOCABLE LIVING TRUS;
" Grantee - V ALENCIK F AMIL Y IRREVOCABLE TRUST
User - BJM
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" FEES
STATE WRIT TAX
JCS/ACCESS TO JUSTICE
AFFORDABLE HOUSING
RECORDING FEES -
RECORDER
RECORDER IMl?ROVEMENT
FUND
COUNTY IMl?ROVEMENT FUND
TOTAL
$0.50
$10.00
$16.00
$16.00
This is a certification page
.
DO NOT DETACH
$3.00
This page is now part
of this legal document.
$2.00
$47.50
RETURN DOCUMENT TO:
MAIL JAMES, SMITH, DIETTERlCK & CONNELLY
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· - Information denoted by an asterisk may chance during
the vertflcation process and may not be reflected on this page.
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Columbus Life
Insurance~Compdny
400 East Fourth Street · P.O. Box 5737 · Cincinnati. Ohio 45201-5737 . 1-800-677-9595 . www.ColumbusLife.com
Life Insurance Policy
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Coverage Provided By This Policy: We agree to pay the Death Benefit to the Beneficiary when
We receive proof of the death of the Insured while this policy is in force. subject to the terms of
this policy. The Death Benefit is explained in the Death Benefit Provisions section. During the
Insured's lifetime, We will provide cash surrender value benefits and other important rights, as
described in the policy.
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Premiums are payable on this policy until the day before the policy anniversary on which the
Insured is age 100. If the policy is still in force at that time, it will continue until the death of the
Insured, as explained in the Extended Coverage Benefit Provision section, with no further
premium payments. Continuation of coverage past the Insured's age 100 may disqualify the policy
for favorable tax treatment as life insurance. You should consult Your attorney, accountant or
other tax adviser.
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Thirty-Day Right To Examine the Policy (Free Look Period): Please read Your policy
carefully. If You are not satisfied with It, You may return It to Us within 30 days after You
receive it. Mall or deliver the polley to Us at Our Home Office (P.O. Box 5737, Cincinnati,
Ohio 45201-5737) or to one of Our agents. The policy will be deemed void as though no
application was made. We will promptly refund any premium paid.
This policy is a legal contract between You. as Owner, and Columbus Life Insurance Company.
Signed for Columbus Life Insurance Company at Cincinnati. Ohio.
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Issued by a Stock Company
PLEASE READ YOUR POLICY CAREFULLY
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Flexible Premium Universal Life Policy
Issued on Insured in Risk Class Shown on Policy Schedule
Flexible Premiums Payable During Life of Insured to Age 100
Death Benefit Payable at Death of Insured
Death Benefit Modified After Insured's Age 100
Non-Participating
EXHIBIT
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CL 82 0307 PA
Page 1
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Table of Contents
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Definitions .................................................... .....4
Basic Policy Terms............. .................. .......... 4
Premiums................. ........ ...... ...... .............. .... 4
Values........................................................... 5
Charges........................................... .............. 6
This Policy Is A COntract.................................. 7
Ownership Provisions ...... ...... ...... ...... ...............7
Ownership, Contingent Owner and Joint Owner 7
Beneficiary Provisions... .......... ...... .......... ......... 7
Primary Beneficiary and Contingent
Beneficiary............................... ...................... 7
Death Benefit Provisions ..................................8
Death Benefit ............. .............. .............. ........ 8
Death Benefit Options ........... .......................... 8
Option 1......................................................... 8
Option 2......................................................... 8
Specified Amount and Death Benefit Option
Changes...... .................... .... ..................... ..... 9
Increasing the Specified Amount ..................... 9
Decreasing the Specified Amount.................... 9
Changing the Death Benefit Option..................10
Premium Payment Provlslons..........................10
Payment of Premiums.... ...... .... ........ ..............10
Planned Premiums...................................... ....1 0
Continuation of Insurance Upon
Discontinuance of Premium Payments.............10
Grace Period and Termination of Coverage......11
Reinstatement .............................................. ....11
Guarantee of Continued Coverage..................12
Five-Year No-Lapse Guarantee .......................12
Extended Coverage Benefit Provision........... ..12
Policy Values.................................................. ..12
Account Value............ ...................... ............ ..12
Interest Rate.......... ................... ........... ...... ....13
Cash Surrender Value.......... ................... ...... ..13
Net Cash Surrender Value ..............................13
Withdrawal... .... ...................................... ...... ..13
Full Surrender ............................. .................. ..13
Loan Provisions ....... .......... ............... ..... ..........14
Right to Borrow and Maximum Loan ................14
Loan Interest.................................... ............ ..14
Policy Termination .. ...... ........................ ..... .....14
Repaying Loans.......... ................ ................ ....14
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Policy Costs and Charges ...............................14
Premium Charges..... ................................... ...14
Premium Expense Charge.............................. .14
State Tax Charge. .... .................................... ..15
Monthly Policy Charges ..................................15
Cost of Insurance Charge............................. ..15
Per Policy Charge......... ................................ ..16
Per $1,000 Charge... ......... .......................... ...16
Rider Charges ............. ............... .................. ..16
Surrender Charge ....................... . ................. ..16
Payment of Proceeds ............. ....... ................. ..16
Policy Proceeds.................. ....... ............ ...... ..16
How We Pay................................................ ..16
Choosing an Income Plan ...............................17
The Income Plans..... .......... .................... ...... ..18
Option 1 - Payments for a Fixed Period ...........18
Option 2 - Payments for Life - Guaranteed
Period.. ..... ................................. .... .............. ..18
Option 3 - Payments of a Fixed Amount...........19
Option 4 - Life Annuity - No Guaranteed
Period...... ............ ........ ................................ .20
Option 5 - Joint and Survivor..........................21
Adjustment to Age. .............. ......................... .21
Additional Interest....... ............................... ... .22
Commutation of Income Options ....................22
General Provisions ..... ............ .......... ...... .........22
Annual Report .............................................. .22
Projection of Benefits and Values................... 22
Reliance............... ........................................ .22
Policy Schedule
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Insured: BETTY R VALENCIK
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Class: STANDARD (NON-TOBACCO USER)
Policy Number: CM5011754U
Policy Date: 08-04-2004 I .f~t-
Insured Age: 81 JiI!U 111i"m
Insured Sex: FEMALE Aft., fJ.'I::
l-c"J~
t.,
Planned Premium: $0.00
Annually
Payable to Age: 100
Owner: BETTY R VALENCIK
. Total Specified Amount: $265,263
Base Specified Amount: $132,632
Additional Life Rider
Specified Amount: $132,631
Minimum Issue Limit
Specified Amount: $25,000
Death Benefit Option:
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Five-Year No-Lapse Guarantee Minimum Monthly Premium: $751.69
Maximum Premium Expense Charge Rates: See Maximum Premium
Expense Charge Page
Maximum State Tax Charge Rate: 3.00%
Maximum Monthly Per Policy Charge: $7.00 Per Policy
Maximum Monthly Per $1,000 Charge Rate: See Maximum Per $1,000
Charge Page
Maximum Monthly Cost of Insurance Charge Rates: See Guaranteed Maximum Cost of
Insurance Charges Page
Surrender Charges: See Surrender Charges Page
Withdrawal Fee: $50.00 for each withdrawal
after first in policy year
Maximum Loan Interest Rate: 7.00%
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Minimum Guaranteed Interest Rate: 3.00%
Accumulation Rate for Five-Year No-Lapse Guarantee
Minimum Monthly Premium: 5.50%
NOTE: It Is possible that coverage will expire prior to the Insured's age 100 If premiums paid are
. not sufficient to continue coverage to that date.
Additional Benefits Provided By Rider: Effective
Date
Benefit
Amount
.
Accelerated Death Benefit Plus Rider
Additional Life Rider
Enhanced No-Lapse Guarantee Rider
08-04-2004
08-04-2004
08-04-2009
N/A
$132,631.00
N/A
Monthly
Rider Cost
N/A
Payable
To Age
N/A
100
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.. See Additional Policy Schedule Page
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CL 82 0307 PA
Page 3
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Policy Schedule (continued)
Enhanced No-Lapse Guarantee Rider
Insured: BETTY R VALENCIK
Age of Insured: 81
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Enhanced No-Lapse
Guarantee Single
Premium: $167,928.13
Effective Date: 08-04-2009
Guidefine Single
Premium: $207,190.78
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Rider Cost of Insurance
Rate Per Thousand Dollars of Specified Amount
Payable
From
Payable
To
08-04-2023
Monthly Rider Cost
0.0800
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08-04-2009
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CL 82 0307 PA
Page 3
Enhanced No-Lapse Guarantee Rider
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Policy Schedule (continued)
Additional Life Rider
Insured: BETTY R VALENCIK
Age of Insured: 81
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Additional Life Rider
Specified Amount: $132,631.00
Effective Date: 013-04-2004
Guaranteed Maximum Cost Of Insurance Charges
Rates Per Thousand Dollars of Net Amount at Risk
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Maximum
Policy Monthly
Year Rate
1 $6.7004200
2 7.5641400
3 8.5501500
4 9.6516900
5 10.8610900
6 12.1744100
7 13.5946400
8 15.1282800
9 16.7939900
10 18.6134200
11 20.6400500
12 22.9685100
13 25.7973400
14 29.5862100
15 35.3661900
16 45.5250800
17 66.3186800
18 83.3333300
19 83.3333300
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This table shows the guaranteed maximum Cost of Insurance Charge rates for the Additional Life
Rider. These rates are individual mortality calculations based on the [1980 CSO Nonsmoker Mortality
Table, Age Last Birthday] as specified by the risk class of the Insured shown on the Policy Schedule.
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CL 82 0307 PA
Page 3
Additional Life Rider
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. Policy Schedule (continued)
Table of Guaranteed Minimum Values
This table assumes that all Planned Premiums as shown on the Policy Schedule are paid as
scheduled. These values are based on the minimum guaranteed interest rate and maximum
. policy charges (including maximum rider costs) and are before adjustment for any loans, partial
surrenders or changes in amount of insurance.
End of Attained Cash
Policy Age of Surrender
Year Insured Value
. 1 82 $ 144,974.81
2 83 $ 137,006.76
3 84 $ 126,430.54
4 85 $ 112,406.63
5 86 $ 93,784.95
. 6 87 $ 69,666.95
7 88 $ 37,012.50
8 89 $ 0.00
9 90 $ 0.00
10 91 $ 0.00
. 11 92 $ 0.00
12 93 $ 0.00
13 94 $ 0.00
14 95 $ 0.00
15 96 $ 0.00
. 16 97 $ 0.00
17 98 $ 0.00
18 99 $ 0.00
19 100 $ 0.00
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Based On Above Assumptions, Policy Terminates in Year 20.
Attained age of Insured is age on the last policy anniversary.
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Flexible Premium Universal Life
Age 81 - Female
Specified Amount. $132,632
Policy Number. CM5011754U
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CL 82 0307 PA
Page 3
Table of Guaranteed Minimum Values
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. Polley Schedule (continued)
Maximum Premium Expense Charge
Coverage Layer Up To In Excess Of
Month Target Premium Target Premium
. 6.50% 3.75%
1 . 144
145 + 3.50% 2.75%
Target Premium Effective Date
. Coverage Layer 1 $11,936.88 08/04/2004
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CL 82 0307 PA
Page 3
Maximum Premium Expense Charge
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Policy Schedule (continued)
Guaranteed Maximum Cost Of Insurance Charges
Rates Per Thousand Dollars of Net Amount at Risk
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Policy
Year
Maximum
Monthly
Rate
.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
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6.700420
7.564140
8.550150
9.651690
10.861090
12.174410
13.594640
15.128280
16.793990
18.613420
20.640050
22.968510
25.797340
29.586210
35.366190
45.525080
66.318680
83.333330
83.333330
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This table shows the guaranteed maximum Cost of Insurance Charge rates for the policy without riders.
These rates are individual mortality calculations based on the (1980 CSO Nonsmoker Mortality Table,
Age Last Birthday) as specified by the risk class of the Insured shown on the Policy Schedule.
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CL 82 0307 PA
Page 3
Guaranteed Maximum Cost of Insurance Charges
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Policy Schedule (continued)
Maximum Per $1,000 Charge
Rate Per Thousand Dollars of Specified Amount
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Coverage Layer Month
1 - 120
121 +
Monthly Rate
.93600
.936000
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Cl 82 0307 PA
Page 3
Maximum Per $1 ,000 Charge
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. Policy Schedule (continued)
Surrender Charges
Policy Month Amount Polley Month Amount
. 1-60 $ 5371.60 103 $ 2805.17
61 $ 5311.91 104 $ 2745.48
62 $ 5252.23 105 $ 2685.80
63 $ 5192.54 106 $ 2626.11
64 $ 5132.86 107 $ 2566.43
65 $ 5073.17 108 $ 2506.74
. 66 $ 5013.49 109 $ 2447.06
67 $ 4953.81 110 $ 2387.38
68 $ 4894.12 111 $ 2327.69
69 $ 4834.44 112 $ 2268.01
70 $ 4774.75 113 $ 2208.32
71 $ 4715.07 114 $ 2148.64
. 72 $ 4655.38 115 $ 2088.95
73 $ 4595.70 116 $ 2029.27
74 $ 4536.01 117 $ 1969.59
75 $ 4476.33 118 $ 1909.90
76 $ 4416.65 119 $ 1850.22
77 $ 4356.96 120 $ 1790.53
78 $ 4297.28 121 $ 1715.93
. 79 $ 4237.59 122 $ 1641.32
80 $ 4177.91 123 $ 1566.72
81 $ 4118.22 124 $ 1492.11
82 $ 4058.54 125 $ 1417.50
83 $ 3998.85 126 $ 1342.90
84 $ 3939.17 127 $ 1268.29
. 85 $ 3879.49 128 $ 1193.69
86 $ 3819.80 129 $ 1119.08
87 $ 3760.12 130 $ 1044.48
88 $ 3700.43 131 $ 969.87
89 $ 3640.75 132 $ 895.27
90 $ 3581.06 133 $ 820.66
. 91 $ 3521.38 134 $ 746.06
92 $ 3461.70 135 $ 671.45
93 $ 3402.01 136 $ 596.84
94 $ 3342.33 137 $ 522.24
95 $ 3282.64 138 $ 447.63
96 $ 3222.96 139 $ 373.03
. 97 $ 3163.27 140 $ 298.42
98 $ 3103.59 141 $ 223.82
99 $ 3043.90 142 $ 149.21
100 $ 2984.22 143 $ 74.61
101 $ 2924.54 144 $ 0.00
102 $ 2864.85 145 or more $ 0.00
. A policy month begins on the Monthly Anniversary Day and ends on the day before the Monthly
Anniversary Day in the next calendar month. Policy month 1 begins on the Policy Date.
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CL 82 0307 PA
Page 3
Surrender Charges
.
Definitions
YOU and YOUR. In this policy, You and Your refer to the Owner of the policy.
WE, OUR and US. Columbus Life Insurance Company.
Basic Policy Terms............ ........................ ...... .......... ...... .......... .............. ........ .....
BENEFICIARY. The person or persons You have named to receive the Death
Proceeds when the Insured dies.
.
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COVERAGE LAYER. A Coverage Layer consists of all base policy and rider
coverages that become effective on a single Monthly Anniversary Day. The first
Coverage Layer consists of coverage effective on the Policy Date. An increase in
base coverage or the addition of rider benefits creates another Coverage layer.
DEATH BENEFIT. The amount We will pay to the Beneficiary under the base policy
when We receive proof that the Insured died while this policy was in force.
.
DEATH PROCEEDS. The Death Benefit plus any insurance on the life of the Insured
provided by riders, excluding any rider that includes its own beneficiary designation.
INSURED. The person named on the application on whose life this policy provides
insurance coverage.
.
MONTHLY ANNIVERSARY DAY. The day each month on which We deduct the
Monthly Policy Charges and credit interest. The initial Monthly Anniversary Day is the
Policy Date.
OWNER. The person or persons who have all rights under this policy. If there are joint
Owners, both must consent in writing to the exercise of any right under this policy.
POLICY DATE. The issue date of the policy and the date from which policy months,
years and anniversaries are measured.
.
POLICY SCHEDULE. The schedule on page 3 of this policy, or the most recent
amended Policy Schedule We have sent You.
SPECIFIED AMOUNT. The amount of insurance coverage You have selected under
the base policy, as shown on the Policy Schedule.
Premiums .. ................ ...................... ............ ...... .... .......... .... .... .... ......... ...... ........ ......
.
NET PREMIUM. The amount of premium paid less the Premium Expense Charge and
the State Tax Charge.
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CL 82 0307 PA
Page 4
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FIVE-YEAR NO-LAPSE GUARANTEE MINIMUM MONTHLY PREMIUM. The
amount of premium due on each Monthly Anniversary Day to assure the policy will not
terminate or begin the Grace Period as described in the Guarantee of Continued
Coverage provision. The Five-Year No-Lapse Guarantee Minimum Monthly Premium
as of the Policy Date is shown on the Policy Schedule. If You add rider coverage
after the Policy Date, the Five-Year No-Lapse Guarantee Minimum Monthly Premium
for Your pOlicy will increase jf the rider has a cost. If Your Specified Amount increases
after the Policy Date, the Five-Year No-Lapse Guarantee Minimum Monthly Premium
for Your policy will increase. We will send You an amended Policy Schedule showing
the new Five-Year No-Lapse Guarantee Minimum Monthly Premium following any such
increase.
.
.
PLANNED PREMIUM. The amount and frequency of the premium You have indicated
You plan to pay, as shown on the Policy Schedule.
TARGET PREMIUM. An amount of premium for a Coverage Layer for a coverage
year that We use to determine the Premium Expense Charge rate(s) applicable to
each premium payment. The Target Premium for the initial Coverage Layer as of the
Policy Date is shown on the Policy Schedule. If You add or remove rider coverage
after the Policy Date, the Target Premium for Your policy will increase or decrease if
the rider has a Target Premium associated with it. If You request an increase or
decrease in Specified Amount after the Policy Date, the Target Premium for Your
policy will increase or decrease. We will send You an amended Policy Schedule
showing the new Target Premium following any such increase or decrease. The initial
Target Premium depends on the age, sex and risk class of each insured person on the
Policy Date. The Target Premium for a new Coverage Layer or for rider coverage You
add will depend on the age, sex and risk class of each insured person on the effective
date of the Coverage Layer or rider.
.
.
Values .... ...... .......... .......... ........ .......... ............" ... ...... .... ...... .... ........ ...... .... ...... ..." ...."
.
ACCOUNT VALUE. The Account Value reflects Your financial interest in the policy.
The Account Value section explains how to calculate the Account Value.
CASH SURRENDER VALUE. The Account Value, less any applicable Surrender
Charge.
INDEBTEDNESS. The amount of any outstanding pOlicy loan(s) plus any accrued
and unpaid loan interest.
.
.
NET AMOUNT AT RISK. The amount of the Death Benefit for which We are at risk.
The Net Amount at Risk on any Monthly Anniversary Day is equal to:
(1) the Death Benefit plus Indebtedness, divided by 1.0024663; minus
(2) the Account Value after deduction of Monthly Policy Charges, other than the
Cost of Insurance Charge, on that Monthly Anniversary Day.
NET CASH SURRENDER VALUE. The Cash Surrender Value less any
Indebtedness.
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CL 82 0307 PA
Page 5
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Cha rges "................ _................ ..................1/1........................"""...."" ......""".....""""."...."""".....
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COST OF INSURANCE CHARGE. An amount deducted from the Account Value
each Monthly Anniversary Day to pay for the cost of insurance coverage under the
base policy. The maximum monthly Cost of Insurance Charge rates for each policy
year are shown on the Policy Schedule.
PER $1,000 CHARGE. An amount deducted on each Monthly Anniversary Day to
partially cover Our expenses of distributing, issuing and administering the policy. The
maximum monthly Per $1,000 Charge rates for any Coverage Layer are shown on the
Policy Schedule.
PER POLICY CHARGE. An amount deducted each Monthly Anniversary Day to
partially cover Our expenses of administering the policy. The maximum monthly Per
Policy Charge is shown on the Policy Schedule.
PREMIUM EXPENSE CHARGE. An amount deducted from each premium payment
before it is credited to the policy to partially cover the costs of distributing the policy.
The maximum Premium Expense Charge rates are shown on the Policy Schedule.
STATE TAX CHARGE. An amount equal to the current applicable state premium tax
rate that is deducted from each premium payment before it is credited to the policy.
The maximum State Tax Charge rate is shown on the Policy Schedule.
SURRENDER CHARGE. An amount deducted from the Account Value if this policy is
surrendered or terminates when a Grace Period ends. without sufficient premium or
loan repayment being paid to keep the policy in force. The Surrender Charges that
would apply in each policy month are shown on the Policy Schedule. If You request
an increase in Specified Amount, new Surrender Charge amounts will apply to the
increase. We will add these Surrender Charges to the original Surrender Charges and
send You an amended Policy Schedule showing the new Surrender Charges that
would apply in each remaining pOlicy month.
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CL 82 0307 PA
Page 6
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This Policy
Is A Contract
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Ownership
Provisions
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Beneficiary
Provisions
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This policy is a contract between You and Us to insure the life of the Insured. We
have issued it in reliance on the statements made in the application and in
consideration for the premiums paid to Us.
Whenever We refer to the policy, We mean the entire contract. The entire contract
consists of:
. the base policy;
. the attached application;
. any attached supplemental applications; and
. any attached riders, endorsements or amendments.
Riders, endorsements and amendments add provisions or change the terms of the
base policy.
Owner, Contingent Owner and Joint Owner
You have all rights in this policy, subject to any assignment and to the rights of any
irrevocable Beneficiary You have named to consent to a change of Beneficiary.
If You are not the Insured, You may name a contingent Owner. If You die before the
Insured, ownership would then pass to the contingent Owner. If there is no contingent
Owner, Your estate would become the Owner.
This policy may be owned by two persons as joint Owners. In that case, both joint
Owners must consent in writing to the exercise of any rights under the policy. You
must also have the consent of any irrevocable Beneficiary to change the Beneficiary.
You do not need the consent of a contingent Owner or a revocable Beneficiary to
exercise any of Your rights. If a joint Owner dies before the Insured, ownership would
pass to the surviving joint Owner(s) under a right of survivorship, unless otherwise
indicated in the application or in a change of ownership notice.
You may change the Owner, or change or revoke any contingent Owner designation,
at any time by written notice to Us. The change will take effect on the date You
signed the notice, but We will not be liable for any actions We take before We receive
the notice at Our Home Office. A change of Owner automatically revokes any
contingent Owner designation. A change of Owner, or a change or revocation of a
contingent Owner designation, does not automatically change or revoke a prior
Beneficiary designation.
Primary Beneficiary and Contingent Beneficiary
The Beneficiary is the person to whom We pay the Death Proceeds upon the
Insured's death. Unless You change them later, the primary and contingent
Beneficiaries are the persons named in the application. If no primary Beneficiary is still
living when the Insured dies, We will pay the Death Proceeds to any contingent
Beneficiary who is still living. If there is no surviving primary or contingent Beneficiary,
We will pay You. If You were the Insured, We will pay Your estate. The interest of
any Beneficiary is subject to the rights of any assignee reflected on Our records.
Two or more persons may be named as primary Beneficiaries or contingent
Beneficiaries. We will pay equal shares when there is more than one Beneficiary of
the same class, unless You specify otherwise on the Beneficiary designation.
No revocable Beneficiary has rights under this poliCY until the Insured dies. An
irrevocable Beneficiary cannot be changed without his or her consent.
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CL 82 0307 PA
Page 7
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Death Benefit
Provisions
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You may change the Beneficiary at any time before the death of the Insured by
sending written notice to Us. The change will be effective as of the date You signed
the notice, but We will not be liable for any payments We make or other actions We
take before the notice is received at Our Home Office.
Unless You have instructed otherwise, if the Beneficiary is the spouse of the Insured,
both die and We cannot tell who died first, We will pay the Death Proceeds as if the
Beneficiary had survived the Insured.
Death Benefit
We will pay the Death Benefit as described in the Payment of Proceeds section
when We receive proof that the Insured died while this policy was in force, and any
other proof that We may require in order to investigate the claim. The Beneficiary
should contact Us at the Home Office or contact one of Our agents for instructions on
how to file a claim.
Death Benefit Options
The Death Benefit will be one of the following two Options, as selected by You on the
application, or as subsequently changed by You. The amount payable when We
receive proof of death of the Insured will be the Death Benefit valued as of the
Insured's date of death.
Option 1
The Death Benefit is the greater of the following, less any Indebtedness: (1) the
Specified Amount; or (2) the Account Value times the applicable factor from the table
below.
Option 2
The Death Benefit is the greater of the following, less any Indebtedness: (1) the
Account Value plus the Specified Amount; or (2) the Account Value times the
applicable factor from the table below.
Your monthly Cost of Insurance Charge will be higher If You choose Death
Benefit Option 2 because the Net Amount at Risk for Your policy will be
higher. Therefore, the amount of premium You need to pay to keep the policy
from terminating may also be higher.
CL 82 0307 PA
Page 8
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Insured's Age Applicable Insured's Age Applicable
Last Policy Anniversary Factor Last Policy Anniversary Factor
40 and under 2.50 61 1.28
41 2.43 62 1.26
42 2.36 63 1.24
43 2.29 64 1.22
44 2.22 65 1.20
45 2.15 66 1.19
46 2.09 67 1.18
47 2.03 68 1.17
48 1.97 69 1.16
49 1.91 70 1.15
50 1.85 71 1.13
51 1.78 72 1.11
52 1.71 73 1.09
53 1.64 74 1.07
54 1.57 75 through 90 1.05
55 1.50 91 1.04
56 1.46 92 1.03
57 1.42 93 1.02
58 1.38 94 1.01
59 1.34 95 or higher 1.00
60 1.30
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Specified Amount and Death Benefit Option Changes
You may request a change in the Specified Amount or Death Benefit Option by
sending notice to Us in writing at Our Home Office. Following Our approval of any
such change, We will send You an amended POlicy Schedule.
Increasing the Specified Amount
You may apply for an increase in the Specified Amount on a supplemental application.
The requested increase is subject to evidence of insurability satisfactory to Us. The
minimum increase is $25,000. Any increase We approve will be effective on the next
Monthly Anniversary Day coinciding with or next following such approval, as shown on
an amended Policy Schedule, subject to deduction of the first month's Cost of
Insurance Charge for the increase from the Account Value of this policy. If you
increase the Specified Amount, We will send You a. revised Table of Surrender
Charges. An increase in Specified Amount will cause Surrender Charges to
Increase, which will reduce Your Net Cash Surrender Value. In addition, Cost
of Insurance Charges will be higher. Therefore, the amount of premium You
must pay to keep Your policy from terminating may Increase.
Decreasing the Specified Amount
At any time after the first poliCY year, You may request a decrease in the Specified
Amount. Any decrease in the SpeCified Amount that You request will become effective
on the first Monthly Anniversary Day after We receive Your request. The minimum
decrease is $25,000. The new Specified Amount must not be less than the minimum
issue limit shown on the Policy Schedule at issue. We may limit the amount of the
decrease to preserve the tax status of this policy as life insurance.
Any decrease You request will occur in the. following order: first against the most
recent increase in Specified Amount, if any; then in order against the next most recent
increases; then finally against the initial Specified Amount.
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CL 82 0307 PA
Page 9
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Premium
Payment
Provisions
Changing the Death Benefit Option
At any time after the first policy year, You may request a change in the Death Benefit
Option. If You change the Death Benefit Option, We will increase or decrease the
Specified Amount of Your policy such that the Death Benefit will be the same both
immediately before and immediately after the change. If You request a change from
Option 1 to Option 2, We will decrease the Specified Amount by the amount, if any,
needed to keep the Death Benefit the same both before and after the change. If You
request a change from Option 2 to Option 1, We will increase the Specified Amount by
the amount, if any, needed to keep the Death Benefit the same troth before and after
the change. You may not make a change in the Death Benefit Option that would
reduce the Specified Amount below the minimum issue limit shown on the Policy
Schedule.
If You change from Option 1 to Option 2, the Net Amount at Risk for Your
polley will not decrease over the life of the polley as It might have under
Option 1, so You may pay higher monthly Cost of Insurance Charges In later
policy years. Therefore, the amount of premium You need to pay to keep the
policy from terminating may also be higher.
paymentofPremwms
Premium payments under this policy are payable during the lifetime of the Insured until
the day before the policy anniversary on which the Insured is age 100. Any premium
You pay must be at least $50. However, We will accept smaller premium payments if
You pay by pre-authorizing Us to make automatic deductions from Your bank account.
There is no maximum premium payment amount except We will not accept any
premium payment which would cause this policy to fail to qualify as life insurance
under federal tax laws, unless such premium is required to keep the policy in force.
In order for this policy to take effect, the first premium paid must equal at least the
Five- Year No-Lapse Guarantee Minimum Monthly Premium as shown on the Policy
Schedule at issue. Premiums after the first are payable at Our Home Office.
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Planned PremIums
Your Planned Premium is shown on the Policy Schedule, but You are not required to
make premium payments according to a set schedule. You may skip a Planned
Premium payment, and You may change the frequency and the amount of the
Planned Premium shown.
.
The amount and frequency of Your premium payments will affect Your policy
values and the length of time for which You have insurance coverage. If Your
Planned Premium Is not enough to keep Your polley in force, You may need to
change Your Planned Premium or make additional premium payments to keep
Your policy from terminating.
Continuation of Insurance Upon DiscontInuance of Premium
Payments
If premium payments are not continued, insurance coverage under this policy and any
benefits provided by rider will be continued until the Net Cash Surrender Value is
insufficient as described below in the Grace Period and Termination of Coverage
section. No rider will be continued beyond the termination date provided in the rider.
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CL 82 0307 PA
Page 1 0
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Reinstatement
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Grace Period and Termination of Coverage
Except as described below in the Guarantee of Continued Coverage section, on
any Monthly Anniversary Day when the Net Cash Surrender Value is less than the
sum of the Monthly Policy Charges for the current month, We will allow a Grace
Period. We will mail You, and anyone shown on Our records as holding this policy as
collateral, a notice indicating the minimum premium You must pay in order to keep the
policy in force. If a no-lapse guarantee is in effect, the amount of premium needed to
keep this policy in force will be the lesser of:
(1) an amount of premium which will result in a Net Cash Surrender Value
sufficient to pay all Monthly Policy Charges due through the end of the Grace
Period; or
(2) the minimum premium needed under the no-lapse guarantee provision to keep
the policy in force through the end of the Grace Period.
If there is not a no-lapse guarantee in effect, the amount of the premium needed to
keep this policy in force is the amount stated in (1) above.
You will have 61 days from the date We mail You this notice to payor mail enough
premium. If You do not payor mail the needed premium within the 61-day Grace
Period, all coverage provided by this policy will terminate without value at the end of
the 61-day period. We will rely on the postmark to determine the date of mailing. If
the Insured dies during the Grace Period, the proceeds paid will be reduced by the
amount of any unpaid charges, not to exceed three times the sum of the Monthly
Policy Charges, or the amount of minimum premium needed under the no-lapse
guarantee provision to keep the policy in force through the date of death, if less. We
will not terminate this policy until at least 61 days after We mail You and anyone
shown on Our records as holding this policy as collateral, notice at the last addresses
shown on Our records.
If the Grace Period expires and Your policy terminates because You have not paid the
needed premium, You may apply to reinstate the pOlicy within five years after the
expiration of the Grace Period if the Insured is still living. The reinstatement is subject
to evidence of insurability satisfactory to Us. In addition, You must pay an amount of
premium which will result in a Net Cash Surrender Value sufficient to pay all accrued
and unpaid costs and charges accrued through the end of the Grace Period plus an
amount sufficient to cover the Monthly Policy Charges for three months beyond the
date of reinstatement. You must also repay or reinstate any Indebtedness that existed
at the time of the termination. The reinstatement will be effective on the Monthly
Anniversary Dayan or following the date the application for reinstatement is approved
by Us.
Following a reinstatement, Surrender Charges will continue to apply from the Policy
Date as if there had been no lapse. We will restore any Surrender Charges deducted
from Your policy at the time of lapse.
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CL 82 0307 PA
Page 11
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Guarantee of
Continued
Coverage
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Extended
Coverage
Benefit
Provision
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Policy Values
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Five-Year No-LapSe Guarantee
Beginning on the Policy Date and continuing to the day before the fifth policy
anniversary, We guarantee that this policy will not terminate or begin the Grace Period
if, on the Monthly Anniversary Day a Grace Period would otherwise begin, (1) is equal
to or greater than (2), where:
(1) is the sum of the premiums paid, less any withdrawals (including withdrawal fees),
plus interest accrued daily on the balance at the effective annual rate shown on
the Policy Schedule as the accumulation rate for Five-Year No-Lapse Guarantee
Minimum Monthly Premium, less the amount of any Indebtedness; and
(2) is the sum of the Five-Year No-Lapse Guarantee Minimum Monthly Premium in
effect on each Monthly Anniversary Day through and including the Monthly
Anniversary Day on which the Grace Period would begin, plus interest accrued
daily on each such premium from the Monthly Anniversary Day it is due at the
effective annual rate shown on the Policy Schedule as the accumulation rate for
Five-Year No-Lapse Guarantee Minimum Monthly Premium.
Following a reinstatement, the above test will continue to apply from the Policy Date
as if there had been no lapse.
If Your policy is in force, and not in a Grace Period, on the day before the policy
anniversary on which the Insured is age 100, the policy will continue in force until the
Insured's death, or until it is surrendered for its Net Cash Surrender Value, whichever
occurs first. On and after the policy anniversary on which the Insured is age 100, no
further premiums may be paid, no charges will be deducted, and the Death Benefit will
be revised to equal the greater of the Specified Amount or the Cash Surrender Value,
less Indebtedness.
No further loans will be permitted. The Account Value will continue to earn interest.
The interest rate credited to that portion of the Account Value equal to Indebtedness
will be increased to 'equal the interest rate charged against policy loans.
Account Value
The Account Value on the Policy Date shall be the Net Premium received for this
policy on or before the Policy Date less the Monthly Policy Charges due on the Policy
Date. On any other day, the Account Value will be:
1. the Account Value on the preceding Monthly Anniversary Day plus interest
thereon to the current day; plus
2. any net premium received since the preceding Monthly Anniversary Day and
interest thereon from the date of receipt to the current day; less
3. any withdrawal (including any withdrawal fee) paid since the preceding
Monthly Anniversary Day and interest thereon from the date of payment to
the current day; less
4. any Monthly Policy Charges due.
CL 82 0307 PA
Page 12
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Interest Rate
Your Account Value will earn interest. Interest will be credited to Your Account Value
on each day after the Policy Date as described in the Account Value section. We
guarantee that this interest rate will never be less than the effective annual rate shown
on the Policy Schedule as the minimum guaranteed interest rate. We may, but are not
required to, credit interest at current rates in excess of the guaranteed rate. Any such
current interest rate will be determined by a prospective, and not retrospective
assessment by Us of investment conditions. We can apply a different rate of interest
to that portion of the Account Value that is equal to Indebtedness, but it cannot be
less than the minimum guaranteed interest rate.
Cash Surrender Value
The Cash Surrender Value of this policy is the Account Value, less any applicable
Surrender Charge, as described in the Surrender Charge section.
Net Cash Surrender Value
The Net Cash Surrender Value of this policy is the Cash Surrender Value less the
amount of any Indebtedness.
Withdrawal
At any time after the first policy year, You may withdraw part of the Account Value of
this policy by written notice to Us. The minimum amount of any withdrawal is $500.
No withdrawal can be made which would reduce the Net Cash Surrender Value to less
than $250. We will charge a withdrawal fee for each withdrawal after the first in a
policy year. The amount of the withdrawal fee is shown on the Policy Schedule.
The amount withdrawn (including any applicable withdrawal fee) will be deducted from
the Account Value. A deduction from the Account Value will reduce the Death Benefit.
In addition, unless the Death Benefit is Death Benefit Option 2, We will reduce the
Specified Amount to the extent necessary such that the difference between the Death
Benefit and the Account Value will be no greater immediately after the withdrawal than
it was before the withdrawal.
We may defer the payment of any withdrawal for a period of up to six months from the
date of Our receipt of the notice giving rise to such payment. Any delay will be on a
nondiscriminatory basis toward You.
Full Surrender
You may surrender this policy for the Net Cash Surrender Value by written notice to
Us. The amount We pay to You will be the Net Cash Surrender Value as of the date
We process the written notice. We will pay proceeds as described in the Payment of
Proceeds section.
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CL 82 0307 PA
Page 13
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Loan
Provisions
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Policy Costs
and Charges
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Right to Borrow and Maximum Loan
You may request a loan from Us. The maximum cumulative loan amount available
under this policy, including any Indebtedness, may not exceed the Cash Surrender
Value at the end of the current policy year, less the amount of loan interest on such
maximum cumulative loan to the next policy anniversary. Indebtedness is secured by a
first lien on this policy and any amounts payable under this policy. This policy will be
the only security We require for the loan.
We may delay granting any loan for up to six months except Jor a loan to pay
premiums on this policy or any other policy We issue. Any delay will be on a
nondiscriminatory basis toward You.
Loan Interest
The maximum loan interest rate We charge is shown on the Policy Schedule. Loan
interest is charged in arrears and is due on each Policy Anniversary and on the date
the loan is repaid in full. The amount of any loan interest charged on the loan that is
not paid when due will be treated as an additional loan.
Policy Termination
If the Indebtedness exceeds the Cash Surrender Value less the Monthly Policy
Charges for the current month on any Monthly Anniversary Day, We will terminate this
policy. We will not do this, however, until 61 days after We mail notice to You
indicating the minimum amount of loan repayment that must be made in order to keep
this policy in force. We will mail the notice to You, and to anyone shown on Our
records as holding this policy as collateral, at the last addresses shown on Our
records. A termination under this provision will not reduce the Grace Period described
in the Grace Period and Termination of Coverage section.
Repaying Loans
Loans can be repaid in whole or in part at any time during the lifetime of the Insured.
Any Indebtedness not repaid will reduce the amounts payable upon surrender of the
policy or at the death. of the Insured.
All payments We receive from You will be credited to Your policy as premium unless
You give Us written notice that the payment is for loan repayment. Loan repayments
will first be applied to pay accrued but unpaid interest on the loan, the balance will
reduce the outstanding balance of Your loan.
Premium Charges
We deduct certain charges from premium payments when We receive them to partially
cover Our expenses of distributing the policy. These charges are 1) the Premium
Expense Charge; and 2) the State Tax Charge.
Premium Expense Charge
We deduct a Premium Expense Charge from each premium payment received. This
charge is deducted before the premium payment is credited to the policy.
The maximum Premium Expense Charge rates are shown on the Policy Schedule. At
Our option, We may charge less than the maximum rates shown.
The maximum Premium Expense Charge rates differ based on the following:
. The length of time a Coverage Layer has been in effect.
· The amount of the Target Premium for a Coverage Layer.
CL 82 0307 PA
Page 14
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To determine the amount of the Premium Expense Charge deducted from each
premium payment, We do the following:
(1) We allocate the premium payment to each Coverage Layer in the same
proportion as the Target Premium for a Coverage Layer bears to the total
Target Premiums for all Coverage Layers.
(2) We determine the coverage year for each Coverage Layer.
(3) For each Coverage Layer, We determine the portions of the premium
payment allocated to the Coverage Layer in its current coverage year that are
below and above the Target Premium for that Coverage Layer.
(4) We multiply each portion of the premium payment allocated to the Coverage
Layer by the applicable Premium Expense Charge rate.
(5) We add together the Premium Expense Charges for all of the Coverage
Layers.
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State Tax Charge
To cover state premium taxes associated with distribution of this policy, We will
deduct a State Tax Charge from each premium received. This charge is deducted
before the premium payment is credited to the policy. To determine the amount of the
charge, We multiply the amount of the premium payment by the applicable State Tax
Charge rate. The State Tax Charge rate We charge will vary by state to reflect the
rate of premium tax charged by each state. We guarantee that the rate will never
exceed the maximum State Tax Charge rate shown on the Policy Schedule.
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Monthly Polley Charges
We deduct certain charges from Your Account Value on each Monthly Anniversary
Day to partially cover Our expenses of distributing, issuing and administering the
policy, and to cover the cost of providing the base policy life insurance and rider
benefits to You. These charges are 1) the Cost of Insurance Charge; 2) the Per
Policy Charge; 3) the Per $1,000 Charge; and 4) cost of insurance charges for any
riders.
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Cost of Insurance Charge
We will deduct a Cost of Insurance Charge from Your Account Value on each Monthly
Anniversary Day. The maximum monthly Cost of Insurance Charge rates for each
policy year are shown on the Policy Schedule. At Our option, We may charge less
than the maximum rates shown.
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To determine the amount of the charge on any Monthly Anniversary Day, We divide
the Net Amount at Risk for Your policy as of that Monthly Anniversary Day by 1000
and multiply by the monthly Cost of Insurance Charge rate for the applicable policy
year.
The current monthly Cost of Insurance Charge rates for Your policy depend on the
age, sex and risk class of the Insured on each policy anniversary. Any change in the
current monthly Cost of Insurance Charge rates will be on a non-discriminatory basis
toward any Insured and will apply equally to all Insureds of the same ages, sexes and
risk classes whose coverage has been in effect for the same length of time.
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CL 82 0307 PA
Page 15
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Payment of
Proceeds
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Per Polley Charge
We will deduct a Per Policy Charge from Your Account Value on each Monthly
Anniversary Day. The maximum monthly Per Policy Charge is shown on the Policy
Schedule. At Our option, We may charge less than the maximum amount shown.
Per $1,000 Charge
We will deduct a Per $1,000 Charge from Your Account Value on each Monthly
Anniversary Day. The maximum monthly Per $1,000 Charge rates for any Coverage
Layer are shown on the Policy Schedule. At Our option, We may charge less than the
maximum rates shown.
To determine the amount of the charge on any Monthly Anniversary Day, We divide
the initial Specified Amount for each Coverage Layer by 1000 and multiply by the
monthly Per $1,000 Charge rate applicable to that Coverage Layer. We then add
together the charges for each Coverage Layer.
The current monthly Per $1,000 Charge rate for a Coverage Layer depends on the
age, sex and risk class of the Insured on the Policy Date or effective date of a
Coverage Layer.
Rider Charges
Cost of insurance charges for any riders You add to Your policy are described in the
applicable rider. Maximum rider cost of insurance charges will be shown in the Policy
Schedule.
Surrender Charge
For a certain period following the Policy Date or the date of any increase in Specified
Amount, We will deduct a Surrender Charge from Your Account Value if either of the
following occurs:
(1) You surrender Your policy; or
(2) a Grace Period ends without sufficient premium or loan repayment being paid
to Us to keep the policy in force.
The amount of the Surrender Charge that would apply in each policy month of Your
policy is shown on the Policy Schedule at issue. If You request an increase in
Specified Amount, new Surrender Charge amounts will apply to the increase. We will
add these Surrender Charges to the original Surrender Charges and send You an
amended Policy Schedule showing the new Surrender Charge amounts that would
apply in each remaining policy month.
The Surrender Charge amounts depend on the age, sex and risk class of the Insured
on the Policy Date or the date of any increase in Specified Amount.
Po/icy Proceeds
The proceeds of this policy may be either Death Proceeds, payable to the Beneficiary
upon the death of the Insured, or Net Cash Surrender Value proceeds, payable to You
if this policy is canceled for its Net Cash Surrender Value during the lifetime of the
Insured .
How We Pay
Proceeds may be paid in a lump sum or under one or more Income Plans. The Income
Plans are described in The Income Plans section.
CL 82 0307 PA
Page 16
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Choosing an
Income Plan
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We may defer the payment of Net Cash Surrender Value proceeds for a period of up
to six months from the date of Our receipt of the notice giving rise to such payment.
Any delay will be on a nondiscriminatory basis toward You.
Death Proceeds will be paid within two months following receipt of due proof of death.
We will pay interest from the date of death or other date proceeds are due to the date
of payment. The rate of interest will not be less than that required by law.
You may choose an Income Plan for Net Cash Surrender Value proceeds or for Death
Proceeds during the lifetime of the Insured. If You choose an Income Plan, a
Beneficiary may not change. it. If You do not choose an Income Plan before the
Insured dies, the Beneficiary can choose one. If the Beneficiary does not choose an
Income Plan within 60 days after the date proceeds are due, We will pay the proceeds
in a lump sum. For each plan We may issue a separate written agreement putting the
plan into effect. The smallest amount that may be applied under an Income Plan is
$2,000. Each payment must be at least $100. We may make less frequent payments
if payments to be made would be less than $100.
The Beneficiary may be the payee for payments under the selected Income Plan, or
may name a different payee to receive the payments under Income Plans. The
Beneficiary may also name a contingent payee to receive any amount still due when
the payee dies. If a payee dies and there is not a contingent payee, any amount due
and unpaid will be paid to the estate of the payee who died. A payee or contingent
payee may not be a fiduciary or non-natural person without Our consent.
CL 82 0307 PA
Page 17
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The Income Plans
In addition to the following options, other Income Plans may be available.
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Option 1 - Payments for a Fixed Period
Equal monthly payments will be made for a stated number of years, which You select
from the Fixed Period Minimum Income Table. The monthly payments will not be less
than those shown in the table.
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Option 1 - Fixed Period Minimum Income Table*
Monthly Payments for each $1,000 applied
Number Monthly Number Monthly Number Monthly
of Install- of Install- of Install-
Vears ments Vears ments Vears ments
1 $84.47 11 $8.86 21 $5.32
2 42.86 12 8.24 22 5.15
3 28.99 13 7.71 23 4.99
4 22.06 14 7.26 24 4.84
5 17.91 15 6.87 25 4.71
6 15.14 16 6.53 26 4.59
7 13.16 17 6.23 27 4.47
8 11.68 18 5.96 28 4.37
9 10.53 19 5.73 29 4.27
10 9.61 20 J 5.51 30 4.18
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* Values are based on interest at an effective annual rate of 3%.
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Option 2 - Payments for Ufe - Guaranteed Period
Equal monthly payments will be made for the guaranteed period chosen and thereafter
during the life of the payee. The amount of each monthly payment depends on the
payee's sex and adjusted age (see, Adjustment to Age) on the date of first payment
and on any guaranteed period chosen. See the One Life Minimum Income Table,
below. We may require proof to Our satisfaction of the payee's age. We may require
like proof that the payee is alive on the date any payment is due. The guaranteed
period may be 10 or 20 years.
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Cl 82 0307 PA
Page 18
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Option 2 - One Life Minimum Income Table*
Monthly Payments for each $1,000 applied
Age of Life Life Age of Life Life
Payee 10 Years 20 Years Payee 10 Years 20 Years
Last Certain Certain Last Certain Certain
Birth. Birth.
day Male Female Male Female day Male Female Male Female
16 and
under $2.81 $2.76 $2.81 $2.75 50 $3.88 $3.64 $3.80 $3.60
16 2.83 2.77 2.82 2.76 51 3.94 3.70 3.85 3.65
17 2.84 2.78 2.83 2.78 52 4.01 3.75 3.91 3.70
18 2.85 2.79 2.85 2.79 53 4.08 3.82 3.96 3.75
19 2.87 2.80 2.86 2.80 54 4.16 3.88 4.02 3.81
20 2.88 2.81 2.88 2.81 55 4.23 3.95 4.09 3.87
21 2.90 2.83 2.89 2.82 56 4.32 4.02 4.15 3.93
22 2.91 2.84 2.91 2.84 57 4.41 4.09 4.21 3.99
23 2.93 2.86 2.93 2.85 58 4.50 4.17 4.28 4.05
24 2.95 2.87 2.94 2.87 59 4.60 4.25 4.35 4.12
25 2.97 2.89 2.96 2.88 60 4.70 4.34 4.42 4.19
26 I 2.99 2.90 2.98 2.90 61 4.81 4.44 4.49 4.26
27 3.01 2.92 3.00 2.92 62 4.92 4.54 4.56 4.33
28 3.03 2.94 3.02 2.93 63 5.04 4.64 4.63 4.41
29 3.05 2.96 3.04 2.95 64 5.17 4.75 4.70 4.49
30 3.07 2.97 3.07 2.97 65 5.30 4.87 4.76 4.56
31 3.10 3.00 3.09 2.99 66 5.44 5.00 4.83 4.64
32 3.12 3.02 3.11 3.01 67 5.59 5.13 4.90 4.72
33 3.15 , 3.04 3.14 3.03 68 5.74 5.27 4.96 4.79
34 3.18 J 3.06 3.17 3.06 5.89 5.42 5.03 4.87
69
35 3.21 3.09 3.20 3.08 70 6.06 5.58 5.08 4.94
36 3.24 3.11 3.22 3.10 71 6.22 5.75 5.14 5.01
37 3.27 3.14 3.26 3.13 72 6.39 5.92 5.19 5.08
38 3.31 3.17 3.29 3.16 73 6.57 6.10 5.24 5.14
39 3.35 3.20 3.32 3.19 74 6.75 6.29 5.28 5.20
40 3.38 3.23 3.36 3.22 75 6.93 6.49 5.32 5.25
41 3.42 3.26 3.39 3.25 76 7.12 6.69 5.35 5.29
42 3.47 3.30 3.43 3.28 77 7.30 6.90 5.38 5.34
43 3.51 3.33 3.47 3.31 78 7.48 7.11 5.41 5.37
44 3.56 3.37 3.51 3.35 79 7.67 7.32 5.43 5.40
45 3.60 3.41 3.56 3.39 80 7.85 7.53 5.45 5.43
46 3.65 3.45 3.60 3.43 81 8.02 7.73 5.47 5.45
47 3.71 3.50 3.65 3.47 82 8.19 7.93 5.48 5.47
48 3.76 3.54 3.70 3.51 83 8.35 8.13 5.49 5.48
49 3.82 3.59 3.75 3.55 84 8.50 8.31 5.50 5.49
85 and 8.64 8.48 5.50 5.50
over
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* Values are based on the "Annuity 2000 Table," with Projection Scale G,
adjusted for age last birthday, with interest at an effective annual rate of 3%.
Option 3 - Payments of a Fixed Amount
Equal monthly payments of a fixed amount will be made until the value applied under
this option, with interest credited at an effective annual rate of 3% on the unused
balance, is exhausted. The amount chosen must be at least $5 per month for each
$1,000 of proceeds placed under this option. The last payment will be for the balance
only. Payments may not be for more than 30 years.
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CL 82 0307 PA
Page 19
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Option 4 . ute Annuity. No Guaranteed PeriOd
Equal monthly payments will be made during the life of the payee. The amount of
each monthly payment depends on the payee's sex and adjusted age (see,
Adjustment to Age) on the date of the first payment. See the One life Minimum
Income Table, below. We may require proof to Our satisfaction of the payee's age.
We may require like proof that the payee is alive on the date any payment is due.
There is no guaranteed period. This means that when the payee dies, no further
payments will be made, even jf only one payment has been made.
.
Option 4 - One Life Minimum Income Table*
Monthly Payments for each $1,000 applied
Age of Life Age of Life
Payee No Years Payee No Years
Last ~Art""in Last Ce rtain
Birthdav MAl... Male
15 or under $2.82 $2.76 50 $3.91 $3.66
16 2.83 2.77 51 3.98 3.71
17 2.84 2.78 52 4.05 3.77
18 2.86 2.79 53 4.12 3.83
19 2.87 2.80 54 4.20 3.90
20 2.89 2.82 55 4.28 3.97
21 2.90 2.83 56 4.37 4.04
22 2.92 2.84 57 4.47 4.12
23 2.93 2.86 58 4.57 4.21
24 2.95 2.87 59 4.67 4.30
25 2.97 2.89 60 I 4.79 4.39
26 2.99 2.90 61 4.91 4.49
27 3.01 2.92 62 5.04 4.60
28 3.03 2.94 63 5.18 4.71
29 3.05 2.96 64 5.33 4.84
30 3.08 2.98 65 5.49 4.97
31 3.10 3.00 66 5.66 5.11
32 3.13 3.02 67 5.85 5.26
33 3.15 3.04 68 6.04 5.43
34 3.18 3.06 69 6.25 5.60
35 3.21 3.09 70 6.48 5.80
36 3.25 3.12 71 6.71 6.00
37 3.28 3.14 72 6.97 6.23
38 3.32 3.17 73 7.24 6.47
39 3.35 3.20 74 7.53 6.73
40 3.39 3.23 75 7.84 7.02
41 3.43 3.27 76 8.18 7.33
42 3.48 3.30 77 8.53 7.66
43 3.52 3.34 78 8.92 8.02
44 3.57 3.38 79 9.33 8.4~
45 3.62 3.42 80 9.77 8.85
46 3.67 3.46 81 10.24 9.31
47 3.73 3.51 82 10.75 9.82
48 3.78 3.55 83 11.29 10.37
49 3.84 3.60 84 11.87 10.96
85 and over 12.49 11.61
.
.
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.
.
.
'Values are based on the "AnnuUy 2000 Table, " with Projection Scale G,
adjusted for age last birthday, with interest at an effective annual rate of 3%.
Cl 820307 PA
Page 20
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CL 82 0307 PA
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Option 5 . Joint and Survivor
Equal monthly payments will be made during the lifetimes of two payees. Upon the
death of either, payments will continue unchanged throughout the lifetime of the
survivor, or they may be reduced to a pre-selected percentage (75%, 66 2/3%, or
50%) of the original payment. Payments will cease upon the death of the survivor.
There is no guaranteed period. This means that when the survivor dies, no further
payments will be made, even if only one payment has been made. The amount of
each monthly payment depends on the sexes and adjusted ages (see, Adjustment to
Age) of both payees on the date of first payment, and the pre-selected percentage for
continuing payments. See the sample monthly payments in the Joint and Survivor
Minimum Income Table, below. The payments for each $1,000 applied will not be less
than those in the Joint and Survivor Minimum Income Table. Values not illustrated in
the table are available upon request. We may require proof to Our satisfaction of the
payees' ages. We may require proof that any payee is alive on the date any payment
based upon the life of such payee is due.
Option 5 . Joint and Survivor
Minimum Income Table*
Sample Monthly Payments for each $1,000 applied
Male Female Joint & Joint & Joint & Joint &
Age Age 100% 75% 662/3% 50%
Survivor Survivor Survivor Survivor
60 60 $3.93 $4.23 $4.34 $4.58
60 65 4.14 4.48 4.61 4.88
60 70 4.34 4.75 4.90 5.24
65 60 4.07 4.44 4.58 4.88
65 65 4.36 4.75 4.90 5.22
65 70 4.66 5.10 5.27 5.64
70 60 4.18 4.65 4.83 5.23
70 65 4.56 5.03 5.22 5.62
70 70 4.97 5.48 5.68 6.12
"Values are based on the "Annuity 2000 Table," with
Projection Scale G, adjusted for age last birthday,
with interest at an effective annual rate of 3% .
Adjustment to Age
The amounts shown in the monthly life income tables for Option 2, Option 4 and
Option 5 are applied at the ages shown through 2009. Thereafter, an adjusted
age will be determined as follows:
Year Life Income
Payment Plan Begins
Age Setback
2010 - 2019
2020 - 2029
2030 - 2039
2040 . 2049
2050 and later
1 year
2 years
3 years
4 years
5 years
To determine the adjusted age, subtract the age setback from the actual age.
For example, for a 67-year-old person in 2028, use age 65 factor per $1,000
from the applicable table.
Page 21
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Additional Interest
We may increase the interest rate above the guaranteed minimum annual rate of 3%
shown in the Income Plans above. Payments under those plans will be based on the
interest rate We are using on the due date of the first payment.
.
Commutation of Income Options
No payment and no amount held under an Income Option may be transferred or
withdrawn before its due date. However, the right to transfer or withdraw may be
made a part of any plan, if We agree. '
General
Provisions
Annual Report
At least once a year We will send You an annual report without charge showing the
current Account Value, Surrender Charge, Cash Surrender Value, Indebtedness, Net
Cash Surrender Value, amount of interest credited to the Account Value, premiums
paid. loan activity, withdrawals, Premium Charges, Monthly Policy Charges, and any
other fees deducted since the date of the last report. Any other information required by
applicable law will also be included in the annual report.
.
.
Project/on of Benefits and Values
You may request other information about this policy, including a projected illustration
of policy benefits and values, based upon assumptions as are necessary and specified
by Us and/or You. We may charge a fee not to exceed $25 to provide this information.
.
Reliance
We have issued this policy in reliance on the answers You have provided to Us in the
application and in any supplemental applications. In the absence of fraud, these
answers are considered representations, and not warranties. We have assumed that
all these answers are true and complete. If they are not, We may have the right for
two years from the POlicy Date, from the date of any increase in Specified Amount, or
from the date of any reinstatement to contest the validity of this policy as explained in
the Umits on Our Contesting This Policy section. If that occurred, We would send
back all the premiums You had paid, or the monthly costs of insurance charges for
any rider We contest.
.
.
Juvenile Insureds
If the Insured was less than 20 years of age on the Policy Date, We will notify the
Insured at least 60 days before the policy anniversary on which the Insured will be age
20 that the Insured may apply for non-tobacco user status. If the Insured does not
respond to the notice by the policy anniversary on which the Insured wnl be age 20, or
if the Insured does not meet Our criteria for non-tobacco user status, We will assign
the Insured to Our uniform default classification of tobacco user status. If the Insured
applies for non-tobacco user status, the application will become part of the application
for the policy.
If the Insured is reclassified as a non-tobacco user at reduced Cost of Insurance
Charge rates based upon the application. We will send an amended Policy Sc~dule
showing the new classification and the new Maximum Cost of Insurance Charge rates.
The reduced rates will be effective on the age 20 anniversary. We will not contest the
amount of insurance attributable to the reduction in Cost of Insurance Charge rates
after the reduced rates have been in effect during the Insured's lifetime for two years
from the date of the reduction.
.
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Cl 820307 PA
Page 22
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Tobacco Use Reclassification
After the policy anniversary on which the Insured is age 20, You may apply for
reclassification of the Insured from tobacco user to non-tobacco user by completing a
form provided by Us. If You apply for a reclassification, the application will become
part of the application for the policy. If the Insured meets our criteria for non-tobacco
user reduced Cost of Insurance Charge rates based upon the application, We will send
an amended Policy Schedule showing the new classification and the new Maximum
Cost of Insurance Charge Rates. The reduced rates will be effective on the Monthly
Anniversary Day following Our receipt of the application. We will not contest the
amount of insurance attributable to the reduction in Cost of Insurance Charge rates
after the reduced rates have been in effect during the Insured's lifetime for two years
from the date of the reduction.
Reclassification will be based upon Our general underwriting rules in effect at the time
of the application, which may include criteria other than smoking and/or tobacco use
status and may include a definition of smoker and/or tobacco use different from that at
issue. No information provided in the application will be used to assign the Insured to
a less favorable classification.
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Urnits on Our Contesting This Polley
No statement will be used in contesting this policy unless it is in an application or
supplemental application and a copy of such application is attached to this policy. No
statement will be used in contesting a rider unless it is in an application or
supplemental application for such rider and a copy of such application is attached to
this policy. This provision shall not apply to any agreement providing benefits in event
of disability or in event of death from accidental means.
We will not contest this policy to the extent of the initial Specified Amount after it has
been in effect during the Insured's lifetime for two years from the Policy Date. We will
not contest the validity of any increase in Specified Amount after such increase has
been in effect during the Insured's lifetime for two years from the effective date of the
increase. We reserve the right to contest the validity of any rider providing disability
benefits or accidental death benefits. Unless otherwise provided in the rider, however,
We will not contest any other rider attached to this policy after such rider has been in
effect during the Insured's lifetime for two years from the effective date of the rider.
We will not contest this policy with respect to statements made in an application for
reinstatement after the policy has been in effect during the Insured's lifetime for two
years from the effective date of the reinstatement. Any premium refund will be limited
to those paid on or after the effective date of the reinstatement.
.
.
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Suicide
We will pay only a limited benefit if the Insured commits suicide while sane or insane,
within two years from the Policy Date. If the policy is in force, We will return the
premiums You paid, less: (1) the amount of any Indebtedness; (2) any withdrawal
amount (including withdrawal fees); and (3) all monthly costs of insurance on all
persons other than the Insured ever covered by rider. If the amount of the Net Cash
Surrender Value is larger, We will pay it instead.
We will not pay with respect to any increases in the Specified Amount jf the Insured
commits suicide while sane or insane, within two years from the effective date of any
such increase. If the policy is in effect and the Insured commits suicide more than two
years after the Policy Date and within two years after the date of an increase in
Specified Amount, We will return the monthly costs of insurance charged for such
increase.
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CL 82 0307 PA
Page 23
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This provision also applies to any rider attached to this policy. The two-year period will
be measured from the rider's date of issue.
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Error In Age or Sex
If the Insured's age or sex as stated in the application is wrong, it could mean the
Monthly Policy Charges are wrong and that policy values have to be recalculated. The
same is true for the age or sex of any other person insured by a rider to this policy. If
the error is discovered while the Insured is still living, We will adjust the Account Value
to the amount it would have been if the monthly Cost of Insurance Charges for the
correct age and sex of the Insured had been applied from the Policy Date. If the error
is discovered after the death of the Insured, We will adjust the amount of the Death
Proceeds payable to the amount that the monthly Cost of Insurance for the month of
death would have purchased at the correct age and sex.
.
Claims of Creditors
The proceeds of this policy will be paid free from the claims of creditors to the extent
allowed by law.
.
Assignment
You may assign this policy by giving Us notice of the assignment. An assignment
does not change the ownership of the policy. But, Your rights and any Beneficiary's
rights will be subject to the terms of the assignment. We will not be responsible for
the validity of an assignment. We will not be liable for any payments We make or
actions We take before We receive notice, satisfactory to Us, at Our Home Office of
an assignment or, as applicable, a release of assignment.
.
.
Required Note on Our Computations
Calculations are based on the Mortality Tables shown on the Policy Schedule. We
have filed a detailed statement of Our computations with the applicable State
Insurance Department. The values under this policy are not less than those required
by the law of the state where the policy is delivered. Any benefit provided by an
attached rider will not increase these values unless stated in the rider.
.
Authority to Make Agreements
All agreements made by Us must be in writing and signed by Our president, a vice
president, Our secretary or an assistant secretary. No other person, including an
insurance agent, can change any of this policy's terms, extend the time for paying
premiums, or make any other agreement which would be binding on Us.
Conformity with Laws
We reserve the right to make any changes necessary to comply with any federal or
state statute, rule or regulation. You will be given the right to accept or reject any
change to the policy that affects Your benefits or coverage under this policy.
.
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CL 820307 PA
Page 24
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When In Force
The policy will not take effect until You receive it and pay the minimum initial premium
as described in the Payment of Premiums section while the Insured is alive and in
the same health as indicated in the application. It will take effect anew on any
reinstatement date. The policy will be "in force" from the time it takes effect until in
ends as described in the Termination section.
.
Termination
This policy will terminate and all insurance coverage under the policy will stop: (1) as
of the date We receive notice from You requesting surrender of the policy; (2) as of
the date the Insured dies (although some riders may provide benefits for other covered
persons beyond the Insured's death); (3) as of the date the Grace Period expires
without payment of the needed premium; or (4) as of the date 61 days after We mail
You notice that the amount of the Indebtedness exceeds the Cash Surrender Value
less the Monthly Policy Charges without payment of the needed loan repayment.
.
Notices
Whenever written notice is required, send it to Our Home Office. The address of Our
Home Office is shown on the front of this policy. Please include the policy number in
Your correspondence.
Nonparticipating
This policy and any riders attached to it are issued at a nonparticipating rate and shall
not share in Our surplus earnings.
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CL 82 0307 PA
Page 25
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(Page Intentionally Left Blank)
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CL 82 0307 PA
.
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Columbus Life
Insurance~Comrfmy
.
Policy No.
CM5011754U
AMENDMENT OF APPLICATION FOR INSURANCE
COLUMBUS LIFE INSURANCE COMPANY
.
It is hereby agreed and understood to amend the application for insurance to COLUMBUS LIFE INSURANCE COMPANY
on the life of the following insured BETTY V ALENCIK
on date of application of
June 18. 2004
as follows:
THE VALUES SHOWN ARE BASED ON AN ANTICIPATED UNSCHEDULED PREMIUM DEPOSIT THAT HAS NOT
YET BEEN RECEIVED. ACTUAL POLICY VALUES WILL BE ADJUSTED TO REFLECT THE ACTUAL MONIES
. RECEIVED AND THE DATE OF RECEIPT.
THE SPECIFIED AMOUNT OF BASE IS $132,632.00 WITH A SUPPLEMENTAL COVERAGE RIDER IN THE
AMOUNT OF $132,631.00 FOR A TOTAL OF $265,263.00 DEATH BENEFIT.
.
SECTION liS AMENDED TO READ AS NONE. THERE IS NO OTHER INSURANCE IN FORCE.
.
.
.
I hereby agree that the abov.e represents change(s) to and shall be made part of the original application and policy issued
thereunder, and will be binding on any person who shall have or claim interest under such policy.
Signed at
this
day of
.
Signature of Witness
Signature of Insured (if age 18 or older)
Signature of Other Insured(s)
Signature of Applicant (if other than Insured)
.
Signature(s) of Child(ren) (if age 18 or older)
Signature of Policyowner (if other than Applicant)
CL 45. 185-PA (6/96)
.
.
; Applicetiol'OI Lif. ".unIlCI
Columbus Lik
Insunma.Compiity
4II01Wt l'ouatH _ . ..0.1015711 . CDoc:lHICo'l1. OIDD 4SlDJ-57S7. _.CcI.uaoJuslaLOlM
USE BlACK INK
.
Name :s~. ~7!~
SSl or Tax 10 I ..=" t7D - /~- -~ ?,3t;
ria Female Ch all
o Male Birth Date / /~ .<,: (9::/.e -.iL
Birth Place ~~~ Ht~' p-. Wt 10 7
Name
SSlorTaxlOI
Rllatlonship to Insured
o Female
o Male Birth Date
Birth Place Ht
Aga_
.
Wt
.
No. of Units
SM .&m ~te of Birth
~
.
.
.
o Waiver of Ins. Cost 0 W.P. (lfVUL CreditAmt.
o SCA (Not included in 0 abovel
DI OIA Term $
o PULA 0 SPlR (Premium Amountl $
D1lnsured Insurability $
01 ADB 11 ADB 12 $
o Dividend Option, jf participating:
One-Year Term Additions. balance to:
I
o T ann Rider $ 0 Proposed Insured 0 O1her Insured
Renewal Period Vrs.: OJ, 0 5 0110 0 20
Conversion Period: 0 Nonconvertible 015 yr. [ilTo age 70
.
Other
o Buy Paid-Up Additions
Accumulate at Interest
Relationship to Insured
Relationship to Insured
-SaJ
.
or;
~
.
boo
Cl4S.238-I'A f4J99)
"-lIe' 019
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AIIIt
Accidental Delth Amt
Yr luUI'-
.
Driver's license number1s) and state NO I.J C~ /1 s e...
t n the past flV8 years, he rive(s license suspended or revoked or had two Of more moving violations? ........................................0 Yes Q1(o
2' H8V8 you ever consulted a physician or medical practitioner for. or been treated for: high blood pressure,
. cancer tumors diahew. ulcers. or heart, lung. or liver disorder, mental or nervous disorder, or back or spine disoroer1..............,BYes l3-Ifo
3 Have You been'treated for AIDS, ARC (AIDS.Related Complex) or any other immune deficiency disorder? ....................................... Yes Q.NO
4: Have you used sedatives, stimulants. hallucinogenic Of narcotic drugs other than Ihose prescribed by a physician Dr
medical practitioner, or boen treated for drug or alcohol use? ...........................................................................................................0 Yes gifo
5 Ever been declined, postponed. rated or modified for insurance or reinstatement? ...........................................................................0 Yes Q.No
6' Within Ibl plst 12 ..nthl have you or any proposed insured smoked a cigarette or used any tobacco products? .....................0 Yes [].HIS
l' In the past three years, have you or any proposed insured participated in the following: parachutin,. scuba diving. motor racing
. or aviation other than regular commercial airline ffights? If "Yes." complete a Supplemental Questionnaire. ..............................0 Yes I4NO
8. Has any member of your immediate family ( rents. brothers or sisters) had heart disease. diabetes. or cencer prior to 50? 0 Yes (3-H6
Personal ~ieian Name/Address: cJ -e.. j I
Details to "Yes. answers and/or SpeCie Instructions (For "Yes. answers, please list quostion I, name, date. physiCian. hospital. address. and
phone.)
.
.
.
DECLARATION: I unde.stand and Igraa to *. following:
A) the representations recorded in this application are trUe and complete to the best of my knowledge arld belief, and constitute the primary
basis for the issuance of any insurance hereunder;
B) only an authorized underwriter of the Company at its Home Office has the authority to determine insurability;
C) no agent is authorized to make Dr alter contracts. to extend the time for payment of premiums. or to waive any of the Company's rights or
requirements;
D) if tb. Compa., ICC'P" 1/1Z of tit. lIilimum Innull p.emia.. Ind , TI.perery Insurance Agr.....nt i. dul, 1.lut.d, thl
Compa.., ia lilbll und.. dli. .pplie.tio. to till .xtont providld In the Temporary IDlurlnee Agreement OIllIMi.., lb.
Company shill incur no lilbility Ind.. this epplieMion unl... , policy i.luld In lbi. app/lcatioa hit ".In "c.i,ed by the
Own.r, lbe first premllm hi. bI.. paid 8ftd any limhatlon or lIodiflcatiol of In'UI'IRc, I,plied for .a. bee. Igr.,d to I,
wrltl., by the Owner, III while tII. he.hh of tho p.rlon(I' now propolld for coverage and .ny otber conditio", rem.ln a.
dalcribed i. thl Ipplic.tion.
E) if the Company amends this application by endorsement. acceptance of any policy issued shall constitute a ratification of change or correction
only to clarify the intent of the policy and/or coverage as applied for on the application without reduction in benefit.
AUlHORlZAnON TO OBTAIN INFORMAnON: I authorize any physician or other medical practitioner. hospital, clinic, other medical care
institution. other companies or instiMions. my employer. consumer reporting agency or the Medical Information Bureau. Ine.. to give Columbus
life Insurance Company, or its reinsurers, information about me or my health for underwriting purposes. Except for the Medicallnfonnation
Bureau reports. information may. in some cases. be obtained by an authorized representati\>e of Columbus life. This information may include an
investigative consumer report. details of other insurance coverage. employment, or medical care including diagnosis. acMce and treatment of any
physical and mental condition regarding me or any of my minor children to be insured. I further consent to the release of any drug or alcohol
related information which may be protected by federal regulations.
USE AND DISCLOSURE: I understand that Columbus life will use this information to determine eligibility for insurance and/or benefits. Also,
~olumbus life or its reinsurers may release this information to the Medical Information Bureau, Inc. reinsurance companies and/or to other
Insurance companies to which' may apply for insurance and/or benefits. This Authorization is valid for two and one-half years form the date
shown below unless a shorter period is legally required. I understand that I have the right to receive a copy of this Authorization upon request A
photocopy of this Authorization will be as valid as the original. My signature below also acknowledges my receipt of the privacy notice found on
pages 6 and 7 explaining the Medical Information Bureau, Inc. and investi~ative consumer reports. Unll.. penalties of perlu!!, I certify t"t
m thl lumber .hOWD on tlti. form i. ., eorRot Tlxpl,er Idlntification Nu..b." 8ad (2) 11111 not cunlRtl, &U'.ta to 'Icku,
withholding a. a reauh of Internal RIVlnue S.rvlc. lotlficadon. lb. Internal Revllu, S.rvlc. do.. not re"ulre ,our CODl.at to
any prowi.ion of thi. documllt ot", th.. th. ,eRifleation. "..ired to avoid blchp wltMloldiltll.
WARNING: Any p.r.on wlto knowinlly an' witll iatlnt to defr.ud .n, in..ranc. complny or ode" p.rson filII a. application
!or i...ranc. or ltltem.nt of claim contll.lng .., m.teri,ll, f,l.. Informltlon or conce.', to. tlte purPO.I of mlll.edlng,
Information concerni.. IIY t.ct .Iteril' thereto commits . traudulent insurencI ICt. which is . cri"l and subjlcta luell
P~l'Ion 10 crl,ml.aland civil penlhl~ . /~.1
Signed at ~fd. WI S~ ~ Date , L_IJ) r
[Cilyand Stater I
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... Zof9
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INSTRUCTIONS 10 THE EXAMINER:
.
/' -....
=~L Columbus Life '~....,
Application for Insurance
111I11111111111111111111I1111
0057244274
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MIddle Initial
V t'J,,- ~ ~ c../ /(
Last Name
.
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5.33
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1. a. N8.IJ)e and Address of your M
personal physician (if none, so state)
b DAte and reason
. last consulted? ::J VIV t ,..".., CJ 0 ~
c. What treatment was given .
or medication prescribed? X/A, v .J'. -
L ~-...I~ODS should be made In priftt.e..
2. Record __ in your own IIaDdwritIDc-
3. Propelled Imured mould sip flIIl Dame.
4. MaD thD repon direct to the Dome 0Iftce.
5. Do DOt deImtr 01' reveal this report to any Aaent.
~ Mail urine speeimealblood Idt direct to laboratory
.. addres8ed on -...,~...
BirtIi
Dale / /
Mcmth
d$
Day
S ~6-~- ,,-...D f 70 .3.!Z' o?.3$ /
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2. Have you ever been diagDosed as luning or been
treated by a member of the. medk:aI profession tor:
a. DIsOrder of eyes. ears, nose, or tb%o8t? . . . . . . . . . . . . . . . . . . .
b.. Di'f.2';lDeaS. fiIiDdD& coDYUlskms, hadachc; ~ r:Idl:d.. panIlysia
or stl'OJre; DleDl:8l or nervous dilImder'? . . . . . . . . . . . . . . . . . . . .
Co SbDftMSS of breaIh, persis1imt hoarseDeu or coush. blood spit-
ting: 1mmchitia, pleurisy, a&raies, uthma, ~, lUber-
c:closis or cbrornic xcspinotDry cIiaordeI"1 . . . . . . . . . . . . . . . . . . .
d. a-t paiD, palpitation, tuah blood ~ rbeumatic mw, bean
DIII1'IIIIJr,~.-:k or ~ dilloIdcr oC1be heart or blood ~
e. JaJIIldjc:e. iIltcstiDlIl bleediDa: ulcer, bernia, appeodicitis, oolitia,
~ ~ rec:urreat iDdigest\oD, or odlec disordec
of the stOIDlICb. iDtcsIiDes,. liw.r or plIbladder? ............
f. Su&u. II1bunliD. blood or put ill uriDo; veDerelIl di.sea.se: stone or
odlec disorder ofkidney, bladder. proItlII'e or reproductive cqam?
g. Di&beteS; tityroid or 0Iber ~ocriIIe dUolders? ... . . . . . . . . .
h. Nearitis. sciatica, Theuma!lsm. ~, gout. or disorder of the
JDIlscles or boDes, including the spine, back or joiD1S? . . , . . . .
i. DelWmity, lameness or amputatioa? . . . . . . . . . . . . . . . . . . . . . .
j. Dilo:rdcr of sJcin, Iympb glands. c:yst, tumor, or cancer? . . . . .
k. Alcoholism or any babit-1brmiDg drup? . . . - . . . . . . . . - . . . . . .
I. AIICIDia. hemophilia, or any blood disorder?.. .. . -. - -. . . . -
Axe you now under observation or taking treattnent? . . . . . . . . . . .
Have you bad ~ change in weight in 1be past year? . . . . . . - . . -
AIDS. ARC. or any other immune ddicie:ncy disorder? ........
Othc tIum. above, ha<ie you within tbr: past S years:
a. Had any mental or ~ca1 disorder not listed above? . . . . . . .
b. Had a checkup, consultation, iDDcsa. or iJUury? . . . - - - - . . . . .
c. Been a plIIient in a hospital, cliDic, 3lID8tOrium. or other medical
1acility? ... . . . . . . . . . . . . . . . . . . . . . . . . . - . . . . . . . . . - - . . . . .
d. Had e1cctrocardioa:ram, X-n;y, or o1ber diaanostic teat? . . - . . .
Co Been advised 10 ba\1oIll ao;y ~" 1Il5t, bospilalhation, or surserY
which was oot c;ompleted? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Have you ever had mililary service delierment, rejection or discbarge
because of a physical or me:otal coDdition1 - . . . . . . . . . . - - . . . . . .
Have you ever requested or re<:ei'l>ed a pellSion, beneIllS. or pllyIDeJJt
because of an injuty. sicll:ness or disability? ........ . . . . . . . . . _
Family History: 'IUbercu1osis. diabetes, cancer. hiah blood pressure,
heart or kidoey disease. meola1 ll1neas or suicide? . . - . - - . . . . . . .
a. Do you now use ~ in any tbnn?-.... ...... .... .....
If yes, specify type (clgaretlles. pipe, etc.). - . . _ _ _ _ . . . _ . '. . _ _ _
b. Did you previously \UlC tobacco and quit? . . . - - . - _ _ _ . . _ . . . _ .
H yes. in what month and year did :you quit? . _ _ _ _ . . . . . . . . . .
c. Daily aveTlIge use of tobacco (pest or present)? .. _ . . . . . . . . . .
d. Do you now use any "stop smoldng" aids? .............. _. 0
n. Have you ~r had any diso:rdcr of menstruation, pregnancy or of the
~roductive OtgllDll or breasts? . . . . . . . . - - . . - . . . . . . . . . . . . . . .. [:J
.
. 3.
4.
S.
(i
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7.
8.
. 9.
10.
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YES NO
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0 [:s;I
0 00
0 G/I
0 ~
0
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0
0
0
0
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0 ~
0 1$1
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[J 19
0 ~
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~K INK
UFlTH STREET
110 .ollI2Cleo3S02
/9'07.:1..
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DETAILS of "Yes" answers. (IDENTIFY QUESTION
NUMBER, CIRCLE APPI..JCABLE ITEMS: Include
~, dates. duration and names and addresses of an at-
tending pbysiciaDs and medical facilities. Use Part 3 if addi.
tional ~ is needed.)
~ tJ 11fr'-rI-/;t'/7"/S~ 1!/I/VaJ' .. Me:/<"
IUd ;'11 /!'bS". dO y.Rr :JJtf" Jit/!-'A/,v.;-S -
$.~1rIt: ;n.b c""#VJ~..fJ" ~
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Age if
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Member
Father
Mother
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No. Dead...l..._..
t..)r..J k' '" Q C/.uJ
Age al
Death?
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p\ele 110 Ibe bat oI~ --... r ~ _..110..... _..may ~ Pti, .. bebaII orw...._--..or-__-......_~or--
or~_ or..., _ who MIl _01'_"" _"''''' po6ey _....-. b. D......,............ _4 r __..., _110 -. _.. _ be 1__
SisDod ..~) CAT,4 t../ I s.r.-9 M Daze;. .::> 3- 0 ~ , I
Wllnea ~&/tJ~ ~4-~4"'7" JUt:' l'YO{lDS<<1ln5W1ld7< l?I.a!it- 1~~~ ___
CL30S i) . V~#fJ e-- cM~ ~l?"..D(J~.;.J.J'zre crlfA C~ _' (5~lDfWlot-~&amlned) __...._ '----,
1__pIo-oioiaDorothoo' _ .,..-........,~. ~~~,o.:...~~ =~or_ employer, _~ _ "" doe M"'h:.1
~ BUrMa. I'ftC., to ~ve ColalDb(.ll. ~~~ CO~I DC' ic:s ~ iIdbItDMioD abwllDC 01' m;v beaI1b I:)r ua4crwrtu:,j' p'lIl'pOte....Eso:pt.". me. MtdIc8J ~ Bureau
_ nus hdbnnatiDll mary. in ,.ornc ~ be. ~ ""1' ft1:bortitr:d ~W. 01 CoI'Dmbu Ufb.
daa~~~::O~;1===~=~~.:~~ot~~:.~~~~~~~~~~~~~-r
1111l4_ '10 ...w. dIis iDJbnNIdoD 10 ............. _"....'"'~':'8E AND DI8CLO$Une:
~. tDQ.. ~~'IIl~ aatlU: to ocbw iDlItRDco ~ ~Tdr 1~ ~for-t'~.::v~:"huf; Lit. d:Illt' ---. Lh~ iDforJutioa ID ~ M.ucallNo~tion
.~"::.~~.:~-..::::=~:':'~~ ~~_ ._p0ri04ls Ieplly __.I___lIwl_thc riIht"'...........<:op>j 01 this Aud>o_....
9l~ol(C~,S-~A~"'1".1'..rA? .??9 Due ~ ~,/L'!;L- 2..h~
Cl30.a (10191) ~ I'ropooed lIlsurod elf <11_ ... lb< - ~...)
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Cause at Death'l
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SIGN I
BOTII l
PUCBS I
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Columbus Life Insurance Company
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Flexible Premium Universal Life Policy
Issued on Insured in Risk Class Shown on Policy Schedule
Flexible Premiums Payable During Life of Insured to Age 100
Death Benefit Payable at Death of Insured
Death Benefit Modified After Insured's Age 100
Non-Participating
CL 82 0307 PA
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ACCELERATED DEATH BENEFIT PLUS RIDER
.
Limited Life Expectancy
An Additional Benefit of this Policy
Issued By
Columbus Life
Insurance~Compmy
.
Notice
Tax
. Consequences
Accelerated
Death Benefit
.
Amount of
Advance
.
.
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.
.
Since advances under this Rider are made as a loan secured by the Death
benefit, the Death Benefit upon death of the Insured will be redulced as a
result of payment of any advances under this rider.
It Is possible that part, or all, of an advance may be considered taxable by
the Internal Revenue Service. You should consult Your attorney,
accountant or other tax adviser before requesting an advance under this
rider.
You may elect to receive an advance on the Death Benefit under the policy upon
the occurrence of any of the following qualifying events: (1) when the Insured
has been diagnosed as having a Critical Illness; (2) when the Insured has been
Permanently Confined to a Nursing Home; or (3) when the Insured has been
diagnosed as having a Terminal Condition. You may make no more than one
election for each type of qualifying event.
The maximum advance amount will be equal to:
1. for Critical Illness, the lesser of (i) $25,000 or (ii) 10% of the base
amount;
2. for Permanent Confinement, the lesser of (i) $250,000 or (ii) 40% of the
base amount; or
3. for Terminal Condition, the lesser of (i) $250,000 or (ii) 60% of the base
amount,
less the current amount of any loans under this rider.
The base amount will be the difference between (a) and (b) on the date of the
first advance payment for that qualifying event, where:
"(a)" is equal to the total Death Benefit under the policy, as defined in the
policy, but calculated as of the date of such first advance payment; and
"(b)" is that amount equal to the total policy loan amount You could borrow
under the policy pursuant to the Loan Provisions section of the policy,
less the current Indebtedness.
The minimum amount of any advance is $5,000.
If more than one qualifying event occurs simultaneously, We will use the
qualifying event with the highest maximum advance amount to determine the
available advance amount, unless You elect otherwise. Maximum advance
amounts will not be additive regardless of the number of qualifying events that
apply.
CLR-1430101 PA
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Payment of
Advance
Amount
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Conditions for
Making Advance
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The minimum amount of any advance payment is $5,000. You may request more
than one advance payment subject to the minimum payment amount and
maximum available advance amount. Advance payments may be requested as
frequently as monthly, but all payments must be made within 12 months of the
first advance payment for Critical Illness or. Terminal Condition, or within 48
months of the first advance payment for Permanent Confinement. Each payment
will be paid in a lump sum to You or any other payee You so designate. Advance
payments may be made on or after the policy anniversary on which the Insured is
age 100 if the Death Benefit is greater than the Net Cash Surrender Value at that
time and the Insured otherwise qualifies for the advance. This benefit terminates
when the policy terminates.
The payment of any advance under this rider is conditioned upon and subject to
Our receipt of all of the following:
1. Your written request for the advance;
2. the written consent of any irrevocable Beneficiary and any assignee;
3. Your written designation of Us as an assignee for a portion of the Death
Benefit proceeds equal to the amount of such advance, including
interest;
4. medical evidence acceptable to Us from a licensed physician other than
the Insured or the Insured's spouse, child, stepchild, parent, brother, or
sister that the Insured has suffered a qualifying event. Such medical
evidence must specify that:
(a) the Insured has been diagnosed as having a Critical Illness or a
Terminal Condition, or is Permanently Confined to a Nursing Home;
and
(b) such Critical Illness, Terminal Condition or Permanent Confinement
meets the criteria set forth in the Definitions section of this rider;
and
We may require medical evidence of a Critical Illness to be certified by a
specialist as set forth in the Definitions section of this rider. We may also require
a second opinion and examination of the Insured at Our expense by a physician
designated by Us.
We reserve the right to assess an administrative charge of not more than $150.00
per qualifying event to process a claim under this rider.
The accelerated death benefit under this rider will be made available to You on a
voluntary basis only. Therefore:
1. If You are required by law to elect this benefit to meet the claims of
creditors, whether in bankruptcy or otherwise, You are not eligible for this
benefit.
2. If You are required by a government agency to elect this benefit in order
to apply for, obtain, or keep a government benefit or entitlement, You are
not eligible for this benefit.
CLR-1430101 PA
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Terms of
Advance
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Benefit Payment
Notice
Definitions
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Advances made under this rider will be payable in the form of a loan secured by a
first lien on the Death Benefit payable under the policy. We will administer this
loan separate and apart from any loan You make under the policy pursuant to the
Loan Provisions section of the policy. This loan does not effect the policy's
Specified Amount, Indebtedness, Account Value, Net Cash Surrender Value,
premiums or charges. However, upon the Death of the Insured, the Death Benefit
will be reduced by the amount of this loan, including interest.
The loan interest rate will be 8% (7.4% in advance) per year. Interest is due and
payable in advance to the next policy anniversary. If interest is not paid when
due, it will be added to the amount of the loan.
The loan may be increased by Us if necessary to keep the policy in effect. If a
premium remains unpaid at the end of the Grace Period, We will increase the
loan by the amount of the premium and interest at 8% to the next policy
anniversary even if such increase causes the loan to exceed the maximum
advance available under this rider.
We may deny Your request to decrease the Specified Amount under the policy
after the date of the first advance payment.
Upon payment of any advance under this rider, we will send you a notice showing
the amount of the payment and the effect of the payment on the Death Benefit.
Qualifying Event Definitions
"Critical Illness" means Advanced Alzheimer's Disease, End-Stage Renal Failure,
Heart Attack, Life Threatening Cancer, Major Organ Transplant, Permanent
Paralysis, or Stroke.
"Nursing Home" means a facility that meets all of the following conditions:
1. it is in the United States or its territories;
2. it maintains a license and operates under the laws of the state or
territory where it is located;
3. it provides nursing services 24 hours a day by or under the supervision
of a registered nurse (R.N.) or a licensed practical nurse (L.P.N.); and
4. it maintains a daily medical record of each patient.
It does not mean any of the following:
1. a place that primarily treats alcoholics;
2. a community living center or a place that primarily provides residential
care or retirement care; or
3. a place owned or operated by the Insured or a member of his/her
immediate family.
CLR-1430101 PA
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"Permanent Confinement" and "Permanently Confined" mean admitted as a
patient in a Nursing Home for a continuous period of at least 90 days with the
expectation that the Insured will remain there for the rest of his/her life. Separate
periods of confinement occurring within 6 months of a previous period of
confinement for the same or a related condition will be considered the same
confinement for the purpose of determining 1) satisfaction of this 90 day
elimination period and 2) when to apply a new elimination period. A new
elimination period will only be applied to a confinement due to a new or
non-related cause or to a confinement occurring more than 6 months from the
most recent confinement for the same or a related condition.
"Terminal Condition" means a condition that is the result of illness or injury that is
expected to result in death within one year of the date the medical evidence is
provided to Us. The determination of the one year limited life expectancy must
have been made while the Insured was covered by the policy.
Medical Terminology Definitions
.
.
.
"Advanced Alzheimer's Disease" means a progressive degenerative disease of
the brain. In order to meet the definition of Advanced Alzheimer's Disease, the
diagnosis must be supported by medical evidence that the Insured exhibits the
loss of intellectual capacity resulting in impairment of memory and judgment.
This impairment results in a significant reduction in mental and social functioning,
such that the Insured requires permanent daily personal supervision and is unable
to perform independently three or more of the following activities of daily living:
transferring (moving in or out of a bed or chair), dressing, bathing, feeding,
toileting, and continence. No other dementing organic brain disorders or
psychiatric illnesses shall meet the definition of Advanced Alzheimer's Disease.
Medical evidence of Advanced Alzheimer's Disease must be certified by a board
certified neurologist.
.
.
"End-Stage Renal Failure" means the chronic irreversible failure of both of the
kidneys (end stage renal disease), which requires treatment with regular dialysis.
Medical evidence of Renal Failure must be certified by a board certified
nephrologist.
.
"Heart Attack" means the death of a portion of the heart muscle, resulting from
the blockage of one or more coronary arteries. The diagnosis of Heart Attack
must be based upon both:
(a) new electrocardiographic changes consistent with and supporting a
diagnosis of Heart Attack; and
(b) a concurrent diagnostic elevation of cardiac enzymes.
.
.
"Life Threatening Cancer" means a malignant neoplasm (including hematologic
malignancy), which is characterized by the uncontrollable growth and spread of
malignant cells and the invasion of tissue, and which is not specifically hereafter
excluded. The following types of cancer are not considered Life Threatening
Cancer: early prostate cancer diagnosed as T1 NOMO or equivalent staging; first
carcinoma in situ; pre-malignant lesions (such as intraepithelial neoplasta), benign
tumors or polyps; any skin cancer other than invasive malignant melanoma in the
dermis or deeper, or skin malignancies that have become Life Threatening
Cancers. Life Threatening Cancer must be diagnosed pursuant to a pathological
diagnosis.
.
"First carcinoma in situ" means the first diagnosis of cancer wherein the tumor
cells still lie within the tissue of the site of origin without having invaded
neighboring tissue. This does not include skin cancer.
CLR-1430101 PA
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When Rider
Ends
.
Other
Provisions
.
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"Major Organ Transplant" means clinical evidence of major organ(s) failure which
requires the malfunctioning organ(s) or tissue of the Insured to be replaced with
the organ(s) or tissue from a suitable donor under generally accepted medical
procedures. Those organs or tissues covered by this definition are limited to:
liver, kidney, lung, entire heart, small intestine, pancreas, pancreas-kidney or
bone marrow. Medical evidence of a Major Organ Transplant must specify that
the Insured is registered by the United Network of Organ Sharing (UNOS).
"Permanent Paralysis" means the complete and permanent loss of the use of
two or more limbs through neurological injury confirmed to have been present for
a continuous period of at least 180 days. Medical evidence of Permanent
Paralysis must be certified by a board certified neurologist. A "limb" means an
arm or leg of the Insured.
"Stroke" means a cerebrovascular accident or infarction (death) of brain tissue
caused by hemorrhage, embolism, or thrombosis producing measurable
neurological deficit persisting for at least 30 days following the occurrence of the
Stroke. Stroke does not include Transient Ischemic Attack (TIA) or other cerebral
vascular events.
This rider will end on the first to occur of the following events:
1. You send us Your written request to terminate the rider;
2. termination of the policy; or
3. When the total loan under this rider, plus accrued interest thereon,
equals or exceeds the Death benefit under the policy. Note: Death
Benefit is net of basic policy loans and accrued interest.
Unless otherwise provided in Your written request for an advance, the payee may
not commute, anticipate, assign, alienate or otherwise encumber any payment
under this rider.
This rider is attached to and made a part of the policy. The effective date of this
rider is shown on. the Policy Schedule. The terms and definitions of the basic
policy apply to this rider except to the extent they are in conflict with its terms.
There is no additional premium charge for this rider.
~
~~
CLR-1430101 PA
.
.
This rider will terminate on the earlier of:
When Rider
Ends
.
.
Other
.
.
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.
.
.
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(1) the Monthly Anniversary Day coinciding with or next following the date We
process Your written request to cancel this rider;
(2) the date the policy terminates;
(3) the date We process Your request for a loan, withdrawal, change in Death
Benefit option, or increase or decrease in Specified Amount prior to the
policy anniversary on which the Insured is age 100; or
(4) the date the Grace Period for this rider expires without payment of the
premium needed to keep this rider in force.
This rider is attached to and made a part of the policy. The terms and
definitions of the base policy apply to the rider except to the extent they are in
conflict with its terms. This rider has no values.
~
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,-1550209 PA
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,.
ENHANCED NO-LAPSE GUARANTEE RIDER
An Additional Benefit of this Policy
Issued By
.
Columbus Life
Insurance~Contfimy
400 East Fourth Street. P.O. Box 5737 · Cincinnati, Ohio 45201-5737 · 1-800-677-9595. www.ColumbusLife.com
.
.
This rider provides a guarantee of continued coverage from the fifth policy
anniversary to the policy anniversary on which the Insured is age 100, so long
as a premium test is met on the fifth policy anniversary. This rider also extends
the policy coverage beyond the policy anniversary on which the Insured is age
100 with a modified Death Benefit. Continuance of coverage past the Insured's
age 100 may disqualify the policy for favorable tax treatment as life insurance.
You should consult Your attorney, accountant or other tax advisor.
This rider will terminate, without value, If You request a loan, make a
withdrawal, change the Death Benefit option or change Your Specified
Amount.
.
Enhanced
No-Lapse
Guarantee
Beginning on the fifth policy anniversary and continuing to the day before the
policy anniversary on which the Insured is age 100, We guarantee that the policy
will not terminate or begin the Grace Period if, on the fifth policy anniversary,
one of the following conditions is true:
.
(a) (1) is equal to or greater than (2) where:
(1) is the sum of the premiums paid, plus interest accrued daily thereon
at the Minimum Guaranteed Interest Rate shown on the Policy
Schedule; and
.
(2) is the Enhanced No-Lapse Guarantee Single Premium, plus interest
accrued daily on such premium from the Policy Date at the Minimum
Guaranteed Interest Rate shown on the Policy Schedule.
Or
.
(b) the sum of the premiums paid equals the maximum amount payable in
the definition of life insurance under federal tax law.
The Enhanced No-Lapse Guarantee Single Premium is shown on the Policy
Schedule.
.
.
CLR-1550209 PA
.
.
Extended
Coverage
Benefit
.
.
Grace Period
and Lapse
.
.
No
Reinstatement
.
Cost of
Insurance
.
.
When Effective
.
.
If this rider is in force on the day before the policy anniversary on which the
Insured is age 100, the policy will continue in force until the Insured's death, or
until it is surrendered for its Net Cash Surrender Value.
On and after the policy anniversary on which the Insured is age 100, the Death
Benefit under the policy will be equal to the greater of the Specified Amount or
the Cash Surrender Value.
On and after the policy anniversary on which the Insured is age 100, We will not:
(1) accept premium payments;
(2) permit loans, or changes to the Specified Amount; or
(3) deduct any monthly policy charges from Your Account Value.
On the fifth policy anniversary, if neither of the conditions in the Enhanced
No-Lapse Guarantee provision above has been satisfied, We will allow a Grace
Period. We will mail You, and anyone shown on Our records as holding this
policy as collateral, a notice indicating the minimum premium You must pay in
order to keep this rider and the Enhanced No-Lapse Guarantee in effect. You
will have 61 days from the date We mail You this notice to pay enough
premium. If You do not pay the needed premium within the 61-day Grace
Period, the Enhanced No-Lapse Guarantee and this rider will terminate at the
end of the 61-day Grace Period.
If the policy or this rider lapses, this rider cannot be reinstated.
The monthly cost of insurance rate for this rider (per $1,000 of the policy's
Specified Amount) is shown on the Policy Schedule.
To determine the monthly cost of insurance on each Monthly Anniversary Day,
We:
(1) divide the Specified Amount for the policy as of that Monthly Anniversary
Day by 1000; and
(2) multiply by the monthly cost of insurance rate.
We will deduct the monthly cost of insurance from the Account Value on each
Monthly Anniversary Day during the period shown on the Policy Schedule.
The effective date of this rider is shown on the Policy Schedule.
CLR.155 0209 PA
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Columbus Life
Insurance~Comp'!my
400 East Fourth Street · P.O. Box 5737 · Cincinnati. Ohio 45201-5737 · 1-800-677-9595 · www.ColumbusLife.com
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Additional Life
Benefit
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ChanfJesin
AdditIonal Life
Rider Specified
Amount
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Changes in
Death Benefit
Option
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Effect of
Withdrawals on
AddItional Life
Rider Specified
Amount
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Effective Date
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ADDITIONAL LIFE RIDER
An Additional Benefit of this Policy
Issued By Columbus Life Insurance Company
This rider provides an amount of additional insurance benefit on the Insured's life.
This additional amount of insurance benefit is called the "Additional Life Rider
Specified Amount." The Additional Life Rider Specified Amount is shown on the
Policy Schedule of the policy.
We will add the Additional Life Rider Specified Amount to the Specified Amount under
the policy, including any extended coverage rider, when We calculate the Death
Benefit under the policy for any reason, other than for the acceleration of the Death
Benefit under any rider added to the policy. This is the exclusive benefit under this
rider.
The Additional Life Rider Specified Amount is included in the Death Proceeds payable
under the policy by its inclusion in the calculation of the Death Benefit.
If You request an increase or decrease in Specified Amount under the base policy, We
will automatically increase or decrease the Additional Life Rider Specified Amount in
proportion to the increase or decrease in Specified Amount. You may not request an
increase or decrease in the Additional Life Rider Specified Amount separately except
as described below.
If the Specified Amount is equal to the minimum issue limit under the base policy, You
may request a decrease in the Additional Life Rider Specified Amount. You may
make such a request atter the first policy year.
If You request a change in the Death Benefit Option under the policy, and We need to
increase or decrease the Specified Amount according to the terms of the base policy,
We will allocate the dollar amount of the increase or decrease proportionately to the
base policy Specified Amount and the Additional Life Rider Specified Amount.
If You make a withdrawal and We need to decrease the Specified Amount according
to the terms of the base policy, We will allocate the dollar amount of the decrease
proportionately to the base policy SpeCified Amount and the Additional Life Rider
Specified Amount.
The effective date of this rider is shown on the Policy Schedule.
ClR-158 0307
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Cost of
Insurance
The monthly cost of insurance for this rider will be deducted as part of the monthly
Cost of Insurance Charge under the base policy. This is because the Additional Life
Rider Specified Amount will be included in the calculation of the Death Benefit for
purposes of determining the Net Amount at Risk under the policy.
.
The maximum monthly cost of insurance rates for each policy year are shown in the
Policy Schedule. The maximum rates are the same as the maximum Cost of
Insurance Charge rates under the base policy. At Our option, We may charge less
than the maximum rates shown. We may charge different current monthly rates for the
rider and for the base policy. If We charge different current rates, We will apply each
rate to the portion of Net Amount at Risk for the policy that corresponds on a pro rata
basis to the Additional Life Rider Specified Amount and Specified Amount,
respectively.
For purposes of any extended coverage rider or any no-lapse guarantee rider added to
the policy, the Additional Life Rider Specified Amount will be added to the Specified
Amount in determining the amount of any charges for the rider.
Nonparticipating This rider is issued at a nonparticipating rate and shall not share in Our surplus.
. Termination This rider will terminate on the first to occur of:
Effect on Other
Rider Costs
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(1) The Monthly Anniversary Day coinciding with or next following the date We
process Your written request to cancel this rider;
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(2) The date the Additional Life Rider Specified Amount has been reduced to
zero; or
Policy Terms
(3) Upon termination of the policy.
This rider is attached to and made a part of the policy. The terms and definitions of
the base policy apply to this rider except to the extent they are in conflict with its
terms. This rider has no values.
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CLR-158 0307
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Columbus Life
Insu~ComJilny
400 East Fourth Street. P.O. Box 5737. Cincinnati. Ohio 45201-5737 · 1-800-677-9696 . www.ColumbusLife.com
ACCELERATED DEATH BENEFIT PLUS RIDER
DISCLOSURE STATEMENT
Notice: Since advances under this Rider are made as a loan secured by the Death Benefit. the Death Benefit upon death of the
Insured will be reduced as a result of payment of advances under this rider. After an advance has been made, we may
increase the amount of the loan by the amount of premiums needed to keep the policy in force.
A. Tax Consequences: IT IS POSSIBLE THAT PART, OR ALL OF AN ADVANCE MAY BE CONSIDERED TAXABLE BY THE INTERNAL
REVENUE SERVICE. YOU SHOULD CONSULT YOUR ATTORNEY, ACCOUNTANT OR OTHER TAX ADVISER BEFORE REQUESTING
. AN ADVANCE UNDER THIS RIDER.
B. Accelerating Conditions: The Insured has been (1) diagnosed as having a Critical Illness (Advanced Alzheimer's Disease. End-Stage Renal
Failure, Heart Attack. Life Threatening Cancer. Major Organ Transplant. Permanent Paralysis. in each case meeting, the criteria set forth in the
rider); (2) Permanently confined to a Nursing Home as a patient for a continuous period of at least 90 days with the expectation that the Insured
will remain there for the rest of hislher life; 131 a Terminal Condition with the determination of the one year limited life expectancy. where such
determination must have been made while the Insured was covered by the policy.
C. Method of Payment Accelerated payment of the Death Benefit (Advances) will be in the form of a special loan secured by a lien against the
death benefit option of the policy. The loan interest rate will be 8% (7.4% in advance) per year.
D. Frequency of Payment Advances may be made as frequently as monthly, but all advances must be made within 12 months of the first
advance payment for Critical Illness or Terminal Condition, or within 48 months of the first advance payment for Permanent Confinement.
E. Maximum Advance: The cumulative maximum advance is equal to (1) for Critical Illness the lesser of (i) $25,000 or (ii) 10% of the base
amount; (2) for Permanent Confinement. the lesser of (il $250.000 or (ii) 40% of the base amount or; 13) for Terminal Condition. the lesser of (i)
$250,000 or lii)60% of the base amount; less the current amount of any special loans. The base amount is equal to the difference on the date
of the first advance between (a) the total death benefit under the policy, as defined in the policy, but calculated as of the date of such first
advance payment; and (b) the maximum policy loan amount that could be borrowed under the policy pursuant to the Loan Provisions section of
the policy reduced by the amount of the any indebtedness currently outstanding. The minimum advance is $5,000.
F. PreRlium for Accelerated Benefit: There is no additional premium charge for this benefit.
G. AdRlinistrative Charge: In addition to the policy loan interest we reserve the right to assess an administrative charge of not more than
$150.00 per qualifying event to process a claim.
H. Impact on Policy Values: A lien will be placed against the policy's death benefit equal to die aRlount of the advance paid plus
any interest due plus any additional preRlium needed to keep the policy in force after an advance has been Rlade. Policy cash
values and the amount available for regular policy loans remain as they were before the option was exercised. The premium for
the policy will not change. Termination of the policy by cancellation or payment of proceeds ends the accelerated death benefit
plus rider.
I. Limitations on the Accelerated Benefit The benefit will be made available to you on a voluntary basis only. If you are required by law to
elect this benefit to meet the claims of creditors, you are not eligible for this benefit. If you are required by a government agency to elect this
benefit in order to apply for, obtain, or keep a government benefit or entitlement (such as Medicaidl. you are not eligible for this benefit.
J. Benefit Payment Notice: Upon payment of a benefit under this rider we will send you a notice showing the amount of the payment and the
effect of the payment on the face amount, any policy cash values, any policy loan and future premiums.
K. RECEIPT OF ACCELERATED BENEM PLUS PAYMENTS MAY ADVERSELY AFFECT THE RECIPIENTS ELIGIBILITY FOR MEDICAID
OR OTHER GOVERNMENT BENEFITS OR ENTITLEMENTS.
(Sign and return to Columbus Life, a copy should be retained for your records)
I have read and understand the Accelerated Death Benefit Plus Disclosure Statement.
Signature of Policy Owner
Date
Signature of Agent
CL 45.267.PA IB/011
FOR ALL LIFE PRODUCTS EXCEPT NAUTICAL TERM
Exceptions: For MS and VT, see CL 5.720; ID Mainsail, see CL 5.720.
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Col~~
'" 'AS' '0""'" ".,~~~ C'.C'..''', 0",0 ",,,.,m.,""""""
IMPORTANT NOTICE TO AGENT
FOR SIGNED ILLUSTRATION
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Policy No.: CI1$(} 1/7 tf", rJ
Insured's Name:
BETTY VAlENCIK
As required by your state insurance department, we are enclosing an illustration to be signed by the
Al>plicantlPolicyowner. Please read the following instructions carefully. If you have questions regarding
this policy or illustration, please contact Columbus life New Business Department.
1. Do not deliver this polley by mail. The attached illustration must be signed by the
Applicant/Owner In your presence as a witness.
2. Please return the Illustration with the proper signatures to the Home Office to the
attention of NEW BUSINESS DEPT.
3. The signed illustration must be received in the Home Office In order for this policy to
be in force and commissions to be paid. The signed illustration must be received
within 60 days or the polley will be processed as not taken.
4. Please provide photocopy of signed illustration to insured.
THIS ILLUSTRATION IS REQUIRED FOR THE FOLLOWING REASON(S):
PLEASE HAVE THIS IllUSTRATION SIGNED AND RETURNED TO HOME OFFICE. THE STATE OF
PENNSYLVANIA REQUIRES A SIGNED ILLUSTRATION.
CL 45.213 (11198)
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Columbus Life
Insurance Compllny
400 EAST FOURiH STREET. BOX 5737 ~ CINCINNAll, OHIO 45201-5737 . (513) 381-6700
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A Life Insurance Policy Illustration
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Flexible Premium Adjustable Life
Explorer II Universal Life
With Enhanced No-Lapse Guarantee Rider
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Designed for
BETTY VALENCIK
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t~
Presented by
ROBERT TRIFELETrI
License No.
PA
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August 4, 2004
The purpose of this illustration is to show how the Explorer II flexible premium adjustable life (universal
. Ufe} policy works and to demonstrate how assumed interest rates may affect the policy account value and
death benefit. This illustration is hypothetical. It does not project or predict actual results.
This illustration has assumed that Pennsylvania is the state of residence.
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Presentoo.by ROBERT TR1FELETTI
. FortTl CL 82 0307 i
TP10000CL 11936.88
Aug 4, 2004 V 2.22.0078
This is Page 1 of 10 and is not valid unless all pages are included
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Columbus Life
Insurance Comptmy
400 EAST FOURlH STREET, BOX 5737 ~ CINCINNAll. OHIO 45201-5737 . (513) 361-6700
Designed for BETTY V ALENCIK
Female Issue Age 81
Standard- TNU
Explorer II UL-
. Flexible Premium
, Adjustable
Universal Life
Insurance
Underwriting class:
. Female Standard-
TNU
.
Death Benefit
Option:
Option 1
Initial Specified
Amount $265,263
LumpSum:
$168,000.00
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Premiums
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Initial Planned
Premium Outlay
$0.00 Annual
Minimum Total
Premium for
. Enhanced No-
· Lapse Guarantee
. (Cap Transfer)*
$168,000.00
.
Minimum Monthly
Premium for Five-
Year Guarantee*
$751.69
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Policy Illustration Explanation
Explorer If UL
The Policy is a flexible premium product because you can change the amount and
frequency of your premium payments within limits. It will remain in force as long as the Net
Cash Surrender Value is sufficient to cover monthly policy expenses. Premium reminder
notices will be sent for planned premiums not paid through monthly bank draft and for
premiums required to keep the policy in force.
The cost of insurance for this illustration is based on the assumption the policy is issued with
the underwriting class listed at the left. Actual cost of insurance will depend on the outcome
of the underwriting process and may vary from what is shown on the illustration.
You may select from two options. Option 1 provides an initial Death Benefit equal to the
Specified Amount. Option 2 provides an initial Death Benefit equal to the Specified Amount
plus the Account Value.
The Specified Amount assumed at issue is shown on the left. The actual amount payable at
death will depend on the Death Benefit Option and may be decreased by loans or
withdrawals, or increased by additional insurance benefits. The insurance contract will
specify how to determine the benefit. The death benefits are illustrated as of the end of
each policy year.
No fixed premium is required, but there are upper and lower limits to the amount of premium
that can be paid. The following premiums are based on the illustrated coverage amount at
issue. Changes to the policy benefits or to the non-guaranteed elements of the policy may
require additional premiums to keep the policy in force.
The planned premiums, including lump-sum premiums are shown in the yearly detail of this
illustration. Values would be different if premiums are paid with a different frequency or in
different amounts.
By paying the Enhanced No-Lapse Guarantee (Cap Transfer) premium, you are receiving a
Benefit that will keep the policy in force for the lifetime of the insured even if your policy Net
Cash Surrender Value is less than the next Monthly Policy Charges, and regardless of the
rate of return on your policy. By rider only. Election of this rider involves an additional cost of
insurance charge. However, the Enhanced No-Lapse Guarantee Rider wiU terminate,
without value, if you request a loan, make a withdrawal, change the Death Benefit option or
change your Specified Amount.
Paying the Minimum Monthly Premium, will keep the policy in force for five years even if
your policy Net Cash Surrender Value is less than the amount of the next Monthly Policy
Charges. One Minimum Monthly Premium must be paid in order to place the policy in force.
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Pres$Oted by ROBERT TRIFElETTI
Form CL82 0307 i
TP10000CL 11936.88
Aug 4, 2004 V 2.22.0018
This is Page 2 of 10 and is not valid unless all pages are included
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Columbus Life
Insurance Compiiny
400 EAST FOURlH S'TREET, BOX 5737 ~ CINCINNATI, OHIO 45201-5737. (513) 36HI700
Designed for BETTY VALENCIK
Female Issue Age 81
Standard- TNU
Policy Illustration Explanation
Explorer II UL
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Optional BenefitS#
Policy vs.
Additional Ufe
Rider (SCR)
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Rider Coverage: You can elect to have a portion of your death benefit as rider coverage I
under our Additional Life Rider (ALR). There are important factors to consider when
deciding whether to purchase all base policy insurance or a combination of base policy
and ALR coverage.
I
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All Base Coverage Only: I
A policy with all base coverage can result in higher premium expense charges and higher I
overall policy costs than if some ALR is elected. These costs can reduce the cash value!
and long term policy performance over time. The ALR cannot be elected after the policy is I
issued. I
A Combination of Rider and Base Policy Coverage: I
A policy with a combination of base coverage and ALR coverage will result in lower I
premium expense charges and lower overall policy costs than if all base coverage is !
elected. However, if approved in your state, your policy will be issued with either the I
Accelerated Death Benefit or Accelerated Death Benefit Plus Rider. These riders allow an I
advance against the Death Benefit of the policy for terminal illness, and in the case of the
Plus rider, for diagnosis of certain critical illnesses or confinement to a nursing home. Any
amount of coverage elected as ALR coverage will NOT be eligible for this advance and wiD
reduce the amount of the accelerated benefits available under policy in the future. I
There is no correct amount of ALR coverage to choose since actual policy experience wi" I
determine the benefits realized. Your choice should be based on your own plans with
respect to premium amounts, level of risk tolerance and the length of time you plan to hold
the policy.
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Here are some factors to consider:
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You should carefully evaluate alt these features and discuss all policy options with your
Columbus Life representative.
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# If the Enhanced No Lapse Guarantee Rider I. added to your policy, you Willi
automatically receive 50% Additional Life Rider coverage. No other options are
available.
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Presented by ROBERT TRlFELETTI
Form CL 82 0307 i
TP10000CL 11936.88
Aug 4, 2004 V 2.22.00'18
This is Page 3 of 10 and is not valid unless all pages are included
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Columbus Life
Insurance Compliny
400 EAST FOUR1H STREET, BOX 5737 ~ ClNCINNA11, OHIO 4520Hl737 . (513) 361-6700
Designed for BETTY VALENCIK
Female Issue Age 81
Standard- TNU
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Non-Guaranteed
Elements of the
Policy
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Policy Illustration Explanation
(Continued)
Explorer II UL
Many elements of your life insurance contract are guaranteed, including the minimum
interest rate and maximum charges. However, other elements of the policy cannot be
predicted. For example, the interest rate credited may exceed the guaranteed rate and
monthly charges may be less than the maximum guaranteed charges.
The non-guaranteed values illustrated provide snapshots of your policy assuming higher
interest and lower charges than those guaranteed. Since these elements can not be
predicted, a range of results is illustrated. The actual policy values may be less or more
favorable than the illustrated results. Variations in the non-guaranteed factors may affect
death benefrts, policy values, total payments over the lifetime of the policy, withdrawals or
loans taken from the policy, and the date coverage may terminate.
Current rates of interest are determined periodically and are subject to change. On a non-
guaranteed basis we currently credit interest after the 12th policy year as follows:
· 5.35% on non-loaned account value between $25,000 to $49,999.99
. 5.60% on non-loaned account value between $50,000 and $249,999.99
· 5.70% on non-loaned account value over $250,000.
On a non-guaranteed basis we currently increase our current interest rate by .20% starting
in policy year 21. This is in addition to the above additional interest.
This illustration assumes that non-guaranteed elements and current company practice
remain unchanged throughout the illustration, which is unlikely.
Based on your planned premium outlay, assuming the guaranteed interest rate, mortality,
expense charges, and stated loans and withdrawals, the insurance coverage will not cease
prior to the death of the insured.
-Presented by ROBERT TR1FELETT'
. Form CL 82 0307 i
TP10000CL 11936.88
Aug 4, 2004 V 2.22.0078 .
This is Page 4 of 10 and is not valid unless all pages are included
.'
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Columbus Life
Insurance Compiiny
400 EAST FOURTH STREET, BOX 5737 ~ CINCINNATI, OHIO 45201-5737 . (513) 361-6700
Designed for BETTY VALENCIK
Female Issue Age 81
Standard- TNU
Explorer II UL
· No-Lapse Withdrawals and loan indebtedness will cause an increase in the premium requirement
. Guarantees under the Five-Year No-Lapse Guarantee. The Five-Year No-Lapse Guarantee takes into
account the time value of money (at 5.50% annual interest rate) with respect to premium
payments and withdrawals. Testing for the Enhanced No-Lapse Guarantee (Cap Transfer)
Rider occurs on the fifth policy anniversary date. It requires the accumulated value of
premiums paid with interest to equal or exceed the Enhanced No-Lapse Guarantee Single
Premium accumulated with interest to that date. The accumulation rate is the policy's
. guaranteed interest rate. If this illustration shows any Enhanced No-Lapse Guarantee
premiums on a basis other than single premium, such premiums have already been
adjusted with interest to assure the test is met. In no event, however, will required premium
payments exceed the federal guideline premium limitation. If the required premium test for
either no-lapse guarantee is not met, you may have to pay significantly higher premiums to
keep your policy in force. In addition, when either no-lapse guarantee ends before the policy
. anniversary on which the insured is age 100, you may need to pay significant additional
premiums to keep the policy in force. Finally, if you pay only the no-lapse guarantee
minimum premium, you may be forgOing the opportunity to build a higher Account Value.
Extended Maturity If the policy is still in force on the policy anniversary following the insured's 100th birthday,
the death benefit will be continued but will be reduced to equal the greater of the Net Cash
. Surrender Value or the Specified Amount less any indebtedness. Beyond age 100,
regardless of issue age or type of rider, no further premiums may be paid, no cost of
insurance or other expense charges will be deducted and no loans will be permitted.
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Presented by ROBERT TRlFELETTl
FormCL 82 0307 i
TP10000CL 11936.88
Aug 4, 2004 V 2.22.0078
This is Page 5 of 10 and is not valid unless all pages are included .
..
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Colwnbus Life
Insurance Comptmy
400 EAST FOUR11i STREET; BOX fi'!37 ~ CINCINNA11. OHIO 4S201-fi'!:rT . (513) 361.6700
Designed for BETTY VALENCIK
Female Issue Age 81
Standard- TNU
Optional Riders and Benefits
Explorer II UL
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Coverage Summary:
To Age
Additional Life Rider (SCR)
Enhanced No-Lapse Guarantee Rider Death
Accelerated Death Benefit Plus Rider
x - indicates the rider is included in this illustration.
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(X) Additional Lower cost permanent coverage that is an extension of the base policy. This rider pays a
Life Rider death benefit on the death of the primary insured. 50% of the total Specified Amount under
(SCR) the policy will be base coverage and 50% will be SCR coverage provided by this rider.
(CLR-158 0307)
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(Xl Enhanced No- This rider provides a guarantee of continued coverage from the fifth policy anniversary to the
Lapse policy anniversary on which the insured is age 100, so long as a premium test is met on the
Guarantee fifth policy anniversary. (CLR-155 0209)
Rider
(CapTransfer)
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(X) Acceterated In addition to the advance avaliable under the Accelerated Death Benefit Rider, this rider wilt
Death Benefit also loan a portion of the death benefit in advance in the event of a named critical illness or
Plus Rider permanent confinement to a nursing home. This rider will be automatically included with your
policy if approved in your state, subject to the underwriting classification of the insured.
(CLR-143 0101)
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. The Enhanced No-Lapse Guarantee Rider (Cap Transfer) will terminate, without value, if you
. request a loan, make a withdrawal, change the Death Benefit Option or change your. Specified
Amount.
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Presented by ROBERT TRIFELETTI
Form CL 82 0307 i
TP10000CL 11936.88
Aug 4, 2004 V 2.22.0018
This is Page 6 of 10 and is not valid unless all pages are included
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Colwnbus~
Insurance
. 400 EAST FOURTH STREET. BOX 5737 ~ CINCINNATI, OHIO 45201.5737 . (513) 361-6700
Designed for BETTY V ALENCIK
Female Issue Age 81 Life Insurance Policy Illustration
Standard- TNU Explorer II Universal Life
Hypothetical Values
This illustration includes a Lump Sum: $168,000.
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Mode: A = Annual; S = Semi-Annual; Q = Quarterly; M = PAT
Premium shown is paid at the beginning of the mode.
Guaranteed Non-Guaranteed Current
. End Net Cash Net Cash
of Premium Account Surrender Death Account Surrender Death
Age Yr Outlay Mode Value Value Benefit Value Value Benefit
82 1 168,000 A 150,346 144,975 265,263 165,255 159,884 265,263
83 2 0 A 142,378 137,007 265,263 171,047 165,675 265,263
. 84 3 0 A 131,802 126,431 265,263 177,080 171,708 265,263
85 4 0 A 117,778 112,407 265,263 183,350 177,979 265,263
86 5 0 A 99,157 93,785 265,263 189,874 184,503 265,263
87 6 0 A 74,042 69,387 265,263 196,460 191,805 265,263
88 7 0 A 40,330 36,390 265,263 203,390 199,451 265,263
89 8 0 A 0 0 265,263 210,684 207,461 265,263
. 90 9 0 A 0 0 265,263 218,383 215,876 265,263
91 10 0 A 0 0 265,263 226,544 224,753 265,263
92 11 0 A 0 0 265,263 236,642 235,747 265,263
93 12 0 A 0 0 265,263 247,382 247,382 265,263
94 13 0 A 0 0 265,263 260,080 260,080 265,282
95 14 0 A 0 0 265,263 273,977 273,977 276,717
96 15 0 A 0 0 265,263 288,837 288,837 288,837
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97 16 0 A 0 0 265,263 304,543 304,543 304,543
98 17 0 A 0 0 265,263 321,145 321,145 321,145
99 18 0 A 0 0 265,263 338,693 338,693 338,693
100 19 0 A 0 0 265,263 357,241 357,241 357,241
101 20 0 A 0 0 265,263 377,177 377,177 377,177
. 102 21 0 A 0 0 265,263 399,004 399,004 399,004
103 22 0 A 0 0 265,263 422,119 422,119 422,119
104 23 0 A 0 0 265,263 446,597 446,597 446,597
105 24 0 A 0 0 265,263 472,520 472,520 472,520
106 25 0 A 0 0 265,263 499,972 499,972 499,972
107 26 0 A 0 0 265,263 529,044 529,044 529,044
. 108 27 0 A 0 0 265,263 559,832 559,832 559,832
109 28 0 A 0 0 265,263 592,435 592,435 592,435
110 29 0 A 0 0 265,263 626,963 626,963 626,963
111 30 0 A 0 0 265,263 663,527 663,527 663,527
. Based on your planned premium outlay, assuming the guaranteed interest rate, mortality, expense
charges, and stated loans and withdrawals, the insurance coverage will not cease prior to the death of
the insured.
TP10000CL 11936.88
Pfe~ted by ROBERT TRIFELETTl Aug 4, 2004 V 2.22.0018
. Form CL 82 0307 i This is Page 7 of 10 and is not valid unless all pages are included
. "
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Designed for BETTY V ALENCIK
Female Issue Age 81
Standard- TNU
Life Insurance Policy Illustration
Explorer \I Universal Life
Hypothetical Values
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This illustration includes a Lump Sum: $168.000.
Guaranteed Non-Guaranteed Current
End Net Cash Net Cash
of Premium Account Surrender Death Account Surrender Death
Age Yr Outlay Mode Value Value Benefit Value Value Benefit
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112 31 0 A 0 0 265,263 702,249 702,249 702,249
113 32 0 A 0 0 265,263 743,255 743,255 743,255
114 33 0 A 0 0 265,263 786,681 786,681 786,681
115 34 0 A 0 0 265,263 832,669 832,669 832,669
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. Based on your planned premium outlay, assuming the guaranteed interest rate, mortality, expense
· charges, and stated loans and withdrawals, the insurance coverage will not cease prior to the death of
the insured.
I.
Presented by ROBERT TRIFELETTI
Form CL 82 0307 i
TP10000CL11936.88
Aug 4, 2004 V 2.22.0078
This is Page 8 of 10 and is not valid unless all nAOA~ ::IrA in~llIrlArf
.
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Designed for BETTY VALENCIK
Female Issue Age 81 Policy Outlays
Standard- TNU Explorer II UL
This illustration includes a Lump Sum: $168.000.
. Premium Outlay Guideline Premiums
End Net Cash Net
of Premium With- Annual Surrender Death Seven
Yr Outlay drawal Loan Value Benefit Single Annual Total Pay
. 1 168,000 0 0 159,884 265,263 207,279 37,782 207,279 42,801
2 0 0 0 165,675 265,263 0 37,782 207,279 42,801
3 0 0 0 171,708 265,263 0 37,782 207,279 42,801
4 0 0 0 177,979 265,263 0 37,782 207,279 42,801
5 0 0 0 184,503 265,263 0 37,782 207,279 42,801
6 0 0 0 191,805 265,263 0 37,782 226,691 42,801
. 7 0 0 0 199,451 265,263 0 37,782 264,473 42,801
8 0 0 0 207,461 265,263 0 37,782 302,255 0
9 0 0 0 215,876 265,263 0 37,782 340,037 0
10 0 0 0 224,753 265,263 0 37,782 377,819 0
11 0 0 0 235,747 265,263 0 37,782 415,601 0
12 0 0 0 247,382 265,263 0 37,782 453,382 0
. 13 0 0 0 260,080 265,282 0 37,782 491,164 0
14 0 0 0 273,977 276,717 0 37,782 528,946 0
15 0 0 0 288,837 288,837 0 37,782 566,728 0
16 0 0 0 304,543 304,543 0 37,782 604,510 0
17 0 0 0 321,145 321,145 0 37,782 642,292 0
18 0 0 0 338,693 338,693 0 37,782 680,074 0
. 19 0 0 0 357,241 357,241 0 37,782 717,855 0
20 0 0 0 377,177 377,177 0 0 717,855 0
21 0 0 0 399,004 399,004 0 0 717,855 0
22 0 0 0 422,119 422,119 0 0 717,855 0
23 0 0 0 446,597 446,597 0 0 717,855 0
24 0 0 0 472,520 472,520 0 0 717,855 0
. 25 0 0 0 499,972 499,972 0 0 717,855 0
26 0 0 0 529,044 529,044 0 0 717,855 0
27 0 0 0 559,832 559,832 0 0 717,855 0
28 0 0 0 592,435 592,435 0 0 717,855 0
29 0 0 0 626,963 626,963 0 0 717,855 0
30 0 0 0 663,527 663,527 0 0 717,855 0
. 31 0 0 0 702,249 702,249 0 0 717,855 0
32 0 0 0 743,255 743,255 0 0 717,855 0
33 0 0 0 786,681 786,681 0 0 717,855 0
34 0 0 0 832,669 832,669 0 0 717,855 0
.
TP10000CL 11936.88
"Presented by ROBERT TRIFELETTI Aug 4, 2004 V 2.22.0078
. FormCl82 0307 i This is Page 9 of 10 and is not valid unless all pages are inctuded.
.J
.. -...
~
.
ColumbusIife
Insurance Compllny
400 EAST FOURlH S"ffiEET, BOX 5737 ~ CINCINNAll, OHIO 45201-57g'1 . (513) 361-6700
Designed for BETTY V ALENCIK
Female Issue Age 81 Policy Illustration Summary
Standard-TNU Explorer II UL
Interest and Cost Non-Guaranteed Non-Guaranteed
. Scenarios: Summary Year Guaranteed Midooint Current
YEAR 5
Guaranteed Premium Outlay 0 0 0
3.00% Interest Rate Cash Value 93,785 143,841 184,503
And Maximum Death Benefit 265,263 265,263 265,263
. Charges
YEAR 10
Premium Outlay 0 0 0
Cash Value 0 93,087 224,753
Midpoint Death Benefit 265,263 265,263 265,263
Interest Rate and
Charges Halfway YEAR 20
.~ Between Current Premium Outlay 0 0 0
And Guaranteed Cash Value 0 0 377,177
Death Benefit 265,263 265,263 377,177
Last Year of Death Death Death
Current Death Benefit
. 5.10% Interest
Rate and Current All Years - Total 168,000 168,000 168,000
Charges Premiums
.
~
This policy as illustrated is a "Modified Endowment Contract" for tax purposes. In general, this means loans and
withdrawals will be treated as income to the extent the cash surrender value exceeds the sum of premiums paid.
Such distributions may also be subject to a 10% penalty tax. Please consult your tax advisor.
I have received a copy of this illustration and understand that any non-guaranteed elements illustrated are subject
to change and could be either higher or lower. The agent has told me they are not guaranteed. I also understand
that this illustration is valid only if Pennsylvania is the state of issue.
.
~icant
1.~4u
~
.
I certify that this illustration has been presented to the applicant and that I have explained that any non-guaranteed
elements illustrated are subject to change. I have made no statements that al'" nsist with the illustration.
A ntif-
.
.
Presented by ROBERT TRIFELETTI
FOrm CL 82 0307 i
TP10000CL 11936.88 .
Aug 4, 2004 V 2.22.0078
This is Page 10 of 10 and is not valid unless all pages are included
.
Entity #: 2902175
, Oat8 Filed: 0610112007
p~(O A. Cortes
,:;!~~~'!.'X of the Commonwealth
.
PENNSYLVANIA DEPARTMENT OF STATE
CORPORATION BUREAU
Articles of Amendment-Domestic Corporation
(I S hC.S.)
.CJ. Bus~ Corporation (g 1915)
m Nonprofit Corporation (~ 5915)
.
Document wiD be returned 10 the
..me JlDd IICIdro:a you oDter to
tbe Ie~
~
NaIDC
Deborah Berrigan
Addn::s$
1144 Park Avenue
c;q. s-
Williamsport, PA
ZipCodc
17701-4634
Commonwealth of Pennsylvania
ARTICLES OF AMENDMENT-NONPROFIT 7 Page(s)
.
fflllflllmlllll~IIIIIH~lmlllllllllllll
T0715247101
Fee: $70
In compliance with the requiremc:nls oCtile applicable provisions (relating to articles of amcndrneut)., the undez'Sigoed,
desiring to lUIlCDd its articles, heceby states that:
.
1. The name oflbeCOrpomtiOll is:
ElderCare Solutions, Inc_
.
2. The <a) address of this c:orporation's CIII7'eIIt regisund office in this Commonwealth or (b) name ofiu
~ rcgistcrcd office provider 8Dd Ibc c:oonty of venue is (the Department is hereby authorized to
CUlTCCt the followiag information to confbrm to the roc:ords of the DepartJnent)~
(a) Number and Street City State Zip
1144 Park Avenue Williamsport PA 17701
COWlty
Lycom.1ng
(b) Name of Commercial Registc=d Office Provider
clo
County
.
3_ The stll1Ute by 01' UIIder which it was incorporated:
15Pa.C.S. See 5306
, 4. The date ofils incorponui;:
~~p~~m~~~ 7, ,q Q
.
j. Check. and if appropriate complete. om< of the following:
W,. The am<:ndment shall be effective upoD filing these Articles of Amendment in the Department ofSl3!e.
i a The amendment sball be effective on: 04/27/ 2 007 at
I Date
Hour
.
:UV! ~ 1,.:,;, ,:-.;'; 'vt!
fJ I :Z ~;d j - ~H1r lOnZ
.
EXHIBIT
f
E
ueflpJes ~eJoqeo
:pa^!a08M
g.d
99 <::<::-<::<::f:-OL9
wdS~:EO LOOl 9l oao
.
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.
DSCB: 15-191 '51'59 J 5-2
.
6. Check. one if the foiluwing:
o The amendment was adopted by the shareholders or mcmbe~ pursuant to 15 Pa.C.S. * 1914(a) and (b) or ~
5914(..).
r:xJ. Thcamendment was adopted by die board ofdirecto~ pursuant to 1'5 Pa. e.s. ~ 1914(c) or ~ 5914(b).
.
7. Check, and if appropriate, complete one oflhe foJlowing;
o The amcodmcnt adopted by the corpor.uion. set Conn in full, is as foUOW$
.
U The amendment adopted by the corporation is set furtb in full in Exhibit A attached hereto and made a part
hereof.
.
8. Check if the amendMent restates the Ar1ic/u;
.(XI The restated Articles of Incorporation supersede Ihe origin3I articles and all amendments thereto.
.
IN TESTIMONY WHEREOF, the Wldc:rsigncd
corporatiOll has caused these Articles of Amendment to be
signed by a duly authori:!llld officer thuoofthis
30th
2007
day of May
.
~~
Signature
.
President
TItle
.
.
g'd
99GG-GGt:-OLS
Wd9~:EO LOOl 9l oao
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: pa~! aoalj
.
d6~:t:0 LO 92: oeo
.
DATE ISSUED.
.
07/23/2007
VW
COLONY INSURANCE COMPANY
8720 STONY POINT PARKWAY
SUITE 300
RICHMOND, VA 23235
(800) 577-6614 (All Inquiries}
NAME & MAILING ADDRESS OF NAMED INSURED
MISCELLANEOUS PROFESSIONAL LIABILITY
DECLARATIONS
E0607129
BURNS & WILCOX (PITTSBURGH)
750 HOLIDAY DRIVE
BUILDING 9, SUITE 650
PITTSBURGH, PA 15220
.
ELDERCARE SOLUTIONS, INC
POBOX 755
WILLlAMSPORT, PA 17703
POLICY -NUMBER
E0607129
_.._._-_..~-- ~
___--.-J
.
In consideration of the premium. insurance under all sections of this policy is provided the named insured only with respect to those
coverages lor which a limit olliabifity is shown, subject to all the terms of this policy including forms and endorsements made pan thereof.
THIS IS A CLAIMS MADE POLICY. PLEASE READ IT CAREFULLY.
RETROACTIVE DATE: 07/15/2004
INCEPTION: 12:01 A.M. STANDARD TIME AT THE ADDRESS OF THE NAMED INSURED AS STATED HEREIN
1_ OPTION TO EXTEND CLAIMS REPORTING PERIOD
a. Available if policy is terminated or not renewed. Restrictions apply.
b. Maximum of five (5) years.
c. Must be requested and premium paid within sixty (60) days of termination or expiration
d. See Section VI. of the Policy for details.
COVERAGE: MISCELLANEOUS PROFESSIONAL LIABILITY
COVERED PROFESSIONS (IF ANY): SEE AP017-0207
LIMITS OF INSURANCE
a. $1,000,000.00 Each Claim
b. $1,000,000.00 Aggregate
DEDUCTIBLE $2,500.00
PREMIUM
Flat Premium: _1.1L~O,OO
.
2.
3_
. 4.
5:
6.
.
7.
Fees
FORMS AND ENDORSEMENTS ATTACHED AT INCEPTION:
AP017.0207 AP041B-0904 AP045-0904 ME29-0104
MEPA-0903 ML0001-0603 U002-D9D4 U094-0702
$0.00
ME35-0602
ZPJCG-0605
.
Signature
j"....
,....',
-~ ne ,;nsr1rt:;- '.r.'(~rc:" ;-:as ::S~~t<:':~c! ~.his if',;:::1..1!";:;:;C:U ':~:.;
i it,: f~' ~-i ~.'::.:
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::\{7U:"r-':.:<~ i,l~<: is
.
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;"~,:;i.r:'~';n':::c
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L.i,j"i':JF: ;:~une C5C.
r:) "'. -j ~ ~ ,., '''~I f":
,-'\ ",'i._L,"'..J.
.
MLDEC (06/06) This Declarations Page and the Forms and Endorsements listed above and attached hereto
complete the above numbered Policy.
Page 1 of 1
L'd
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LAST WD.J... AND TESTAMENT
(pour-Over Will)
OF
BETrY R. V ALENCIK
IDENTITY
I, BETIY R. V ALENCIK, residing in the County of Columbia, Commonwealth of Pennsylvania,
being of sound mind and memory, and not acting under duress or undue influence of any person
whomsoever, hereby declare this to be my Last Will and Testament, and I do hereby revoke all other
former Wills and Codicils to Wills heretofore made by me. My Social Security Number is 200-16-3836.
All reference made herein to "spouse or my spouse" refers to the person to whom I am currently
married, namely, CHESTER L. V ALENCIK SR. By the ensuing provisions of this Will, it is my intention
to dispose of my interest in our property; I do not intend to dispose of anything belonging to my husband
or to put him to any election.
I have the following child: Chester L. Valellcik, Jr., born November 24, 1949 and currently
residing in Mechanicsburg, Pennsylvania.
DEBTS, TAXES AND ADMINISTRATION EXPENSES
I have provided for the payment of all my debts, expenses of administration of property wherever
situated passing under this Will or otherwise, and estate, inheritance, transfer, and succession taxes, other
than any tax on a generation-skipping transfer that is not a liability of my Estate (including interest and
penalties, if any) that become due by reason of my death, under THE CHESTER L. V ALENCIK, SR.
AND BETTY R. V ALENCIK REVOCABLE LIVING TRUST executed on even date herewith (the
"Revocable Trust"), or if my spouse predeceases me, under the Survivor's Trust created by the said
Revocable Trust. If the Revocable Trust assets should be insufficient for these purposes, my Executor
shall pay any unpaid items from the residue of my Estate passing under this Will, without any
apportionment or reimbursement. fu the alternative, my Executor may demand in a writing addressed to
the Trustee of the Trust an amount necessary to pay all or part of these items, plus claims, pecuniary
legacies, and family allowances by court order.
PERSONAL AND HOUSEHOLD EFFECTS
It is my intent that all my personal and household effects were transferred to the Revocable Trust
as a result of the Declaration offutent signed this date. If there are any questions regarding the ownership
or disposition of these assets, it is my desire that such assets pour into the Revocable Trust, signed by me
this date in accordance with the provisions of the section titled "Residue of Estate."
RESIDUE OF ESTATE
I give, devise and bequeath all the rest, residue and remainder of my property of every kind and
description (including lapsed legacies and devices), wherever situated and whether acquired before or
after the execution of this Will, to the Trustee under that certain Trust executed by me on the same date of
the execution of this Will. The Trustee shall add the property bequeathed and devised by this item to the
corpus of the above described Trust and shall hold, administer and distribute said property in accordance
with the provisions of the said Trust, including any amendments thereto made before my death.
EXHIBIT
POUR-OVER WILLS
Page 1
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Testatrix
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If for any reason the said Trust shall not be in existence at the time of death, or if for any reason a
comt of competent jurisdiction shall declare the foregoing testamentary disposition to the Trustee under
said Trust as it exists at the time of my death to be invalid, then I give all of my Estate including the
residue and remainder thereof to that person who would have been the Trustee under the Trust, as
Trustee, and to their substitutes and successors under the Trust, described herein above, to be held,
managed, invested, reinvested and distributed by the Trustee upon the terms and conditions pertaining to
the period beginning with the date of my death as are constituted in the Trust as at present constituted
giving effect to amendments, if any, hereafter made and for that purpose I do hereby incorporate such
Trust by reference into this my Will.
EXECUTOR
I hereby nominate and appoint Chester L. Valencik, Sr. as my Independent Executor of this, my
Last Will and Testament, to serve without bond.
In the event the fIrst named Executor shall predecease me or is unable or unwilling to act as my
Executor for any reasons whatsoever, then and in that event, I hereby nominate and appoint Troy A.
Valencik and to serve without bond as my Joint Executors.
In the event that one of the Joint Executors shall predecease me, or is unable or unwilling to act as
my Executor for any reason whatsoever, then and in the event I hereby nominate and appoint the
remaining Executor to serve without bond as my Independent Executor.
Whenever the word .'Executor" or any modifying or substituted pronoun therefore is used in this
my Will, such words and respective pronouns shall be held and taken to include both the singular and the
plural, the masculine, feminine and neuter gender thereof, and shall apply equally to the Executor named
herein and to any successor to substitute' Executor acting hereunder, and such successor or substitute
Executor shall possess all the rights, powers, duties, authority, and responsibility conferred upon the
Executor originally named herein.
EXECUTOR POWERS
By way of lllustration and not of limitation and in addition to any inherent, implied or statutory
powers granted to executors generally, my Executor is specifically authorized and empowered with
respect to any property, real or personal, at any time held under any provision of this my Will: to allot,
allocate between principal and income, assign, borrow, buy, care for, collect, compromise claims, contract
with respect to, continue any business of mine, convert, deal with, dispose of, enter into, exchange, hold,
improve, incorporate any business of mine, invest, lease, manage, mortgage, grant and exercise options
with respect to, take possession of, pledge, receive, release, repair, sell, sue for, make distributions in cash
or in kind of partly in each without regard to the income tax basis of such asset and in general, exercise all
of the powers in the management of my Estate which any individual could exercise in the management of
similar property owned in its own right upon such terms and conditions as to my Executor may seem best,
and execute and deliver any and all instruments and do all acts which my Executor may deem proper or
necessary to carry out the purpose of this my Will, without being limited in any way by the specific grants
or power made, and without the necessity of a court order.
My Executor shall have absolute discretion, but shall not be required, to make adjustments in the
rights of any BenefIciaries, or among the principal and income accounts to compensate for the
consequences of any tax decision or election, or of any investment or administrative decision, that my
executor believes has had the effect, directly or indirectly, of preferring one Beneficiary or group of
Beneficiaries over others. In determining the Federal Estate and Income Tax liabilities of my Estate, my
POUR-OVER WILLS
Page 2
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Testatrix
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Executor shall have discretion to select the valuation date and to determine whether any or all of the
allowable administration expenses in my Estate shall be used as Federal Estate Tax deductions or as
Federal Income Tax deductions and shall have the discretion to file a joint income tax return with my
spouse.
CONTESTS AND SPECIFIC OMISSIONS
If any beneficiary under this will, singly or in conjunction with any other person or persons,
directly or indirectly:
1. contests in any court the validity of this will or, in any manner, attacks or seeks to impair or
invalidate any of its provisions;
2. contests in any court the validity of the Testator's/Testatrix's Will or, in any manner, attacks or
seeks to impair or invalidate any of its provisions;
3. seeks to obtain an adjudication in any proceeding in any court that this trust or any of its
provisions or that Testator'srrestatrix's Will or any of its provisions is void;
4. claims entitlement by way of any written or oral contract to any portion of the
Testator'srrestatrix's estate, whether in probate or under this instrument;
5. unsuccessfully challenges the appointment of any person named as Executor or successor
Executor of the Testator'srrestatrix's Will;
6. objects in any manner to any action taken or proposed to be taken in good faith by the Executor
ofthe Testator'srrestatrix's Will;
7. objects to any construction or interpretation of this Will, or any provision of it, that is adopted or
is proposed in good faith by the Executor;
8. unsuccessfully seeks the removal of any person acting as the Executor of the
Testator's/Testatrix's Will;
9. files any creditor's claim in Testator's/Testatrix's estate (without regard to its validity), whether
the claim arose before or after the date of this instrument, but excepting claims for cash advanced
or paid for expenses of the Testator'srrestatrix's last illness or funeral paid by said claimant;
10. attacks or seeks to invalidate any designation of beneficiaries for any life insurance policy on
Testator'slTestatrix's life;
11. attacks or seeks to invalidate any designation of beneficiaries for any pension or IRA or other
form of qualified or non-qualified asset or deferred compensation account, agreement or
arrangement;
12. attacks or seeks to invalidate any will which Testatorrrestatrix has created or may create during
Testator' slTestatrix' s lifetime, or any provision thereof, as well as any gift which
POUR-OVER WILLS
Page 3
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Testatrix
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Testator/Testatrix has made or will made during Testator'strestatrix's lifetime, whether before or
after the date of this instrument;
13. attacks or seeks to invalidate any transaction by which Testator/Testatrix sold any assets (whether
to a relative of Testator'sffestatrix's or otherwise); or
14. refuses a request of Testator'sffestatrix's, Executor or other fiduciary to assist in the defense
against any of the foregoing acts or proceedings,
then that person's right to take any interest given to him or her by this trust shall be determined as it would
have been determined if the person had predeceased the execution of this will instrument without issue
surviving.
The provisions of the foregoing paragraph shall not apply to any disclaimer by any person of any benefit
under this will. In the event that any of this provision is held to be invalid, void or illegal, the same shall
be deemed severable from the remainder of this provision and shall in no way affect, impair or invalidate
any other provision in this will; and if such provision shall be deemed invalid due to its scope or breadth,
such provision shall be deemed to exist to the extent of the scope or breadth permitted by law.
SIMULTANEOUS DEATH
If my spouse and I should die under circumstances such that the order of our deaths cannot be
determined, then it shall be conclusively presumed for the purpose of this Will that my spouse survived
me,
If any other Beneficiary should not survive me for sixty (60) days, then it shall be conclusively
presumed for the purpose of this my Will that said Beneficiary predeceased me.
~~A?~
BE R. V ALENCIK
Testatrix
POUR-OVER WILLS
Page 4
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This instrument consists of 6 typewritten pages, including the Attestation Cla~se, Self- oving
. ignature of Witnesses, and acknowledgment of officer. I have signed my nam ttom of
f ~~Ceding P'/l7Th~S instrument is being signed by me on this day of
ATTESTATION CLAUSE
The Testatrix whose name appears above declared to us, the undersigned, that the foregoing
instrument was his Last Will and Testament, and she requested us to act as witnesses to such instrument
and to her signature thereon. The Testatrix thereupon signed such instrument in our presence. At the
Testatrixr's request, the undersigned then subscribed our names to the instrument in our own handwriting
in the presence of the Testatrix. The undersigned hereby declare, in the presence of each of us, that we
believe the Testatrix to be of sound and disposing mind and memory.
Signed by us on the same day and year as this Last Will and Testament was signed by the
Testatrix.
WITNESSES:
ADDRESSES:
't/./~ !: if~
M'lw~6..~
(Printed Name of Witness)
~~~~
t!~L4VA.-j~ d~
City, State, Zip ;7
~rud (). c(~
cR~~ A ~
(Printed Name of Witness)
.?fV'~#~P#
~~^-#- /:7~
City, State, Zip
POUR-OVER WILLS
Page 5
t,(v
Testatrix
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COMMONWEALTH OF PENNSYLVANIA
COUNTY OF COLUMBIA
SELF-PROVING CLAUSE
BEFOJU}IM~~...,th~ ungerlijned authority, oy.~ _~~ jcWY ~~naJ1.v appeared BETTY R.
VALENCIK,MPVtwl e;. ,~~ and\lLMl!Y/ -~~ . ,lmown to me
to be the Testatrix and the witnesses, respectively, whose names are subscribed to the foregoing
instrument in their respective capacities, and all of them being by me du1y sworn, BETTY R.
V ALENCIK, Testatrix, declared to me and to the witnesses, in my presence, that the instrument is her
Will and that she had willingly made and executed it as her free act and deed for the purposes therein
expressed; and the Witnesses, each on his or her oath, stated to me in the presence and hearing of the
Testator, that the Testator had declared to them that the instrument is her Will and that she executed the
same as such and wanted each of them to sign it as a witness; and upon their oaths, each witness stated
further that she did the same as a witness in the presence of the Testatrix, and at her request and that she
was at that time eighteen (18) years of age or over and was of sound mind, and that each of the witnesses
was then at least fourteen (14) years of age.
~,tl)j~
BETTY . V ALENCIK
Testatrix
~~6~
~ ./~.
q~.
(Printed Name of Witness)
_s;/~Il, j(~
~Ai-~
inted Name of Witness)
SUBSCRIBED AND ACKNOWLEDGE
.~p~ore ~ by
sylvania
POUR-OVER WILLS
Page 6
.
REVOCABLE LIVING TRUST AGREEMENT
.
~ TH~REE~l.AND DECLARATION OF TRUST, made effective the ~ day of
'. ~u. , 20~, between CHESTER L. V ALENCIK SR. AND BETTY R. V ALENCIK,
husband and wife, residents of the County of Columbia, Commonwealth of Pennsylvania, as Grantors,
CHESTER L. V ALENCIK SR. AND BETTY R. V ALENCIK, as Settlors, and CHESTER L.
V ALENCIK, SR. AND BETTY R. V ALENCIK, as Co-Trustees;
.
WITNESSETH;
WHEREAS, in order to provide the future comfort and security of themselves and the other
beneficiaries hereafter mentioned, Grantors desire to create a revocable trust for the purposes hereinafter
set forth;
.
ARTICLE ONE
Terms of the Trust
Section 1.01 - Trust Estate Dermed
.
.
NOW, THEREFORE, in consideration ofthe premises and of the mutual covenants herein contained, this
Revocable Trust is formed to hold title to real and personal property for the benefit of the Settlors of this
Trust and to provide for the orderly use and transfer of these assets upon the death of the Settlors. The
"Trust Estate" is defined as all property transferred or conveyed to and received by the Trustee held
pursuant to the terms of this instrument. The Trustee is required to hold, administer, and distribute this
property as provided in this Trust Agreement.
The name of this Trust Agreement shall be:
.
THE CHESTER L. V ALENCIK, SR. AND BETTY R. V ALENCIK
REVOC~G TRytf AGREEMENT
DATED. J~ 20.0
I.. ' -
Section 1.02 - Definitions of Terms
.
In the interpretation or construction of the provisions of this Trust Agreement, the following words and
phrases shall have the meanings set forth below:
1. The term "Husband" shall mean CHESTER L. V ALENCIK, SR.
.
2.
The term "Wife" shall mean BETTY R. V ALENCIK.
3. The term "Settlor" shall refer individually and collectively to Husband and Wife.
4.
The term "Descendant" shall mean the lawful issue of a deceased parent in the line of
descent, but does not include the issue of any parent who is a descendant of the deceased
person in question and who is living at the time in question.
EXHIBIT
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REVOCABLE LIVING TRUST AGREEMENT I
Page 1
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5. The terms "Child" and "Descendant" include any issue born to decedent, a child legally
adopted by the decedent, and a posthumous child of a decedent. A posthumous child is to
be considered as living at the time of his or her parent's death.
6.
The term "Survives" or "Surviving", unless otherwise indicated herein, shall be construed
to mean surviving the decedent for at least sixty (60) days. If the person referred to dies
within sixty (60) days of the death of the decedent, the reference to him or her will be
construed as if he or she had failed to survived the decedent; provided, however, that any
such person will have, during such period, the right to the use and enjoyment as a life
tenant of all property in which his or her interest will fail by reason of death during such
period.
7. The term "Issue" will include all natural and adopted children, if applicable, and
descendants and those legally adopted into the line of descent.
8.
The term "Per Stirpes" means strict per stirpes and does not mean per capita with
representation. Beneficiaries entitled to take under a "per stirpes" clause will include
both natural and adopted children and their descendants.
9.
The terms "Trust Assets" and "Trust Estate" include all assets of any trust created
hereunder and income derived from such assets and all proceeds of any description
derived from the sale, exchange, or other disposition of such assets.
10. When required to give reasonable effect to the context in which used, pronouns in the
masculine, feminine, or neuter gender include each other, and nouns and pronouns in the
plural or singular number include each other.
Section 1.03 - Trustee Designation
Husband and wife are hereby designated as Co-Trustees. The Co-Trustees shall serve jointly and
severally and either shall have full authority to act for the Trust independently. Should either husband or
wife become unable because of death, incapacity, or other cause to serve as a Co-Trustee, or should either
resign as Co-Trustee before the natural termination of this Trust, the remaining Co-Trustee, husband or
wife, shall thereafter serve as sole Trustee. The term "Trustee" as used in this Trust Agreement shall refer
collectively to husband and wife so long as they serve as Co-Trustees, to the spouse who serves as the
sole Trustee, and/or to any Successor Trustee who assumes the role of Trustee. These Trustees shall
serve in the order as provided in Section 9.01 of this Trust Agreement.
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Section 1.04 - Additions to Trust Properties
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1.
The Trustee, at any time during the continuance of this Trust in his or her sole discretion
after consideration of the possible tax consequences to all concerned, is authorized to
receive into the Trust additions of cash and other properties from any source whatsoever,
whether by gift, will, or otherwise. However, the Trustee shall accept all assets which
any person or persons may give, devise, or bequeath by Last Will and Testament to this
Trust, and shall accept all assets transferred to this Trust pursuant to the provisions of any
other Trust document or documents.
2.
In addition, any person or persons may designate this Trust as the Beneficiary, Primary or
Contingent, of any death benefits to include insurance benefits, pension benefits, or other
benefits. Until such benefits mature, the Trustee shall have no responsibility with respect
to those benefits.
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Section 1.05 - Apportionment
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The Trustee of the Trust is directed to apportion receipts and expenditures of the types described below
between principal and income as follows:
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1. Whenever the principal, or any part thereof, of the Trust property is invested in securities
purchased at a premium or at a discount, any premium will be charged against principal
and any discount will be credited to principal;
2.
Any stock dividends and rights to purchase additional stock issued on securities held in
trust will be treated as principal. All other dividends, except liquidating distributions,
will be treated as income; and
3.
The amount of any applicable depletion allowance for federal income tax purposes will
be treated as income.
Section 1.06 - Administration of Trust During Our Lifetime
During our lifetime, the trust shall be held and administered as follows:
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1.
All property and other assets transferred to this trust shall be allocated to and held in
separate shares, the fIrst such share being designated the "Chester L. Valencik Sr. Trust
Share" and the second share being designated the" Betty R. Valencik Trust Share".
2. Each Grantor's separate Trust Share shall be composed of the assets as follows:
a.
The Grantor's one-half interest in jointly held property transferred to the Trust;
and
b. The Grantor's individually owned property which is transferred to the Trust.
While each share shall be held and administered separate from the other, for tax and accounting
pmposes, the Trustee is authorized to hold or invest the separate shares in common investments
and co-ownership of assets.
3.
The Trustee shall pay to or apply for the benefit of CHESTER L. V ALENCIK, SR. all of
the net income of the CHESTER L. V ALENCIK, SR. Trust Share, in convenient
installments, not less often than quarter-annually, and in addition thereto, shall pay so
much of the income and principal of such Trust Share to or for the benefIt of CHESTER
L. V ALENCIK, SR. as he may direct from time to time, or in the absence of a direction,
as the Trustee may determine to be advisable for his medical care, support, maintenance,
and general welfare.
4.
The Trustee shall pay to or apply for the benefit of BETTY R. V ALENCIK all of the net
income of the BETTY R. V ALENCIK Trust Share in convenient installments, not less
often than quarter-annually, and in addition thereto, shall pay so much of the income and
principal of such Trust Share to or for the benefit of BETTY R. V ALENCIK as she may
direct from time to time, or in the absence of a direction, as the Trustee may determine to
be advisable for her medical care, support, maintenance, and general welfare.
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All property that a Settlor transfers to the Trustee pursuant to this instrument which was
community property, quasi-community property, or separate property at the time of the
transfer shall remain respectively community property, quasi-community property, or the
separate property of the Settlor transferring such property to the Trust.
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Community and quasi-community property transferred to the Trustee by the Settlors shall
be their community property and treated as such. This property, as invested and
reinvested, together with the rents, issues, and profits therefrom (hereinafter referred to as
the "Community Estate" or the "Community Property") shall retain its character as
community property during the joint lifetimes of the Settlors in spite of any change in the
situs of the Trust, subject, however, to the provisions of this Agreement.
Section 1.07 - Discretionary Termination
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The Trustee may terminate any Trust when, in the opinion of the Trustee, the principal is reduced to such
an extent that it is not in the best interest of the Beneficiary or Beneficiaries to continue the Trust. The
judgment of the Trustee with respect to this decision to terminate will be final and not subject to judicial
review. If the Trustee terminates a Trust according to this Section, the date the Trust terminates will be
deemed the date fixed for termination of the Trust, and the Trustee will distribute the assets of the
terminating Trust to the Beneficiary or Beneficiaries pursuant to this Agreement.
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Section 1.08 - Amendment and Revocation
We hereby retain the following powers, exercisable at any time during our lifetimes:
1.
To withdraw any of the property included in our separate share of the Trust Estate by
giving the Trustee written notice specifying the property so withdrawn, in which event,
the Trustee shall promptly transfer and deliver such property to us or our designee.
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2.
To amend the provisions of this Trust declaration in any respect without the necessity of
securing the consent of the Trustee to such changes, in which event, a copy of the
amendment shall be promptly furnished to the Trustee; provided, however, that following
the death of one of us, the survivor shall have no power to amend the terms of the Trust
declaration with respect to the Trust Share of the first of us to die.
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3.
To revoke this Trust by giving the Trustee written notice of such revocation, in which
event, the Trustee shall promptly transfer and deliver the property constituting the Trust
Estate to us or our designee together with an accounting therefore; provided, however,
that following the death of one of us, the survivor shall have no power to revoke the
terms of the Trust declaration with respect to the Trust Share of the first of us to die.
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Section 1.09 - Revocation or Alteration by Settlor Alone
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The rights of revocation, withdrawal, alteration, and amendment reserved in this Article may only be
exercised by the Settlor and may not be exercised by any other person, including an agent, a guardian, or
a conservator.
Section 1.10 - Irrevocability
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Except as otherwise provided, on the death of either Settlor, the designation of Beneficiaries of specific
gifts in this Trust shall become irrevocable and not subject to amendment or modification.
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Section 1.11 - Settlor Powers
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The surviving Settlor shall be the Trustee unless and until he or she resigns in writing or is determined
incompetent under the terms provided herein. The surviving Settlor shall retain all absolute rights to
discharge or replace any Successor Trustee of any portion or share of the Trust which is revocable by the
surviving Settlor so long as the Settlor is competent.
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ARTICLE TWO
Trust Administration
Section 2.01 - Trust Income
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During the j oint lives of the Settlors, the Trustee shall at least annually, unless otherwise directed by both
Settlors in writing, pay to or apply for the benefit of husband and wife, all of the net income from the
Trust Estate in the same proportions as each of the spouse's respective interests in the Trust Estate.
Section 2.02 - Protection of Settlor in Event of Incapacity
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During the joint lives ofthe Settlors, shQuld either Settlor become incapacitated as defmed in Section 2.03
below, the Trustee may, in the Trustee's absolute discretion, pay income and principal for the benefit of
the incapacitated Settlor. In addition, the Trustee, in his or her absolute discretion, may pay to or apply,
for the benefit of that Settlor, such sums from the net income and from the principal of the Settlor's
separate Estate as the Trustee believes is necessary or advisable for the medical care, comfortable
maintenance, and welfare of the Settlor.
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Section 2.03 - Incapacity
1. A person is determined to be incapacitated if any Trustee or Beneficiary hereunder comes into
possession of any of the following:
a.
A jurisdictionally applicable court order holding the party to be legally incapacitated to
act on his or her behalf and appointing a guardian or conservator to act for him or her; or
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b.
Written certificates which are duly executed, witnessed, and acknowledged of two
licensed physicians, each certifying that the physician has examined the person and has
concluded that, by reason of accident, mental deterioration, or other cause, such person
has become incapacitated and can no longer act rationally and prudently in his or her own
financial best interest; or
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c. Evidence which such Trustee or Beneficiary deems to be credible and currently
applicable that a person has disappeared, is unaccountably absent, or is being detained
under duress, and that he or she is unable to effectively and prudently look after his or her
own best interests, then in that event and under those circumstances:
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1) Such person is deemed to have become incapacitated, as that term is used in this
Trust agreement; and
2) Such incapacity is deemed to continue until such court order, certificates, and I or
circumstances are inapplicable or have been revoked.
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2.
A physician's certificate to the effect that the person is no longer incapacitated shall revoke a
certificate declaring the person incapacitated. The certificate which revokes the earlier certificate
may be executed by either the original certifying physician or by two other licensed, board
certified physicians. No Trustee shall be under any duty to institute any inquiry into a person's
possible incapacity. The reasonable expense of any such inquiry shall be paid from the Trust
Assets.
Section 2.04 - Principal Invasion
During the joint lives of the Settlors, should the net income of assets contained in this Trust be
insufficient to provide fOT the care, maintenance, or support of the Settlors as herein defined, the Trustee
may, in the Trustee's sole and absolute discretion, pay to or apply for the benefit of the Settlors or either
of them, or any of their dependents, such amounts from the principal of the Trust Estate as the Trustee
deems necessary or advisable for the care, maintenance, or support of the Settlors.
Section 2.05 - Residence
If the Settlor's residence property is a part of the Trust, the Settlors shall have possession of and full
management ofthe residence and shall have the right to occu!,~ II rree uf:ent. Any expenses arising from
the maintenance of the property and from all taxes. lie~:", assessments, and lll:>l.u ,"-<lce premiums, are to be
paid from the Trust to the extent that assets aTP dvailable for payment. It is the intent of the Settlors to
retain all homestead rights available to the'::" under the applicable state law.
ARTICLE THREE
Administration upon Death of First Settlor
Section 3.01 - Provisions After The First Death
On the death of either Settlor leaving the other Settlor surviving him or her, the Trustee shall collect all
insurance proceeds payable to the Trustee by reason of such death and all bequests and devises
distributable to the Trust Estate.
Section 3.02 - Control of Assets
The surviving spouse may, at any time by written notice, require the Trustee either to make any
nonproductive property of this Trust productive or to convert productive property to nonproductive
property, each within a reasonable time. The surviving spouse may further require the Trustee to invest
part or all of this share of Trust Assets for the purpose of maximizing income rather than growth or
growth rather than income.
Section 3.03 - Division into Shares
1.
Upon the death of either Settlor, if the deceased Settlor is survived by the other Settlor, the
deceased's individual Trust Share, including any additions made by reason of the deceased
Settlor's death, shall be divided into two shares.
2.
The Trustee, in his or her sole discretion, may defer the division or distribution of the deceased's
individual Trust Share until six months after the deceased Trustor's death. If the division or
distribution of the deceased's individual Trust Share is so deferred, the deferred division or
distribution shall be made as if it had taken place at the time prescribed above. In addition, all
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rights given to the Beneficiaries under the provisions of this Trust Agreement which follow shall
be considered to have accrued and vested as of that prescribed time.
Upon the death of the first Settlor to die ("Predeceased Spouse"), the Trustee shall divide the
deceased's individual Trust Share (which shall include any property which may be added from
the Predeceased Spouse's general estate) as follows:
a.
The Trustee shall divide the balance of the deceased Trustor's individual Trust Share into
two (2) separate shares (hereinafter designated as "Share A" and "Share B"). Share B
shall be composed of cash, securities, and/or other property of the deceased's individual
Trust Share (undiminished by any estate, inheritance, succession, death, or similar taxes)
having a value equal to the maximum marital deduction as finally determined in the
Predeceased Spouse's federal estate tax proceedings, less the aggregate amount of marital
deductions, if any, allowed for such estate tax purposes by reason of property or interest
in property passing or which have passed to the Surviving Spouse otherwise than
pursuant to the provisions of this paragraph; provided, however, that the amount of Share
B hereunder shall be reduced by the amount, if any, needed to increase the Predeceased
Spouse's taxable estate (for federal estate tax purposes) to the largest amount that, after
allowing for the unified credit against federal estate tax and the state death tax credit
against such tax (but only to the extent that the use of such state death tax credit does not
increase the death tax payable to any state), will result in the smallest (if any) federal
estate tax being imposed on the Predeceased Spouse's estate. The term "Maximum
Marital Deduction" shall not be construed as a direction by the Predeceased Spouse to
exercise any election respecting the deduction of estate administration expenses, the
determination of the estate tax valuation date, or any other tax election which may be
available under any tax laws, only in such manner as will result in a larger allowable
estate tax marital deduction than if the contrary election had been made. The Trustee
shall have the sole discretion to select the assets which shall constitute Share B. In no
event, however, shall there be included in Share B any assets or the proceeds of any asset
which will not qualify for the federal estate tax marital deduction. Share B shall be
reduced to the extent that it cannot be created with such qualifying assets. The Trustee
shall value any asset selected by the Trustee for distribution in kind as a part of Share B
at the value of such asset at the date of distribution of such asset. The balance of the
deceased's individual Trust Share, after the assets have been selected for Share B, shall
be allocated to Share A.
Share A and Share B shall be administered and distributed as hereinafter set forth.
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Section 3.04 - Credit Shelter Trust
If either of the Settlors survives the other, the Trustee shall set apart and hold as a separate trust (the
"Credit Shelter Trust") the assets referred to as Share A in Section 3.03 above. The Trustee shall hold,
manage, invest, and reinvest the assets of this Credit Shelter Trust, shall collect the income therefrom, and
shall pay the net income to or for the benefit of the surviving Settlor in convenient installments at least
quarter-annually; provided, however, that the surviving Grantor may elect to pass any portion of said
income to the remainder Beneficiaries of the Trust.
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In addition, the Trustee may pay to or for the benefit of the surviving Settlor for the health, education,
maintenance, or support of the surviving Settlor, any part or all of the principal of this Trust, as the
Trustee may determine in its sole discretion, without considering other resources available to the
surviving Settlor. The surviving Settlor shall have the right to demand and receive, from the principal of
this Trust in each of its fiscal years, the greater of five thousand dollars ($5,000.00) or five percent (5%)
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of the fair market value of such principal determined as of the last day of such fiscal year. Such right
shall lapse to the extent it is not exercised in any year. Any commission payable with respect to principal
so withdrawn shall be charged against such principal.
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No person, who at any time is acting as Trustee hereunder, shall have any power or obligation to
participate in any discretionary authority which the Settlor has given to the Trustee to pay principal or
income to such person, or for his or her benefit or in relief of his or her legal obligations; provided,
however, that if an individual Trustee has discretion to invade principal for himself or herself and such
discretionary authority is limited by an ascertainable standard, then such Trustee may invade principal (if
limited by such standard) for himself or herself, but not in relief of his or her legal obligations.
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The plan of distribution and all terms of this Credit Shelter Trust shall be irrevocable and unamenab1e at
any time after said Credit Shelter Trust comes into being.
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The Credit Shelter Trustee(s) shall invest the assets of the Credit Shelter Trust to produce a reasonable
income for the benefit of the surviving Grantor without subjecting the principal to unreasonable risk of
loss. The Credit Shelter Trustee(s) shall be authorized and empowered to invest, reinvest, manage,
transfer, and convey any and all property held in this Credit Shelter Trust, including all powers now or
hereafter conferred upon Trustees by applicable state law, and also those power appropriate to the orderly
and effective administration of the Trust.
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The Credit Shelter Trustee( s) shall make a written accounting to all income. and remainder Beneficiaries
or to their guardians at least annually and at the time that all assets of this Credit Shelter Trust are
distributed. Said accounting shall consist of a record showing assets on hand at the time of the last
accounting, plus additions, minus expenses and distributions, which shall equal current assets on hand.
The Credit Shelter Trustee(s) shall not be required to obtain authority or approval of any court in the
exercise of any power conferred upon the Trustee(s), nor shall said Trustee(s) be required to make
accountings or reports to any court.
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Upon the death of the surviving Settlor, any accrued income shall be paid to the estate of the surviving
Settlor and the remaining principal of this Credit Shelter Trust shall be held, administered, and disposed
of in accordance with the dispositive provisions of this agreement.
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Section 3.05 - Qualified Terminable Interest Trust
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If either of the Grantors survives the other and there are assets allocated to Share B described in Section
3.03 above, then the Trustee shall set apart said assets and hold them as a separate trust (the "Qualified
Terminable Interest Trust"). The Trustee shall hold, manage, invest, and reinvest the assets of this
Qualified Terminable Interest Trust, shall collect the income therefrom, and shall pay the set income to or
for the benefit of the surviving Grantor in convenient installments at least quarter-annually.
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Upon the surviving Grantor's death, any accrued, undistributed income shall be distributed to said
surviving Grantor's estate. The remaining principal shall be added to and become part of the Credit
Shelter Trust and shall be held and administered and disposed of in accordance with the plan of
distribution for the Credit Shelter Trust as provided in Sections 3.04 and 4.03, after provision has first
been made for the payment of any estate, inheritance, transfer, succession, or other death taxes, payable
by reason of the inclusion of the value of the Trust property in said surviving Grantor's estate.
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The Trustee(s) of the Qualified Terminable Interest Trust are hereby authorized, in the Trustee(s) sole
discretion, to determine whether to elect (under Section 2056(b)(7) of the Internal Revenue Code) to
qualify all or a specific portion of the Qualified Terminable Interest Trust created herein for the federal
estate tax marital deduction. The Trustee(s) of the Qualified Terminable Interest Trust, in exercising such
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discretion, shall attempt to minimize, or eliminate if possible, the federal estate tax payable by the estate
of the decedent spouse's estate.
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However, if the Trustee(s) of the Qualified Terminable Interest Trust determine that it is in the best
interest of the persons who may receive any assets after the decedent spouse's death and after the
surviving Grantor's death to pay some federal estate tax in the decedent spouse's estate, taking into
consideration any other tax that is to be paid because of the decedent spouse's death and the surviving
Grantor's death, and any income tax liability that may be affected by the election, the Trustee(s) of the
Qualified Terminable Interest Trust may elect to take a marital deduction that does not reduce the tax to
zero if the payment of the tax will not jeopardize the ability of the Qualified Terminable Interest Trust to
provide the surviving spouse with the level of support and maintenance contemplated by this Declaration
of Trust. The decision of the Qualified Terminable Interest Trustee(s) to make this election shall be final
and binding on all persons.
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The Trustee(s) of the Qualified Terminable Interest Trust is (are) authorized and empowered to invest,
reinvest, transfer, and convey any and all property held in this Qualified Terminable Interest Trust. This
includes all power now or hereafter conferred upon Trustees by applicable state law, and also those
powers appropriate to the orderly and effective administration of the Trust.
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The Trustee(s) shall make a written accounting to the surviving Grantor at least annually and shall make a
written accounting to all remainder Beneficiaries at the time that all assets of this Qualified Terminable
Interest Trust are distributed.
Section 3.06 - Power to Appoint Agents
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The surviving spouse shall have the right to retain an accountant and / or an attorney at law for
professional services on behalf of the Trust Estate or Estates herein. The surviving spouse shall not be
responsible for the acts of such agents beyond his or her obligation to use reasonable care in the selection
of such agents.
Section 3.07 - Maximum Marital Deduction
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Except as otherwise expressly stated herein, the term "Maximum Marital Deduction" shall not be
construed as a direction by the deceased Settlor to exercise any election respecting the deduction of Estate
administration expenses, the determination of the Estate tax valuation date, or any other tax election
which may be available under any tax laws, only in such manner as will result in a larger allowable Estate
tax marital deduction than if the contrary election had been made.
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Section 3.08 - Trust Income After The First Death
Following the death of either Settlor and until the death of the surviving Settlor, the Trustee shall, at least
annually, pay to or apply for the benefit of the surviving Settlor all of the net income from the Trust
Estate.
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Section 3.09 - Simultaneous Death
If the Settlors should die under circumstances which would render it doubtful as to which Settlor died
first, it shall be conclusively presumed for the purposes of this Trust that Chester L. Valencik, Sr. died
first. If any other Beneficiary and a Settlor should die under such circumstances, it shall be conclusively
presumed that the Beneficiary predeceased such Settlor.
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3.
If all of the Settlor's Beneficiaries and their children should fail to survive the final distribution of
the Trust Estate, all of the Trust Estate not disposed of as hereinabove provided shall be
distributed as provided for in this Trust Agreement.
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Section 4.05 - Principle of Representation
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Unless indicated differently in this Trust Agreement or in the "Special Directives" section that follows, in
the event any of the named Beneficiaries should predecease both Settlors, all of that person's share of the
Trust Estate is to be divided equally among the deceased Beneficiary's children or issue per stirpes. In
the event the predeceased Beneficiary leaves no surviving children or issue, then all of that person's share
of the Trust Estate shall be divided equally among the remaining Beneficiaries per stirpes.
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If a Beneficiary of the Settlors survives both Settlors, but should fail to survive to collect his or her share
at distribution, that share shall pass to the surviving issue of that deceased Beneficiary per stirpes and with
right of representation.
ARTICLE FIVE
Trustee Powers & Provisions
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Section 5.01 - Non-Income Producing Property
During the j oint lives of the Settlors, the Trustee is authorized to retain in the Trust, for so long as the
Trustee may deem advisable, any property received by the Trustee from the Settlors, whether or not such
property is of the character permitted by law for the investment of Trust funds.
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Section 5.02 - Trustee Powers
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The Trustee shall have all powers conferred upon a Trustee by law for the orderly administration of the
Trust Estate. If any property is distributed outright under the provision of this Trust Agreement to a
person who is a minor, distribution may be made under the Pennsylvania Uniform Transfer to Minors Act
("P AUTMA"). The Trustee is further authorized to sign, deliver, and/or receive any documents necessary
to carry out the powers contained within this Section.
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The Trustee of any trust created under this Trust Agreement (including any substitute or successor
Trustee) will have and be subject to all of the powers, duties, and responsibilities granted or imposed by
the Pennsylvania Consolidated Statutes (20 Pa. C.S. Section 101 et seq.) as such Statute may provide at
the time of administration of the Trust, except to the extent that the same are inconsistent with the
provisions ofthis Agreement.
Section 5.03 - Specific Powers of Trustee
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In addition, the Trustee will have the following specific powers:
1.
Trust Estate: The Trustee may leave invested any property coming into its hands hereunder in
any form of investment even though the investment may not be of the character of investments
permitted by law to trustees, without liability for loss or depreciation in value. The Trustee may
sell, exchange, or otherwise dispose of and reinvest property which may at any time be a part of
the Trust Estate upon such terms and conditions as the Trustee may deem advisable. The Trustee
may invest and reinvest the Trust Assets from time to time in any property, real, personal, or
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mixed, including without limitation, secuntIes of domestic and foreign corporations and
investment trusts or companies, bonds, debentures, preferred stocks, common stocks, mortgages,
mortgage participation, and interests in common trust funds, all with complete discretion to
convert realty into personalty or personalty into realty or otherwise change the character of the
Trust Estate, even though such investment (by reason of its character, amount, proportion to the
total Trust Estate, or otherwise) would not be considered appropriate for a fiduciary apart from
this provision and even though such investment caused part or all of the total Trust Estate to be
invested in investments of one type or of one business or company.
2.
Holding Property: The Trustee may hold property in the Trustee's name, as trustee, or in the
name of a nominee without disclosing the Trust.
3.
Release of Power: If the Trustee deems it to be in the best interest of the Trust and its
Beneficiaries, the Trustee, by written instrument signed by such Trustee, will have the power and
authority to release, disclaim, or restrict the scope of any power or discretion granted in this Trust
Agreement or implied by law.
4. Agents, Employees: The Trustee may employ one or more agents to perform any act of
administration, whether or not discretionary, including attorneys, auditors, investment managers,
or others, as the Trustee shall deem necessary or advisable. The Trustee may compensate agents
and other employees and may delegate to them any and all discretions and powers.
5.
Leases: The Trustee may lease any Trust Assets generally or for oil, gas, and mineral
development, even though the lease term may extend beyond the term of the Trust of which the
property is a part. The Trustee may enter into any covenants and agreements relating to the
property so leased or concerning any improvements which may then or thereafter be erected on
such property.
6. Common Funds: The Trustee may hold any of the Trust Assets in a common fund with property
from other trust estates and may make investments jointly with any other trust, the property of
which is included in the common fund.
7.
Securities: With respect to securities held in the Trust Estate, the Trustee may exercise all the
rights, powers, and privileges of an owner, including but not limited to, the power to vote, give
proxies, and to pay assessments and other sums deemed by the Trustee necessary for the
protection of the Trust Estate. In addition, the Trustee may participate in voting trusts,
foreclosures, reorganizations, consolidations, mergers, and liquidations, and in connection
therewith, to deposit securities with and transfer title to any protective or other committee under
such terms as the Trustee may deem advisable. In addition, the Trustee may exercise or sell stock
subscription or conversion rights and may accept and retain as an investment any securities or
other property received through the exercise of any of the foregoing powers, regardless of any
limitations elsewhere in this instrument relative to investments by the Trustee. In addition, The
Trustee may Buy, sell exchange, assign, convey, settle and exercise commodities future contracts
and call and put options on stocks and stock indices traded on a regulated options exchange and
collect and receipt for all proceeds of any such transactions. Establish or continue option accounts
for the principal with any securities of a futures broker. In general, exercise all powers with
respect to commodity and option transactions that the principal could if present.
8. Purchases from Estate: The Trustee may purchase property of any kind from the Executor or
Administrator of our Estates.
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9.
Lending: The Trustee may make loans, secured or unsecured, to the Executor or Administrator
of our Estates, to any Beneficiary of the Trust, or to the Trustee. Further, the Trustee may use
Trust Assets to guarantee obligations of any income Beneficiary of the Trust (unless such
Beneficiary is serving as Trustee).
10.
Distributions to or for Beneficiaries: The Trustee may make any distribution contemplated by
this Trust Agreement (1) to the Beneficiary; (2) if the Beneficiary is under a legal disability or if
the Trustee determines that the Beneficiary is unable to properly manage his or her affairs, to a
person furnishing support, maintenance, or education for the Beneficiary or with whom the
Beneficiary is residing for expenditures on the Beneficiary's behalf; or (3) if the Beneficiary is a
minor, to a trustee of an existing trust established exclusively for the benefit of such minor,
whether created by this Trust Agreement or otherwise, or to a custodian for the Beneficiary, as
selected by the Trustee, under the Pennsylvania Uniform Transfer to Minors Act. Alternatively,
the Trustee may apply all or a part of the distribution for the Beneficiary's benefit. Any
distribution under this paragraph will be a full discharge of the Trustee with respect thereto. On
any partial or final distribution of the Trust Assets, the Trustee may apportion and allocate the
assets of the Trust Estate in cash or in kind, or partly in cash and partly in kind, or in undivided
interests in the manner deemed advisable at the discretion of the Trustee and to sell any property
deemed necessary by the Trustee to make the distribution. The Trustee may distribute gifts of up
to the maximum allowable per year per donee out of principal andlor interest.
11.
Insurance: The Trustee may purchase new life insurance, pay the premiums on existing life
insurance on the life of any Trust Beneficiary, purchase annuities (either commercial or private)
from any corporation, trust, or individual, and may procure and pay the premiums on other
insurance of the kinds, forms, and amounts deemed advisable by the Trustee to protect the
Trustee and the Trust Estate.
12.
Borrowing: The Trustee may borrow money from the Trust Estate and others. To secure the
repayment thereof, the Trustee may mortgage, pledge, or otherwise encumber part or all of the
Trust Assets, and in connection with the acquisition of any property, the Trustee may assume a
liability or may acquire property subject to a liability.
13.
Repairs: The Trustee may make ordinary and extraordinary repairs and alterations to buildings
or other Trust Assets.
14. Reserves: The Trustee may establish such reserves out of income for taxes, assessments, repair,
and maintenance as the Trustee considers appropriate.
Continuation of Business: The Trustee may continue any business or businesses in which the
Trust has an interest at the time of the Settlors' death for so long as the Trustee may, in its sole
discretion, consider necessary or desirable, whether or not the business is conducted by the
Settlors at the time of their death individually, as a partnership, or as a corporation wholly owned
or controlled by them, with full authority to sell, settle, and discontinue any of them when and
upon such terms and conditions as the Trustee may, in its sole discretion, consider necessary or
desirable.
16. Retain Property for Personal Use: The Trustee may retain a residence or other property for the
personal use of a Beneficiary and allow a Beneficiary to use or occupy the retained property free
of rent and maintenance expenses.
.
17.
.
Dealings with Third Parties: The Trustee may deal with any person or entity regardless of
relationship or identity of any Trustee to or with that person or entity. The Trustee may hold or
REVOCABLE LIVING TRUST AGREEMENT
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22.
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23.
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invest any part of or all of the Trust Estate in common or undivided interests with that person or
entity.
18.
Partitions, Divisions, Distributions: The Trustee will have the power to make all partltJ.ons,
divisions, and distributions contemplated by this Trust Agreement. Any partitions, divisions, or
other distributions may be made in cash, in kind, or partly in cash and partly in kind, in any
manner that the Trustee deems appropriate (including composing shares differently). The Trustee
may determine the value of any property, which valuation will be binding on all Beneficiaries.
No adjustments are required to compensate for any partitions, divisions, or distributions having
unequal consequences to the Beneficiaries.
19.
Claims, Controversies: The Trustee may maintain and defend any claim or controversy by or
against the Trust without the joinder or consent of any Beneficiary. The Trustee may commence
or defend at the expense of the Trust any litigation with respect to the Trust or any property of the
Trust Estate as the Trustee may deem advisable. The Trustee may employ, for reasonable
compensation, such counsel as the Trustee shall deem advisable for that purpose.
20.
Merger of Trusts: If at any time the Trustee of any trust created hereunder shall also be acting as
trustee of any other trust created by trust instrument or by trust declaration for the benefit of the
same beneficiary or beneficiaries and upon substantially the same terms and conditions, the
Trustee is authorized and empowered, if in the Trustee's discretion such action is in the best
interest of the Beneficiary or Beneficiaries, to transfer and merge all of the assets then held under
such trust created pursuant to this Trust Agreement to and with such other trust and thereupon to
terminate the trust created pursuant to this Trust Agreement. The Trustee is further authorized to
accept the assets of any other trust which may be transferred to any trust created hereunder and to
administer and distribute such assets and properties so transferred in accordance with the
provisions of this Agreement.
21.
Termination of SmaIl Trust: Any corporate Trustee which is serving as the sole Trustee of any
Trust or any Share thereof may at any time terminate such Trust or Share if, in the Trustee's sole
judgment, the continued management of such Trust or Share is no longer economical because of
the small size of such Trust or Share and if such action will be deemed to be in the best interests
of the Beneficiary or Beneficiaries. In case of such termination, the Trustee will distribute
forthwith the share ofthe Trust Estate so terminated to the income Beneficiary, per stirpes. Upon
such distribution, such Trust or Share will terminate and the Trustee will not be liable or
responsible to any person or persons whomsoever for its action. The Trustee will not be liable for
failing or refusing at any time to terminate any Trust or a Share thereof as authorized by this
paragraph.
Power to Determine Income and Principal: Dividends payable in stock of the issuing
corporation, stock splits, and capital gains will be treated as principal. Except as herein otherwise
specifically provided, the Trustee will have full power and authority to determine the manner in
which expenses are to be borne and in which receipts are to be credited as between principal and
income. The Trustee has the power to determine what will constitute principal or income and
may withhold from income such reserves for depreciation or depletion as the Trustee may deem
fair and equitable. In determining such matters, the Trustee may give consideration to the
provisions of the Pennsylvania Statutes (or its successor statutes) relating to such matters, but it
will not be bound by such provisions.
Generation-Skipping Taxes and Payment: If the Trustee considers any distribution or
termination of an interest or power hereunder as a distribution or termination subject to a
generation-skipping tax, the Trustee is authorized:
REVOCABLE LIVING TRUST AGREEMENT
Page 14
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24.
To augment any taxable distribution by an amount which the Trustee estimates to be sufficient to
pay such tax and charge the same to the particular trust to which the tax related without
adjustment of the relative interests of the Beneficiaries;
.
a.
To pay such tax, in the case of a taxable termination, from the particular trust to which
the tax relates without adjustment of the relative interests of the Beneficiaries. If such tax
is imposed in part by reason of the Trust Assets, the Trustee will pay only the portion of
such tax attributable to the taxable termination hereunder taking into consideration
deductions, exemptions, credits, and other factors which the Trustee deems advisable;
and
.
b. To postpone final termination of any particular trust and to withhold any portion or all of
the Trust Estate until the Trustee is satisfied that the Trustee no longer has any liability to
pay any generation-skipping tax with reference to such trust or its termination.
.
Section 5.04 - Special Provision for S Corporation Stock
.
Notwithstanding what is otherwise provided in this Trust Agreement, if at any time the Trust contains any
stock of a corporation which elects or has elected treatment as an tIS Corporation" as defined by Section
1361(a)(l) of the Internal Revenue Code (or any corresponding successor statute), such stock will be
segregated from the other assets of such and treated as a separate trust. The Trustee will further divide the
separate trust into shares for each Beneficiary and such shares will be distributed outright or held in trust
as herein provided. In addition, all other provisions of this Trust Agreement will apply to each share held
in trust (and constituting a separate trust) except that the Trustee will distribute all of the income from
each separate trust to its Beneficiary in convenient installments at least annually. It is the Sett1ors' intent
that each separate trust will be recognized as a "Qualified Subchapter S Trust" ("QSST") under Section
1361 (d)(2) of the Internal Revenue Code (or any corresponding successor statute). Notwithstanding any
provisions of this Trust Agreement to the contrary, the Trustee's powers and discretions with respect to
the administration of each separate trust (including methods of accounting, bookkeeping, making
distributions, and characterizing receipts and expenses) will not be exercised or exercisable except in a
manner consistent with allowing each separate trust to be treated as a QSST as above described.
.
.
ARTICLE SIX
Trustee Powers with a Probate Estate
Section 6.01 - Coordination with Settlor's Probate Estate
.
1.
At any time during the continuance of this Trust, including subsequent to the death of either
Settlor, the Trustees may, in their sole and uncontrolled discretion, distribute to the deceased
Settlor's Probate Estate cash and / or other property as a Beneficiary of the Trust.
2.
All other provisions to the contrary notwithstanding, under no circumstances shall any restricted
proceeds, as hereinafter defined, be either directly or indirectly: (i) distributed to orfor the benefit
of the Settlor's Executors or the Settlor's Probate Estate; or (ii) used to pay any other obligations
of the Settlor's Estate. The term "Restricted Proceeds" means:
.
a.
All qualified plans, individual retirement accounts, or similar benefits which are received
or receivable by any Trustee hereunder, and which are paid solely to a Beneficiary other
than the Executor of the Settlor's Gross Estate for Federal Estate Tax purposes; and
.
REVOCABLE LIVING TRUST AGREEMENT
Page 15
.
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b. All proceeds of insurance on the Settlor's life which, if paid to a Beneficiary other than
the Settlor's Estate, would be exempt from inheritance or similar death taxes under
applicable state death laws.
.
Section 6.02 - Direction to Minimize Taxes
.
In the administration of the Trust hereunder, its Fiduciaries shall exercise all available tax related
elections, options, and choices in such a manner as they, in their sole but reasonable judgment (where
appropriate, receiving advice of tax counsel), believe will achieve the overall minimum in total combined
present and reasonably anticipated future administrative expenses and taxes of all kinds. This applies not
only to said Trust, but also to its Beneficiaries, to the other Trusts hereunder and their Beneficiaries, and
to the Settlor's Probate Estate.
.
Without limitation on the generality of the foregoing direction (which shall to that extent supercede the
usual fiduciary duty of impartiality), such Fiduciaries shall not be accountable to any person interested in
this Trust or to Settlor's Estate for the manner in which they shall carry out this direction to minimize
overall taxes and expenses (including any decision they may make not to incur the expense of a detailed
analysis of alternative choices). Even though their decisions in this regard may result in increased taxes
or decreased distributions to the Trust, to the Estate, or to one or more Beneficiaries, the Fiduciaries shall
not be obligated for compensation readjustments or reimbursements which arise by reason of the manner
in which the Fiduciaries carry out this direction.
.
Section 6.03 - Judgment and Discretion of Trustee
.
In the absence of proof of bad faith, all questions of construction or interpretation of any trusts created by
this Trust Agreement will be finally and conclusively determined solely by the Trustee, according to the
Trustee's best judgment and without recourse to any court. Each determination by the Trustee is binding
on the Beneficiaries and prospective Beneficiaries hereunder, both in being and unborn, as well as all
other persons, firms, or corporations. The Trustee, when exercising any discretionary power relating to
the distribution or accumulation of principal or income or to the termination of any trust, will be
responsible only for lack of good faith in the exercise of such power. Each determination may be relied
upon to the same extent as if it were a final and binding judicial determination. In the event of a conflict
between the provisions of this Trust Agreement and those of the Pennsylvania Statutes, the provisions of
this Agreement will control.
.
ARTICLE SEVEN
Resolution of Conflict
.
Section 7.01 - Resolution of Conflict
.
Any controversy between the Trustee or Trustees and any other Trustee or Trustees, or between any other
parties to this Trust, including Beneficiaries, involving the construction or application of any of the terms,
provisions, or conditions of this Trust shall, on the written request of either or any disagreeing party
served on the other or others, shall be submitted to arbitration. The parties to such arbitration shall each
appoint one person to hear and determine the dispute and, if they are unable to agree, then the two persons
so chosen shall select a third impartial arbitrator whose decision shall be final and conclusive upon both
parties. The cost of arbitration shall be borne by the losing party or in such proportion as the arbitrator(s)
shall decide. Such arbitration shall comply with the commercial arbitration rules of the American
Arbitration Association, 140 West 51st Street, New York, NY 10200.
.
REVOCABLE LIVING TRUST AGREEMENT
Page 16
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Section 7.02 - Incontestability
.
The beneficial provisions of this Trust Agreement are intended to be in lieu of any other rights, claims, or
interests of whatsoever nature, whether statutory or otherwise, except bona fide pre-death debts, which
any Beneficiary hereunder may have in Settlor's Estate or in the properties in trust hereunder.
Accordingly, if any Beneficiary hereunder asserts any claim (except a legally enforceable debt), statutory
election, or other right or interest against or in Settlor's Estate, or any properties of this Trust, other than
pursuant to the express terms hereof, or directly or indirectly contests, disputes, or calls into question,
before any court, the validity of this Trust Agreement, then:
.
1.
Such Beneficiary shall thereby absolutely forfeit any and all beneficial interests of whatsoever
kind and nature which such Beneficiary or his or her heirs might otherwise have under this Trust
Agreement and the interests of the other Beneficiaries hereunder shall thereupon be appropriately
and proportionately increased; and
.
2.
All of the provisions of this Trust Agreement, to the extent that they confer any benefits, powers,
or rights whatsoever upon such claiming, electing, or contesting Beneficiary, shall thereupon
become absolutely void; and
3.
Such claiming, electing, or contesting Beneficiary, if then acting as a trustee hereunder, shall
automatically cease to be a Trustee and shall thereafter be ineligible either to select, remove, or
become a Trustee hereunder.
.
Section 7.03 - Trust Contests and Specific Omissions
.
If any beneficiary under this trust, singly or in conjunction with any other person or persons, directly or
indirectly:
1. contests in any court the validity of this trust or, in any manner, attacks or seeks to impair or
invalidate any of its provisions;
.
2. contests in any court the validity of the Settlor's Trust or, in any manner, attacks or seeks to
impair or invalidate any of its provisions;
3. seeks to obtain an adjudication in any proceeding in any court that this trust or any of its
provisions or that Settlor's Trust or any of its provisions is void;
.
4. claims entitlement by way of any written or oral contract to any portion of the Settlor's estate,
whether in probate or under this instrument;
5. unsuccessfully challenges the appointment of any person named as Trustee or successor Trustee
of this Trust,
.
6. objects in any manner to any action taken or proposed to be taken in good faith by the Trustee
Settlor's Trust;
7. objects to any construction or interpretation of this Trust, or any provision of it, that is adopted or
is proposed in good faith by the Trustee;
.
8. unsuccessfully seeks the removal of any person acting as Trustee of any Trust created under this
REVOCABLE LIVING TRUST AGREEMENT
Page 17
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instrument;
.
9. files any creditor's claim in Settlor's estate (without regard to its validity), whether the claim arose
before or after the date of this instrument, but excepting claims for cash advanced or paid for
expenses of the Settlor's last illness or funeral paid by said claimant;
IO. attacks or seeks to invalidate any designation of beneficiaries for any life insurance policy on
Settlor's life;
.
1 I. attacks or seeks to invalidate any designation of beneficiaries for any pension or IRA or other
form of qualified or non-qualified asset or deferred compensation account, agreement or
arrangement;
.
12. attacks or seeks to invalidate any trust which Settlor has created or may create during Settlor's
lifetime, or any provision thereof, as well as any gift which Settlor has made or will made during
Settlor's lifetime, whether before or after the date of this instrument;
13. attacks or seeks to invalidate any transaction by which Settlor sold any assets (whether to a
relative of Settlor's or otherwise); or
.
14. refuses a request of Settlor's Trustee, Executor or other fiduciary to assist in the defense against
any of the foregoing acts or proceedings,
then that person's right to take any interest given to him or her by this trust shall be determined as it would
have been determined if the person had predeceased the execution of this trust instrument without issue
survlvmg.
.
The provisions of the foregoing paragraph shall not apply to any disclaimer by any person of any benefit
under this trust or under the Settlor's Trust. In the event that any provision of this Article is held to be
invalid, void or illegal, the same shall be deemed severable from the remainder of the provisions of this
Article and shall in no way affect, impair or invalidate any other provision in this Article; and if such
provision shall be deemed invalid due to its scope or breadth, such provision shall be deemed to exist to
the extent of the scope or breadth permitted by law.
.
Section 7.04 - Benefits Confidential
.
The Settlors further declare that it is their desire and intent that the provisions of this Trust Agreement are
to remain confidential as to all parties. The Settlors direct that only the information concerning the
benefits paid to any particular Beneficiary shall be revealed to such individual and that no individual shall
have a right to information concerning the benefits being paid to any other Beneficiary.
.
ARTICLE EIGHT
General Provisions
Section 8.01 - Distribution in Kind or in Cash
.
On any division of the assets of the Trust Estate into shares or partial shares, and on any final or partial
distribution of the assets of the Trust Estate, the Trustee, at his or her absolute discretion, may divide and
distribute undivided interests of such assets on a pro rata or non-pro rata basis, or may sell any part of or
REVOCABLE LnnNG TRUST AGREEMENT
Page 18
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.
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all of such assets and may make divisions or distributions in cash or partly in cash and partly in kind. The
decision of the Trustee, either prior to or on any division or distribution of such assets, as to what
constitutes a proper division of such assets of the Trust Estate, shall be binding on all persons interested in
any trust provided for in this Trust Agreement.
Section 8.02 - Spendthrift Provision
.
Neither the principal nor the income of the trust shall be liable for the debts of a Beneficiary. Except as
otherwise expressly provided in this Agreement, no Beneficiary of any trust shall have any right, power,
or authority to alienate, encumber, or hypothecate his or her interest in the principal or income of this
Trust in any manner, nor shall the interests of any Beneficiary be subject to the claims of his or her
creditors or liable to attachment, execution, or other process of law. The limitations herein shall not
restrict the exercise of any power of appointment or the right to disclaim.
Section 8.03 - Definition of Children
.
The terms "Child" and "Children" as used in this Agreement mean the lawful issue of a Settlor or of the
Settlors together. This definition also includes children legally adopted by a Settlor or by the Settlors
together.
Section 8.04 - Handicapped Beneficiaries
.
Any Beneficiary who is determined by a court of competent jurisdiction to be incompetent shall not have
any discretionary rights of a Beneficiary with respect to this Trust, or to their share or portion thereof.
The Trustee shall hold and maintain such incompetent Beneficiary's share of the Trust estate and shall, in
the Trustee's sole discretion, provide for such Beneficiary as that Trustee would provide for a minor.
Notwithstanding the foregoing, any Beneficiary who is diagnosed for the purposes of governmental
benefits (as hereinafter delineated) as being not competent or as being disabled, and who shall be entitled
to governmental support and benefits by reason of such incompetency or disability, shall cease to be a
Beneficiary of this Trust. Likewise, they shall cease to be a Beneficiary if any share or portion of the
principal or income of the Trust shall become subj ect to the claims of any governmental agency for costs
or benefits, fees, or charges.
.
.
The portion of the Trust Estate which, absent the provisions of this section, would have been the share of
such incompetent or handicapped person shall be retained in trust for as long as that individual lives. The
Trustee, at his or her sole discretion, shall utilize such funds for the maintenance of that individual. If
such individual recovers from his or her incompetency or disability and is no longer eligible for aid from
any governmental agency, including costs or benefits, fees, or charges, such individual shall be reinstated
as a Beneficiary after 60 days from such recovery and the allocation and distribution provisions as stated
herein shall apply to that portion of the Trust Estate which is held by the Trustee subject to the foregoing
provisions of this section. If said handicapped Beneficiary is no longer living and shall leave children
then living, the deceased child's share shall pass to those children per stirpes. If there are no children, the
share shall be allocated proportionately among the remaining Beneficiaries.
.
.
.
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Page 19
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ARTICLE NINE
Successor Trustee Appointments
.
Section 9.01 - Trustees
All Trustees are to serve without bond. The following will act as Trustees of any Trusts created by this
Trust Agreement, in the following order of succession:
First:
The undersigned, Chester L. Valencik, Sr. and/ or Betty R. Valencik.
.
Second:
The Surviving Spouse.
Third:
Upon the end of the terms of the original Trustees, Troy A. Valencik and Chester
L. Valencik, Jr. are designated as Joint Successor Trustees.
.
Fourth:
fu the event that one of my Joint Successor Trustees is unwilling or unable to
serve, then the remaining Joint Successor Trustee shall continue to serve.
Last:
A Trustee chosen by the majority of Beneficiaries, with a parent or legal guardian
voting for minor Beneficiaries; provided, however, that the children of any
deceased Beneficiary sh"" ; J'~,",v.~.': ';' }.<1ve> '~;~:" one vote,
.
Section 9.02 - Allocation ~~J ':':"lstribution of The Trust Assets
The Tru:;.ct:s shall allocate, hold, administer, and distribute the Trust Assets as hereinafter provided:
1.
Upon the death of the first Settlor, the Trustee shall make any separate distributions that
have been specified by the deceased Settlor. The Trustee shall also take into
consideration the appropriate provisions of this Article.
.
2. Upon the death of the Surviving Spouse, the Trustee shall hold, administer, and distribute
the Trust Assets in the manner hereinafter prescribed.
.
Section 9.03 - Personal Property Distribution
.
Notwithstanding any provision of this Trust Agreement to the contrary, the Trustee must abide by any
memorandum by the Settlors, particularly that contained in the section entitled "Special Directives"
incorporated into this Trust fustrument, directing the disposition of Trust Assets of every kind including,
but not limited to, furniture, appliances, furnishings, pictures, china, silverware, glass, books, jewelry,
wearing apparel, and all policies of fire, burglary, property damage, and other insurance on or in .
connection with the use of property. Otherwise, any personal and household effects of the Settlors shall
be distributed with the remaining assets of the Trust Estate.
.
.
REVOCABLE LIVING TRUST AGREEMrnNT
Page 20
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Section 9.04 - Liability of Trustee
.
The Trustee will not be responsible or liable for any loss which may occur by reason of depreciation in
value of the properties at any time belonging to the Trust Estate nor for any other loss which may occur,
except that the Trustee will be liable for each Trustee's own negligence, neglect, default, or willful wrong.
The Trustee will not be liable or responsible for the acts, omissions, or defaults of any agent or other '
person to whom duties may be properly delegated hereunder (except officers or regular employees of the
Trustee) if such agent or person was appointed with due care. The Trustee may receive reimbursement
from the Trust Estate for any liability, whether in contract or in tort, incurred in the administration of the
Trust Estate in accordance with the provisions hereof, and the Trustee may contract in such form that such
Trustee will be exempt from such personal liability and that such liability will be limited to the Trust
Assets.
.
Section 9.05 - Successor Trustees
.
Any Successor Trustee shall have all the power, rights, discretion, and obligations conferred on a Trustee
by this Trust Agreement. All rights, titles, and interest in the property of the Trust shall immediately vest
in the successor Trustee at the time of appointment. The prior Trustee shall, without warranty, transfer to
the Successor Trustee the existing Trust property. No Successor Trustee shall be under any duty to
examine, verify, question, or audit the books, records, accounts, or transaction of any preceding Trustee;
and no Successor Trustee shall be liable for any loss or expense from or occasioned by anything done or
neglected to be done by any predecessor Trustee. A Successor Trustee shall be liable only for his or her
own acts and defaults.
.
.
ARTICLE TEN
Rule Against Perpetuities
Section 10.01 - Perpetuities Savings Clause
.
Notwithstanding any other provision of this instrument, the Trusts created hereunder shall terminate not
later than twenty-one (21) years after the death of the last survivor of all Sett10rs and any other
Beneficiary or Beneficiaries named or defined in this Trust living on the date of the death of the first
Settlor to die. The Trustee shall distribute remaining Trust principal and all accrued or undistributed net
income hereunder to the Beneficiary or Beneficiaries. If there is more than one Beneficiary, the
distribution shall be in the proportion in which they are Beneficiaries; if no proportion is designated, then
the distribution shall be in equal shares to such Beneficiaries.
.
ARTICLE ELEVEN
General Provisions
Section 11.01 - Governing Law
.
It is not intended that the laws of only one particular state shall necessarily govern all questions pertaining
to all of the Trust hereunder.
1. The validity of the Trust hereunder, as well as the validity of the particular provisions of that
Trust, shall be governed by the laws of the state which has sufficient connection with the Trust to
support such validity.
.
REVOCABLE LIVING TRUST AGREEMENT
Page 21
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2. The meaning and effect of the terms of this Trust Agreement shall be governed by the laws of the
Commonwealth of Pennsylvania.
3.
The administration of this Trust shall be governed by the laws of the state in which the principle
office of the Trustee then having custody of the Trust's principal assets and records is located.
.
The foregoing shall apply even though the situs of some Trust Assets or the home of the Settlor, a
Trustee, or a Beneficiary may at some time or times be elsewhere.
.
Section 11.02 - Invalidity of Any Provision
If a court finds that any provision of this Trust Agreement is void, invalid, or unenforceable, the
remaining provisions of this Agreement will continue to be fully effective.
Section 11.03 - Headings
.
The use of headings in connection with the various articles and sections of this Trust Agreement is solely
for convenience and the headings are to be given no meaning or significance whatsoever in construing the
terms and provisions of this Agreement.
Section 11.04 - Internal Revenue Code Terminology
.
.
As used herein, the words "Gross Estate," "Adjusted Gross Estate," "Taxable Estate," "Unified Credit,"
"State Death Tax Credit," "Maximum Marital Deduction," "Marital Deduction," and any other word or
words which from the context in which it or they are used refer to the Internal Revenue Code shall be
assigned the same meaning as words have for the purposes of applying the Internal Revenue Code to a
deceased Settlor's Estate. Reference to sections of the Internal Revenue Code and to the Internal
Revenue Code shall refer to the Internal Revenue Code amended to the date of such Settlor's death.
.
.
.
.
REVOCABLELIWNGTRUSTAGREEMENT
Page 22
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SPECIAL DIRECTIVES
OF
.
CHESTER L. V ALENCIK, SR.
.
I, CHESTER L. V ALENCIK, SR. a resident of the County of Columbia, Commonwealth of
Pennsylvania, being of lawful age, and of sound and disposing mind and memory, and not acting under
duress, fraud, or undue influence, hereby make, publish and declare this to be my Special Directive, and I
incorporate TIlE CHESTER L. V ALENCIK, SR. AND BETTY R. V ALENCIK REVOCABLE LNING
TRUST AGREEMENT.
FIRST
.
The natural objects of my affection are:
1.
My Wife -
Betty R. Valencik
2.
My Child -
Chester L. Valencik, Jr.
.
SECOND
.
I direct that all estate and inheritance taxes payable as a result of my death, not limited to taxes
assessed on property, shall be paid out of the residue of my Estate, and shall not be deducted or collected
from any League, Devisee, or Beneficiary hereunder.
THIRD
.
In the event any of my named Beneficiaries should predecease me, all of that person's share ofthe
Trust Estate shall be divided equally among that person's issue per stirpes. ill the event any such
predeceased Beneficiary leaves no surviving children or issue, then all of that person's share shall be
distributed to the remaining Beneficiaries.
FOURTH
.
In the event all of my named Beneficiaries and their children and issue predecease me, all of the
Trust Estate shall be distributed to my heirs at law.
FIFTH
.
I direct that all outstanding debts and/or loans owed by any Beneficiary shall be forgiven and
deemed as having not existed.
.
REVOCABLE LIVING TRUST AGREEMENT
Page 23
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.
SIXTH
.
I direct that, before any distribution of the assets of the Trust Estate to the named Beneficiaries,
certain specific distributions, if any, shall be made from the assets as set forth on the list attached hereto
and marked "Exhibit A."
SEVENTH
.
I hereby acknowledge and accept the "Special Directives," if any, of my spouse.
.
.
.
.
.
.
.
REVOCABLE LIVING TRUST AGREEMENT
Page 24
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.
SPECIAL DIRECTIVES
OF
.
BETTY R. V ALENCIK
.
I, BETTY R. V ALENCIK., a resident of the County of Columbia, Commonwealth of
Pennsylvania, being of lawful age, and of sound and disposing mind and memory, and not acting under
duress, fraud, or undue influence, hereby make, publish and declare this to be my Special Directive, and I
incorporate THE CHESTER L. V ALENCIK., SR. AND BETTY R. V ALENCIK. REVOCABLE LIVING
TRUST AGREEMENT.
.
FffiST
The natural objects of my affection are:
1.
My Husband -
Chester L. Valencik, Sr.
.
2.
My Child -
Chester L. Valencik, Jr.
SECOND
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I direct that all estate and inheritance taxes payable as a result of my death, not limited to taxes
assessed on property, shall be paid out of the residue of my Estate, and shall not be deducted or collected
from any League, Devisee, or Beneficiary hereunder.
TlllRD
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In the event any of my named Beneficiaries should predecease me, all of that person's share of the
Trust Estate shall be divided equally among that person's issue per stirpes. In the event any such
predeceased Beneficiary leaves no surviving children or issue, then all of that person's share shall be
distributed to the remaining Beneficiaries.
.
FOURTH
In the event all of my named Beneficiaries and their children and issue predecease me, all of the
Trust Estate shall be distributed to my heirs at law.
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FIFTH
I direct that all outstanding debts and/or loans owed by any Beneficiary shall be forgiven and
deemed as having not existed.
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REVOCABLE LIVING TRUST AGREEMENT
Page 25
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SIXTH
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I direct that, before any distribution of the assets of the Trust Estate to the named Beneficiaries,
certain specific distributions, if any, shall be made from the assets as set forth on the list attached hereto
and marked "Exhibit A. If
SEVENTH
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I hereby aclmowledge and accept the "Special Directives," if any, of my spouse.
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REVOCABLE LIVING TRUST AGREEMENT
Page 26
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DATED to be effective this:;/ day o~.I<41I
V.J .
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SETTLORS:
.lCP...~"j~ SR~
CHESTER 1. V LENCIK, SR.
~ g~ ~ 4r.ee.:6
BETTY . V ALENCIK
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ACCEPTED BY CO-TRUSTEES:
~~~
x:~A? V~
BETT . V ALENCIK
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COMMONWEALTH OF PENNSYLVANIA
COUNTY OF COLUMBIA
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This instrument was aclmowledged before me on the date herein set forth by CHESTER 1.
V ALENCIK., SR. as Settlor and Co-Trustee to certify which witness my hand and seal of office.
N~OnWealth of Pennsylvania
COMMONWEALTH OF PENNSYL VANIA
.
COUNTY OF COLUMBIA
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This instrument was aclmowledged before me on the date herein set forth by BETTY R.
V ALENCIK. as Settlor and Co-Trustee to certify which witness my hand and seal of office.
~
Notary Pu lie, Commonwealth of Pennsylvania
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NOTARIAL SEAL. .
TOOD B. GARRY. Nota,ry ~UtlllC
I ~- SouthemrAO!l ,.W~.,~: ~
M CommIssIon Expiree M ~t o.N'9
REVOCABLE LnnNG TRUST AGREEMENT
Page 27
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THE CHESTER L. V ALENCIK, SR. AND BETTY R. V ALENCIK
REVOCABLE LIVING TRUST AGREEMENT
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Declaration of Intent
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The undersigned hereby declare that, as Trustee of THE CHESTER L. V ALENCIK., SR. AND
BETTY R. V ALENCIK REVOCABLE LNING TRUST, they are acquiring and will hold in the name
CHESTER L. V ALENCIK, SR. and BETTY R. V ALENCIK, but without further reference to their
fiduciary capacity, all items listed on the attached schedule(s) hereto and incorporated herein as amended,
from time to time, as well as household furnishings, automobiles, jewelry, bank accounts, securities,
bonds, clothing and other personal property of any kind in their name or in either of their names and
henceforth such assets shall and will belong to said Trust and not to them individually; and they further
declare that, except to the extent of interest provided to them under the terms and provisions of said Trust,
they have no personal interest in any of the above itemized personal properties, it being intended and this
Declaration constitutes an affirmation of Trust ownership and an assignment to this Trust and shall be
binding on their heirs, administrators, executors and assigns.
~ WITNESS WHEREqF..." undersigned have executed this instrument this r day of
~ ~) ~.
~i!1/~
CHESTER L. V ALENCIK, SR.
Settlor/Trustee
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.
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.6~,f )/~~A.
BETTY ,V ALENCIK
Settlor rustee
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COMMONWEALTH OF PENNSYL VANIA
COUNTY OF COLUMBIA
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BEFORE ME, the undersigned authority, on this day personally appeared CHESTER L.
V ALENCIK, SR. and BETTY R. V ALENCIK, known to me to be the persons whose names are
subscribed to the foregoing instrument, and acknowledged to me that they executed the same for the
purposes and consideration therein expres,sed ~d ~e capacity ~in statej.
SUBSCRIBED AND SWORN thIS 7/.~' day ol'~~ ;2.L!f?,
.
N~onunonWealth ofPennsylvani,
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T . NOTARIAL SEAL
lower ~:' GARRY, Nol~ Public
I My Commis~. OIIEx,,~~P., BUclcs County
....res May 3, 2004
.
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SPECIAL INSTRUCTIONS FOR PREPARING AND ATTACHING AN
"EXIDBIT A"
TO YOUR REVOCABLE LIVING TRUST AGREEMENT
If you have special instructions for bequests of property that were not included in the original
trust planning documents, it is important that they be prepared correctly in order to accomplish your
wishes. "Exhibit A" is not an amendment; it is a part of your original trust document.
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1.
The page(s) entitled "SPECIAL DIRECTIVES OF CHESTER L. V ALENCIK., SR." and
"SPECIAL DIRECTIVES OF BETTY R. V ALENCIK." found near the end of the trust
document entitled THE CHESTER L. V ALENCIK., SR. AND BETTY R. V ALENCIK
REVOCABLE LIVING TRUST AGREEMENT needs to have a paragraph that basically
says the following:
I direct that my trust estate (or personal property or
whatever the items in question are) be distributed.
according to the list attached hereto and marked
"EXHIBIT A".
If your trust is a joint trust, an "Exhibit A" must be mentioned in the SPECIAL
DIRECTIVES of both.
2.
Make as many copies of your blank "EXHIBIT A" as it takes to distribute your personal
items, listing the individual property, the beneficiary of the property, and, if applicable,
the dollar or percentage amount of trust property you wish to bequeath.
3.
When you finish, number and initial each page, and sign the last page. Be sure to sign
your signature and initials in front of your witnesses and a notary public. Date your
"Exhibit A" the same date you signed your original trust agreement. (All gift pages
must be entitled "EXHIBIT A." All pages must be numbered. Each page must have a
place at the bottom for your initials; the last page must have a line for your full signature.
Your signature must have two witnesses and a notary.)
4.
Attach the original signed and witnessed copy to your original REVOCABLE LIVING
TRUST AGREEMENT. Put a copy of your "EXHIBIT A" with any trust copies you
have stored, i.e., safe deposit box.
5. See attached sample for further help. If you have any questions, contact the attorney who
prepared your trust.
6.
Any changes made subsequent to the trust date should be placed in the" AMENDMENT
TO REVOCABLE LIVING TRUST AGREEMENT" which follows "Exhibit A".
LOOK FOR YOUR PERSONALIZED "EXHIBIT A" PAGES BEHIND THE CHESTER L.
V ALENCIK, SR. AND BETTY R. V ALENCIK REVOCABLE LIVING TRUST AGREEMENT.
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SAMPLE ONLY
"EXIDBIT A"
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ADDITIONAL SPECIAL DIRECTIVES OF CHESTER L. V ALENCIK, SR. AND BETTY R.
V ALENCIK,
TRUSTEES AND SETTLORS OF
THE CHESTER L. V ALENCIK, SR. AND BETTY R. V ALENCIK REVOCABLE LIVING
TRUST
.
I direct that JAMES DOE get my railroad pocket watch.
I direct that JANE DOE get the money in the FIRST NATIONAL BANK of Altuna, Texas,
Account #111-111-111.
.
I direct that JAMES DOE and JANE DOE each receive a Yz ownership in the house at 23
Lexington Avenue, Philadelphia, Pennsylvania.
I direct that my railroad stock be divided equally among the children of JAMES DOE.
.
I direct that my telephone stock be divided equally among the children of JANE DOE.
I direct that each of my grandchildren receive $5,000 from my trust estate. It is my intent that
this money be used for their college education.
.
I direct that my car go to my granddaughter, MELISSA DOE, and my truck go to my grandson,
JAMES DOE, JR.
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"EXHIBIT A"
ADDITIONAL SPECIAL DIRECTIVES OF
JOHN S. DOE AND MARY A. DOE
Page of
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"EXHIBIT A"
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ADDITIONAL SPECIAL DIRECTIVES OF
CHESTER L. V ALENCIK, SR. AND BETTY R. V ALENCIK
TRUSTEES AND SETTLORS OF
THE CHESTER L. V ALENCIK, SR. AND BETTY R. V ALENCIK
REVOCABLE LIVING TRUST
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"EXHIBIT A"
ADDITIONAL SPECIAL DIRECTIVES OF
CHESTER L. V ALENCIK, SR. AND BETTY R. V ALENCIK
Page of
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"EXHIBIT A"
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ADDITIONAL SPECIAL DIRECTIVES OF
CHESTER L. V ALENCIK, SR. AND BETTY R. V ALENCIK
TRUSTEESANDSETTLORSOF
THE CHESTER L. V ALENCIK, SR. AND BETTY R. V ALENCIK
REVOCABLE LIVING TRUST
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"EXHIBIT A"
ADDITIONAL SPECIAL DIRECTIVES OF
CHESTER L. V ALENCIK, SR. AND BETTY R. V ALENCIK
Page of
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"EXHIBIT A"
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ADDITIONAL SPECIAL DIRECTIVES OF
CHESTER L. V ALENCIK, SR. AND BETTY R. V ALENCIK
TRUSTEESANDSETTLORSOF
THE CHESTER L. V ALENCIK, SR. AND BETTY R. V ALENCIK
REVOCABLE LMNG TRUST
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"EXHIBIT A"
ADDITIONAL SPECIAL DIRECTIVES OF
CHESTER L. V ALENCIK, SR. AND BETTY R. V ALENCIK
Page of
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ItEXHIBIT A"
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ADDITIONAL SPECIAL DIRECTIVES OF
CHESTER L. V ALENCIK, SR. AND BETTY R. V ALENCIK
TRUSTEES AND SETTLORS OF
THE CHESTER L. V ALENCIK, SR. AND BETTY R. V ALENCIK
REVOCABLE LIVING TRUST
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ItEXHIBIT A It
ADDITIONAL SPECIAL DIRECTIVES OF
CHESTER L. V ALENCIK, SR. AND BETTY R. V ALENCIK
Page of
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The foregoing instrument consists of , typewrittenlhandwritten pages including
the signature of Witnesses, and aclmowledgrnent of officer. We have signed our names at the bottom of
each of the preceding pages.
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DATED this
. day of
CHESTER 1. V ALENCIK, SR.
.
BETTY R. V ALENCIK
Witness
Address
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Witness
Address
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"EXIDBIT A"
ADDITIONAL SPECIAL DIRECTIVES OF
CHESTER L. V ALENCIK, SR. AND BETTY R. V ALENCIK
Page
of
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COMMONWEALTH OF PENNSYLVANIA
COUNTY OF COLUMBIA
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This instrument was acknowledged before me on the day of
, by CHESTER L. V ALENCIK, SR.-as Settlor and Co-Trustee to certify which witness my hand
and seal of office.
.
Notary Public, Commonwealth of Pennsylvania
COMMONWEALTH OF PENNSYL V ANlA
.
COUNTY OF COLUMBIA
This instrument was acknowledged before me on the day of ,
, by BETTY R. V ALENCIK as Settlor and Co-Trustee to certify which witness my hand and seal
of office.
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Notary Public, Commonwealth of Pennsylvania
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"EXIllBIT A"
ADDITIONAL SPECIAL DIRECTIVES OF
CHESTER L. V ALENCIK, SR. AND BETTY R. V ALENCIK
Page of
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TENANCY AGREEMENT
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This Tenancy Agreement is entered into on this day by and between CHESTER L. V ALENCIK,
SR. AND BETTY R. V ALENCIK.
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FACTUAL SUMMARY
~~/~ L. J;Y~TK., SR. AND BETTY R. V ALENCTK. were married on
vr' LJ,~ 7P--' '-L.CL, and since that date have acquired title to property as joint tenants with
right of survivorship.
.
CHESTER L. V ALENCTK., SR. AND BETTY R. V ALENCIK have created an estate plan using
a revocable living trust and companion pour-over wills, and they now wish to convert all or part of their
joint tenancy into tenancy in common property.
CHESTER L. V ALENCIK, SR. AND BETTY R. V ALENCIK are aware that they may, by
agreement, convert their joint tenancy property into tenancy in common property so that they may better
control their respective interests in the property on each of their deaths.
.
AGREEMENT TO CHANGE JOINT TENANCY ASSETS
TO TENANCY IN COMMON
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CHESTER L. V ALENCIK, SR. AND BETTY R. V ALENCIK hereby grant, convey and
transfer their respective interests in their joint tenancy property to themselves as tenants in common,
except for jointly-held property in Schedule A of this Tenancy Agreement, if any.
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CHESTER L. V ALENCIK, SR. AND BETTY R. V ALENCIK intend this agreement to be
binding on themselves and on all others as to property held in joint tenancy with right of survivorship as
of the date of this agreement regardless of the manner or form of the written title.
1,,( CHE~ 9/ V AILEN~~. AND BETTY R. V ALENCIK make this agreement on the
~dayo(~~;./h'- ,J.
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f!ft ~~)~;-< S ,.
CHESTER L. ALENCIK, SR.
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,g~/{)/~
BETTY; . V ALENCIK
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REVOCABLE LIVING TRUST AGREEMENT
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COMMONWEAL TII OF PENNSYLVANIA
ss. ACKNOWLEDGMENT
.
COUNTY OF COLUMBIA
This instrument was aclmowledged before me on the date herein set forth CHESTER L.
V ALENCIK, SR. AND BETTY R. V ALENCIK as husband and wife to certify which witness my hand
and seal of office.
.
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Notary p. i
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My iommis~IIXPires:
I~. V) 21'1Y
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NOTARIAL SEAL
TooO B. GARRY, ~ubI~
u;;r~T~.,~.- ~.Z004
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REVOCABLE LnnNG TRUST AGREEMENT
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SCHEDULE A
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REVOCABLE LIVING TRUST AGREEMENT
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SEP ARA TE PROPERTY LISTING
OF CBESTERL. VALENCIK, SR.
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The following items are the separate property of CHESTER L. V ALENCIK , SR. either by
operation oflaw or by agreement of both spouses:
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1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
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REVOCABLE LIVING TRUST AGREEMENT
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32
33
. 34
35
36
37
. 38
39
40
Signed this day of '-
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CHESTER L. V ALENClK, SR., Declarant
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Approved and accepted this
day of
'-'
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BETTY R. V ALENClK, Spouse
COMMONWEALTH OF PENNSYL V ANlA
COUNTY OF COLUMBIA
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On this the day of , , before me, a Notary
Public, personally appeared CHESTER L. V ALENClK, SR. and BETTY R. V ALENClK, personally
known to me to be the persons whose names are subscribed to this instrument, and acknowledged that
they executed it for the purposes herein expressed.
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Notary Public, Commonwealth of Pennsylvania
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REVOCABLE LIVING TRUST AGREEMENT
!.
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SEPARATE PROPERTY LISTING
OF BETTY R. V ALENCIK
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The following items are the separate property of BETTY R. V ALENCIK, either by operation of
law or by agreement of both spouses:
.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
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REVOCABLE LIVING TRUST AGREEMENT
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32
33
34
35
36
37
38
39
40
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Signed this
day of
'-"
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BETTY R. V ALENClK, Declarant
.
Approved and accepted this
day of
'-"
.
CHESTER L. V ALENCIK, SR., Spouse
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF COLUMBIA
.
On this the day of , , before me, a Notary
Public, personally appeared CHESTER L. V ALENClK, SR. and BETTY R. V ALENClK, personally
known to me to be the persons whose names are subscribed to this instrument, and aclmowledged that
they executed it for the purposes herein expressed.
.
Notary Public, Commonwealth of Pennsylvania
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REVOCABLE LIVING TRUST AGREEMENT
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/-'
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REVOCA TION OF PO\VER OF ATTORNEY
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I, BETTY R. V ALENCIK, CURRENTLY RESIDING AT 73 LICK RUN ROAD,
LOCUST TO\VNSHIP, CATA\VISSA, COLUMBIA COUNTY, PENNSYLVANIA,
17820, BY PRIOR \VRITTEN INSTRUMENTS, APPOINTED MY SON,
CHESTERL. VALENCIK,JR., AS MY AGENT AND ATTORNEY-IN-FACT.
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NOTICE IS HEREBY GIVEN THAT I HAVE REVOKED AND DO HEREBY
REVOKE ANY AND ALL SUCH DESCRIBED PO\VERS OF ATTORNEY AND
ALL POWERS AND AUTHORITY THEREBY GIVEN, OR INTENDED TO BE
GIVEN TO CHESTER L. V ALENCI~ JR., EFFECTIVE THIS 11TH DAY OF
DECEMBER, 2007.
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THIS DOCUMENT ACKNOWLEDGES AND CONSTITUTES NOTICE THAT I
HEREBY REVOKE, RESCIND AND TERMINATE ALL SUCH POWERS OF
ATTORNEY AND ALL AUTHORITY, RIGHTS A..ND POWER THERETO
EFFECTIVE THIS DATE.
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IN \VI1NESS 'WHEREOF, I HAVE SIGNED BELOW UNDER SEAL, THIS 11TH
DAY OF DECEMBER 2007.
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7<~>'\1 ~/__1. ./J
/. . .'....-/-; ""'-f:,,_.;;t'.~/
! ;_.. ....<. .... C' ,.., ~.
BETTYH. V ALENCIK
[SEAL]
DATE: DECEMBER 11, 2007
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EXHIBIT
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ACKNO\VLEDGMENT:
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I, BETTY R. VALENCIK, HAVING SIGNED THE ATTACHED REVOCATION
OF POWER OF ATTORNEY, DO HEREBY ACKNOWLEDGE THAT I
EXECUTED THAT INSTRUMENT OF AS MY VOLUNTARY ACT FOR THE
PURPOSES STATED THEREIN.
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, . J '-.....//l.R... '~B
:'0 fV~ / (,(,'V ' ,
BETTY'R. V ALENCIK
DATE: December 11, 2007
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COMl\10NWEALTH OF PENNSYLVANA:
COUNTY OF DAUPHIN : SS.
.
ON DECEMBER 11, 2007, BEFORE ME, A NOTARY PUBLIC, PERSONALLY
APPEARED, PERSONALLY KNOWN TO ME (OR PROVED TO l\-fE ON THE
. a . .
BASIS OF SATISFACTORY EVIDENCE) TO BE THE PERSON "'HOSE NAME
IS SUBSCRIBED TO THE A TT ACHED WRITTEN INSTRUMENT AND TO
THE ACKNOWLEDGEMENT ABOVE AND ACKNOWLEDGED TO ME THAT
SHE ExECUTED THE SAME AS HER OWN VOLUNTARY ACT FOR THE
PURPOSES STATED THEREIN AND THAT BY HER SIGNATURE ON THE
INSTRUMENT SHE EXECUTED THE INSTRUl\1ENT. IN \VITNESS OF
WHICH I HAVE SIGNED BELOW WITH MY OFFICIAL SEAL.
~~)
COMMONWEALTH OF PENNSYLVANIA
Notarial Seal
Karen Louise FISher, Notary Public
City Of Hanisbug, Dauphin County
. My Commission Expires June 7, 2008
Member, Penns);','?.');;; ....~~';ociation Of Notaries
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DURABLE HEALTH CARE POWER OF ATTORNEY
I, BETTY R. VALENCIK, of COLUMBIA County, Pennsylvania, appoint the person named
below to be my health care agent to make health and personal care decisions for me.
Effective immediately and continuously until my death or revocation by a writing signed
by me or someone authorized to make health care treatment decisions for me, I
authorize all health care providers or other covered entities to disclose to my health
care agent, upon my agent's request, any information, oral or written, regarding my
physical or mental health, including, but not limited to, medical and hospital records and
what is otherwise private, privileged, protected or personal health information, such as
health information as defined and described in the Health Insurance Portability and
Accountability Act of 1996 (Public Law 104-191, 110 Stat. 1936), the regulations
promulgated thereunder and any other State or local laws and rules. Information
disclosed by a health care provider or other covered entity may be redisclosed and may
no longer be subject to the privacy rules provided by 45 C.F.R. Pt. 164.
The remainder of this document will take effect when and only when I lack the ability to
understand, make or communicate a choice regarding a health or personal care decision
as verified by my attending physician. My health care agent may not delegate the
authority to make decisions.
MY HEALTH CARE AGENT HAS ALL OF THE FOllOWING POWERS SUBJECT TO THE
HEALTH CARE TREATMENT INSTRUCTIONS THAT FOLLOW IN PART III (CROSS OUT ANY
POWERS YOU DO NOT WANT TO GIVE YOUR health care AGENT):
1. To authorize, withhold or withdraw medical care and surgical procedures.
2. To authorize, withhold or withdraw nutrition (food) or hydration (water) medically
supplied by tube through my nose, stomach, intestines, arteries or veins.
3. To authorize my admission to or discharge from a medical, nursing, residential or
similar facility and to make agreements for my care and health insurance for my care,
including hospice and/or palliative care.
4. To hire and fire medical, social service and other support personnel responsible for
my care.
5. To take any legal action necessary to do what I have directed.
6. To request that a physician responsible for my care issue a do-not-resuscitate (DNR)
order, including an out-of-hospital DNR order, and sign any required documents and
consents.
APPOINTMENT OF HEALTH CARE AGENT
I appoint the following health care agent:
Health care agent: TROY VALENCIK (GRANDSON)
Address: 73 LICK RUN ROAD, CATAWISSA, PA 17820
Telephone Number: HOME: C7c 79<102c.."lE! WORK: /', 5-7'0 {,2~
IF YOU DO NOT NAME A HEALTH CARE AGENT, HEALTH CARE PROVIDERS WILL ASK
YOUR FAMILY OR AN ADULT WHO KNOWS YOUR PREFERENCES AND VALUES FOR HELP
IN DETERMINING YOUR WISHES FOR TREATMENT. NOTE THAT YOU MAY NOT APPOINT
YOUR DOCTOR OR OTHER HEALTH CARE PROVIDER AS YOUR HEALTH CARE AGENT
UNLESS RELATED TO YOU BY BLOOD, MARRIAGE OR ADOPTION.
..., , .~1 /. ,,,-
t ' e L' ',/ r..... 't/'lfI/V6v;rt
BETTY R. VAlENCIK
DATE: 12/11/2007
EXHIBIT
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t_ .t--...
ACKNOWLEDGMENT:
I, BETTY R. V ALENCIK, HAVING SIGNED THE A TT ACHED DURABLE
HEAL TH CARE POWER OF ATTORNEY, DO HEREBY ACKNOWLEDGE
THAT I EXECUTED THAT INSTRUMENT OF AS MY VOLUNTARY ACT FOR
THE PURPOSES STATED THEREIN.
M.J ,P I 11 ''l
~ft ~~Jr~6~t~
DATE: December 11, 2007
COMMONWEALTH OF PENNSYL V ANA:
COUNTY OF DAUPHIN : SS.
ON DECEMBER 11, 2007, BEFORE ME, A NOTARY PUBLIC, PERSONALLY
APPEARED, PERSONALLY KNOWN TO ME (OR PROVED TO ME ON THE
BASIS OF SATISFACTORY EVIDENCE) TO BE THE PERSON WHOSE NAME
IS SUBSCRIBED TO THE ATTACHED WRITTEN INSTRUMENT AND TO
THE ACKNOWLEDGEMENT ABOVE AND ACKNOWLEDGED TO ME THAT
SHE EXECUTED THE SAME AS HER OWN VOLUNTARY ACT FOR THE
PURPOSES STATED THEREIN AND THAT BY HER SIGNATURE ON THE
INSTRUMENT SHE EXECUTED THE INSTRUMENT. IN WITNESS OF
WHICH I HAVE SIGNED BELOW WITH MY OFFICIAL SEAL.
~1lDJ)~'~M~A)
N TARY P BLIC
COMMONWEAlTH OF PENNSYLVANIA
NolaIlaI SellI
Karen L.Wse FIsher. NolaIy Public
CIty Of Hatrisburg. ~ Cou1ty
Mi CommIssion ExpIres June 7. 2008
Member, Pennsylvllnia ARSo-cilltlon Of Notaries
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DURABLE POWER OF ATTORNEY
FOR HEALTH CARE OF
BETTY R. V ALENCIK
COMMONWEAL TIl OF PENNSYL V ANlA
COUNTY OF COLUMBIA
DESIGNATION OF HEALTH CARE AGENT
I, BETTY R. V ALENCIK, of 73 Lick Run Road, Catawissa, County of Columbia,
Commonwealth of Pennsylvania, designate my husband, Chester L. Valencik, Sr. of 73 Lick Run Road,
Catawissa, County of Columbia, Commonwealth of Pennsylvania, as my agent to make all health care
decisions for me, except to the extent I state otherwise in this document. This Durable Power of Attorney
for Health Care takes effect if I become unable to make my own health care decisions and this fact is
certified in writing by my physician.
DESIGNATION OF ALTERNATE AGENT
If the person designated above as my agent is unable or unwilling to make health care decisions
for me, I designate the following person to serve as my agent to make health care decisions for me as
authorized by this document:
Chester L. Valencik, Jr.
5108 Inverness Drive
Mechanicsburg, P A 17055
(717) 761-1954
I hereby authorize my agent to perform the following acts if I become incapable of giving informed
consent:
A) Request, receive, and review any information, verbal or written, regarding my physical
condition or mental health including, but not limited to, medical and hospital records and
consent to disclosure of my medical records;
B)
Consent, refuse to consent, or withdraw consent to any treatment or care to maintain,
treat, or diagnose a physical or mental condition;
C) Consent to withdrawal or withholding of any type of treatment that would keep me alive -
this power includes the power to withdraw or withhold hydration or food if I am
comatose and/or terminally ill;
D)
Make all decisions concerning an autopsy, the necessity for such and the extent of that
autopsy, if so chosen; and,
E)
Dispose of my body or body parts as may be permitted by the laws of the state or country
where I may be incapacitated.
DURABLE HEALTH CARE POWER OF AITORNEY
Page 3
EXHIBIT
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It is my intention, by this instrument, to provide for my personal and medical assistance without the
necessity of court action. Accordingly, I request, in the strongest possible terms that any court which may
receive or act upon a petition for the appointment of a guardian for me should deny such petition so long
as my agent is acting as appointed. If any court shall deem it necessary to appoint a guardian in spite of
this request, then I request that my agent be appointed unless I have provided otherwise.
This instrument shall be governed by the laws of the Commonwealth of Pennsylvania including its
construction, interpretation and tennination and, to the extent permitted by law, shall be applicable to
wherever and in whatever state of the United States or foreign country I may be at the time.
If any part of any provision of this instrument shall be invalid or unenforceable under applicable law, such
part shall be ineffective to the extent of such invalidity only, without affecting the remaining, valid
provisions of this instrument.
This instrument may be amended or revoked by me. My agent (and any alternate) may be removed by
my revocation or amendment by me. If this instrument has been recorded in the public records, then the
instrument of revocation, amendment or removal shall be filed or recorded in the same public records. My
agent may resign by the execution of a written resignation delivered to me, or if I am mentally
incapacitated, by delivery to any person with whom I am residing or who has the care and custody of me,
or in the case of an alternate agent, by delivery to my agent.
My agent shall have full power and authority to do so and perform all acts whatsoever requisite and
necessary to be done in order to fully accomplish the aforementioned to all intents and purposes as I
might or could so otherwise. I hereby ratify and confirm all that my agent shall so or cause to be done by
virtue of this instrument.
Every physician, hospital, care providers, or other person, firm or corporation to which this instrument is
presented to (or presented a photocopy hereof) is expressly authorized to honor and give effect to all
instruments signed pursuant to the foregoing authority without inquiring as to the circumstances of their
issuance or the disposition of the property delivered pursuant thereto.
For purposes of this instrument, I shall be considered to be disabled if! lack sufficient capacity to make or
communicate responsible decisions concerning my welfare by reason of mental illness, mental deficiency,
mental disorder, physical illness or disability, chronic use of drugs, chronic intoxication or other cause.
This existence of such a disability shall be conclusively established by attaching to this instrument the
sworn statement of my attending physician stating that he or she has examined me and believes that the
existence of one (or more) of such stated conditions exists to cause my incapacity.
The validity of (i) my restoration of my competency or (ii) the declaration of my disability which gave
rise to the effectiveness of this Durable Power of Attorney for Health Care may only be revoked by my
express written revocation or by the express written revocation of my duly appointed conservator.
In the event that this Durable Power of Attorney for Health Care becomes effective by reason of my
disability, my revocation shall be accompanied by a sworn statement of a physician stating that he or she
(i) has examined me, (ii) believes that the condition giving rise to the effectiveness of this Durable Power
of Attorney for Health Care has been removed and (iii) believes that I possess the understanding and
capacity to make responsible decisions regarding my welfare.
DURABLE HEALTH CARE POWER OF ATTORNEY
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The original of this docwnent is kept at the following location:
Mr. & Mrs. Chester L. Valencik, Sr.
73 Lick Run Road
Catawissa, Pennsylvania 17820
The following individuals or institutions have signed copies:
Name:
Address:
Dr. Dennis Sheeshe
353 Main Street
Catawissa, P A 17820
(570) 356-2351
Phone:
Name:
Address:
Phone:
DURATION
I understand that this Power of Attorney exists indefinitely from the date I execute this document
unless I establish a shorter time or revoke this Power of Attorney. If I am unable to make health care
decisions for myself when this Power of Attorney expires, the authority I have granted my agent
continues to exist until the time I become able to make health care decisions for myself.
PRIOR DE SIGNA TIONS REVOKED
I revoke any prior Durable Power of Attorney for Health Care.
ACKNOWLEDGMENT OF DISCLOSURE STATEMENT
I have been provided with the notice explaining the effect of this docwnent.
;;r~;:~:;~
I have read and
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, at
,g~t<2/~
BETTY: . V ALENCIK
Declarant
,-...
DURABLE HEALTH CARE POWER OF ATTORNEY
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STATEMENT OF WITNESSES
I declare under penalty ofpetjury that the principal has identified himselfto me, that the principal
signed or acknowledged this Durable Power of Attorney for Health Care in my presence, that I believe the
principal to be of sound mind, that the principal has affirmed that the principal is aware of the nature of
the document and is signing it voluntarily and free from duress, that the principal requested that I serve as
witness to the principal's execution of this document, that I am not the person appointed as the agent by
this document, and that I am not a provider of health or residential care, the employee of a provider of
health or residential care, the operator of a community care facility, or an employee of an operator of a
health care facility.
I declare that I am not related to the principal by blood, marriage, or adoption and that to the best
of my knowledge, I am not entitled to any part of the estate on the death of the principal under a will or by
operation oflaw.
~J~C~
Witness
MWN~~ k~
Print Name
~~/l,~~
/)HjJ~J~
Print Name
Address
C~/-' Jit-/7&
City, State, Zip./
DURABLE HEALTH CARE POWER OF ATTORNEY
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COMMONWEALTH OF PENNSYLVANIA
COUNTY OF COLUMBIA
BEFORE ME, the undersigned, a Notary Public in and for said County and State, on this day
personally appeared Betty R. Valencik, known by me to be the person whose name is subscribed to the
foregoing instrument, and acknowledged to me that she is an adult and that she executed the foregoing
inStrum. en! for the purposes and consideration therein expressed ye c.p8X'~~,
'J-If} . GIVEN UNDER MY HAND and seal of office this day J:i4~
4~ ..'
Notary IC, Commonwealth of PennsylvanIa
COMMONWEALTH OF PENNSYLVANIA
. NOTARIAL SEAL
TOOO B. GARRY, Nota'y Public
lower ~ Twp., Bucks f"IYAftIu
CommissiOn Expires U 3, '2004'"
COUNTY OF COLUMBIA
BEFORE ME, the unders;~e.>i, a }Jotary Public ~Jilg, f9r ~aid j:ounty and State, on this day
personally appeareatJ! tl/tJA- IF hI~ anVlfHl- A.- /N:IL ' each of
whom declared to me that they were eighteen years of age or more and that they signed as witnesses to
the foregoing instrument. /) ~
tJdNEN UNDER MY HAND and seal of office thi~ day o~~
Notary P
. NOTARIAlSEAl
~~. GARRY, ~ Public
~T~.,Buclls~
Exp;reS 3, 2004
DURABLE HEALTH CARE POWER OF ATTORNEY
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HEALTH CARE AGENT NOTICE
TO WHOM IT CONCERNS:
I, Chester L. Valencik, Sr., the undersigned Mfiant, named as the Health Care Agent for BETTY R.
V ALENCIK. the 'Cipal, in ;;:in - Durable Power of Attorney for Health Care document dated:
the;2t;o day of ~ ,20t!)>.
declare and state the following:
I hereby accept this appointment and agree to serve as Agent for the Principal concerning her Health Care
decisions in the event that she is incapable in making such decisions herself. I understand that I have a
duty to act consistently with the desires of the Principal as expressed in such appointment.
I understand that said document gives me authority over health care decisions for her only if she becomes
incapable and that I must act in good faith in exercising my authority under such appointment. I
acknowledge that the principal, if competent, may revoke said Health Care Power of Attorney at any time
and in any manner.
If I choose to withdraw during the time the principal is competent, I must notifY her of my decision. If!
choose to withdraw when the principal is incapable of making her own health care decisions then I must
notifY his physician.
COMMONWEALTH OF PENNSYL VANIA
COUNTY OF COLUMBIA
On the ~ ~ ~ before me, the wlllersigned NotaIy Public,
personally appeared , n ~ P , who acknowledged before me to
be the person executing this instrument by his (her) signature as his (her) free act and deed.
~
My Commission Expires:
~~~~
. NOTARlALSEAL
TOOD B. GARRY. Notary Public
Lower~ Twp., Bucks Coonty
mm .A 3.2004
DURABLE HEALTH CARE POWER OF ATTORNEY
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THE PENNSYL Y ANIA STATUTE FOR AnY ANCE DIRECTIVE FOR HEALTH CARE
(20Pa. C.S.A. & 5404(b))
A Living Will in Pennsylvania is referred to as an "Advance Directive for Health Care."
a.
Consenting Adults. An individual of sound mind over the age of 18, or who has graduated from
high school, or who has married, may execute an Advance Directive for Health Care.
b.
Execution. The document must be signed and witnessed by two persons over the age of 18. A
person may have another person sign a document on his or her behalf, but such a person cannot
be one (1) of the two (2) witnesses to the document.
c. Effect of Declaration. A Declaration becomes operative when (1) a copy is provided to the
attending physician, and (2) the attending physician determines the patient to be incompetent and
in a terminal condition or in a state of permanent unconsciousness.
d.
Duty to Confirm Diagnosis. If the attending physician diagnoses the declarant as described
above, the attending physician shall: (1) Certify the diagnosis in writing and (2) Arrange for a
physical examination and confirmation of the diagnosis by a second physician.
Liability of Physician. No physician or health care provider who carries out the Declarations of
a patient lacking sufficient capacity to make or communicate decisions concerning himself or
herself shall be subject to criminal or civil liability or be found to have committed an act of
unprofessional conduct.
Unwillingness to Comply. If the physician cannot in good conscience carry out the patient's
Declaration, the physician shall assist in transferring the patient to another physician who will
comply with such Declaration.
g. Emergency Medical Services. A Declaration is effective in emergency medical situations only
if:
(1)
The attending physician makes the prescribed diagnosis, certifies such a diagnosis in
writing, and has a second physician examine and confirm such a diagnosis; and
(2) The original Declaration is presented to the emergency medical services personnel.
H.
o,t
Attending Physician. The physician who has primary responsibility for the treatment and care
of the declarant.
I. Declarant. A person who makes a declaration in accordance with 20 P A C.S.A. ~ 5404.
J. Declaration. A written document voluntarily executed by the declarant in accordance with 20
P A C.S.A. ~ 5404.
LIVING Wll..LS
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EXHIBIT
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Health Care Provider. A person who is licensed or certified by the laws of this Commonwealth
of administer health care in the ordinary course of business or practice of a profession.
Incompetent. The lack of sufficient capacity for a person to make or communicate decisions
concerning himself.
Life-sustaining Treatment. Any medical procedure or intervention that, when administered to a
qualified patient, will serve only to prolong the process of dying or to maintain the patient in a
state of permanent unconsciousness. Life-sustaining treatment shall include nutrition and
hydration administered by gastric tube or intravenously or any other artificial or invasive means if
the declaration of the qualified patient so specifically provides.
N.
Medica) Command Physician. A licensed physician who is authorized to give medical
command under the act of July 3, 1985 (p.L. 164, No. 45), known as the Emergency Medical
Services Act.
o.
Permanently Unconscious. A medical condition that has been diagnosed in accordance with
currently accepted medical standards and with reasonable medical certainty as total and
irreversible loss of consciousness and capacity for interaction with the environment. The term
includes, without limitation, a persistent vegetative state or irreversible coma.
P.
Person. An individual, corporation, partnership, association or Federal, State or local
government or governmental agency.
Q. Qualified Patient. A person who has executed a declaration and who has been determined to be
in a terminal condition or to be permanently unconscious.
R.
Terminal Condition. An incurable and irreversible medical condition in an advance state caused
by injury, disease or physical illness which will, in the opinion of the attending physician, to a
reasonable degree of medical certainty, result in death regardless of the continued application of
life-sustaining treatment.
S.
Statutory Form. The accepted form for an Advance Directive for Health Care is set forth at 20
Pa. C.S.A. ~ 5404(b). See Attachment.
LIVING WILLS
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ADVANCE HEALTH CARE DECLARATION (LIVING WILL)
I, BErrY R. V ALENCIK, of Columbia County, Pennsylvania, being of sound mind, willfully
and voluntarily make this Declaration of my wishes and instructions concerning my treatment to be
followed if I become incompetent. This Declaration reflects my firm and settled commitment to refuse
life-sustaining treatment if I should be in a terminal condition or in a state of permanent unconsciousness,
or if there is no reasonable expectation of my recovering from a seriously incapacitating or lethal illness
or condition. I direct my physician, hospital, and other health care providers or facility, my family, and
any Agent or surrogate designated by me herein appointed by me in my durable power of attorney, or by a
court, to carry out my wishes.
Desilll1ation of ARent or Surroszate
I designate Chester L Valencik, Sr., 73 Lick Run Road, Catawissa, Pennsylvania 17820, as my Agent
or surrogate regarding any and all health care decisions to be made for me, including but not limited to
the decision to refuse life-sustaining treatment, if I should be unable to make such decisions for myself.
This power shall remain in effect during, and shall not be affected by, my subsequent illness, disability,
or incapacity. My Agent shall have authority to interpret this Health Care Declaration and make
decisions about my health care as specified in my instructions or, when my wishes are not clear, as my
Agent believes to be consistent with my wishes. I hereby release and agree to hold harmless my Agent
from any and all claims whatsoever arising from decisions made in exercise of this power.
I designate the following name as my agent or surrogate, if surrogate designated above is unable to
serve, regarding any and all health care decisions to be made for me, including but not limited to the
decision to refuse life-sustaining treatment, if I should be unable to make such decisions for myself:
Chester L Valencik, Jr., 5108 Inverness Drive, Mechanicsburg, PA 17055.
I direct that treatment be limited to measures to keep me comfortable and to relieve pain,
including any pain that might occur by withholding or withdrawing life-sustaining treatment and that life-
sustaining treatment that serves only to prolong the process of my dying should be withheld or
withdrawn.
In addition, if I am in the condition described above, I feel especially strong about the following
forms of treatment:
I [ ] do J(I do not want cardiac resuscitation.
I [ ] do b(I do not want mechanical respiration.
I [ ] do [..(J. do not want tube feeding or any other artificial or invasive form of nutrition (food) or
hydration (water).
I [ ] do K.do not want blood products.
I [ ] do f4do not want any form of surgery or invasive diagnostic tests.
I [ ] do Jd'do not want kidney dialysis.
I [ ] do..(...lslo not want antibiotics.
I [ ] do [ ] do not want
I realize that if I do not specifically indicate that I do not want a form of treatment listed above, I
may receive that form of treatment.
LIVING WILLS
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COMMONWEALTH OF PENNSYLVANIA
COUNTY OF COLUMBIA
BEFORE ME, THE UNDERSIGNED, A NOTARY PUBLIC WITHIN AND FOR THE
COUNTY OF COLUMBIA, COMMONWEALTH OF PENNSYL VANIA, PERSONALLY APPEARED
Betty R. Valencik KNOWN TO ME TO BE THE PERSON WHOSE NAME IS SUBSCRIBED TO THE
WITHIN INSTRUMENT, AND ACKNOWLEDGED UNDER OATH, TO MY SATISFACTION THAT
SHE IS THE MAKER OF THIS ADVANCE DIRECTIVE FOR HEALTH CARE AND EXECUTED
THE SAME FOR THE PURPOSES THEREIN CONTAINED.
"'~S~F' I have hereunto set my hand and official seal this ~ day of
~
My Commission Expires:
Ji'VJt;w
. NOTARlAlSEAL
rOOD 8. GARRY, NOOIy Public
~ ~ Twp., BUcks"",......
MY CommiIIiOn -- . 3, iXr4'"
LIVING WILLS
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ACKNOWLEDGMENT ACCEPTANCE OF HEALTH CARE REPRESENTATIVE
I, Chester L. Valencik, Sr., accept this appointment and agree to serve as Health Care Representative for
BETTY R. V ALENClK. I understand that I must act consistently with her desires as per this Advance
Directive or otherwise made known to me. If I do not know her desires, then I have a duty to act in good
faith in what I believe to be in her best interest. I understand that this document allows me to decide
about her health care only while he cannot do so. I understand that she may revoke this appointment. If I
learn that this document has been suspended or revoked, I will inform her current health care provider if
known to me.
COMMONWEALTH OF PENNSYLVANIA
COUNfY yLUMBIA
On the day o~ ,20 a before me, the undersigned Notary Public,
personally appeared the ab ve named Affiant who acknowledged before me to be the individual named
above and executed the foregoing instrument and acknowledged that he/she executed the same as his/her
free act and deed.
~.
M#;~;;;
LIVING WILLS
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Declarant
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IN THE COURT OF COMMON PLEAS
OF COLUMBIA AND MONTOUR COUNTIES, PENNSYLVANIA
. IN RE: ) ORPHANS' COURT DIVISION
. )
BETTY R. V ALENCIK, ) No.
)
AN ALLEGED ) PETITION FOR THE APPOINTMENT
. INCAP ACIT A TED PERSON ) OF A PERMANENT GUARDIAN
. ) FOR THE PERSON AND EST A TE OF
AND ) BETTY R. V ALENCIK, TO VACATE
) ALL PRIOR POWERS OF ATTORNEY
CHESTER L. V ALENCIK, JR., ) APPOINTING CHESTER L. V ALENCIK,
. INDIVIDUALLY, AND IN HIS CAPACITY ) JR. AND LINDA D. V ALENCIK, FOR AN
. AS DURABLE POWER OF ATTORNEY ) ACCOUNTING BY CHESTER L.
FOR BETTY L. V ALENCIK AND IN HIS ) V ALENCIK, JR., AS POWER OF
CAP ACITY AS TRUSTEE OF THE ) ATTORNEY FOR BETTY R. V ALENCIK
V ALENCIK F AMIL Y IRREVOCABLE ) AND AS TRUSTEE OF THE V ALENCIK
TRUST DATED AUGUST 4, 2005 ) FAMILY IRREVOCABLE TRUST
. ) DATED AUGUST 4, 2005, AND FOR
. AND ) OTHER RELIEF
LINDA D. V ALENCIK, IN HER CAPACITY
AS SUBSTITUTE DURABLE POWER OF
. ATTORNEY FOR BETTY L. V ALENCIK
.
PROOF OF NOTICE
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I, Bruce G. Baron, attorney for Petitioner in the above incapacity proceeding, certify that
on January 7, 2008, I served the foregoing Petition for Appointment of a Permanent Guardian in
the above-captioned matter by mailing a true and correct copy to the following persons and/or
institutions at the addresses indicated below certified mail, return receipt requested and by
regular first class United States mail, postage prepaid as follows:
Chester L. Valencik, Jr., individually, as Power of Attorney for Betty R. Valencik, and
as Trustee for the Valencik Family Irrevocable Trust dated August 4,2005
5108 Inverness Drive, Mechanicsburg, Pennsylvania 17050
.
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Linda D. Valencik, as Substitute Power of Attorney for Betty R. Valencik,
5108 Inverness Drive
Mechanicsburg, Pennsylvania 17050
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Shelly Valencik Capozzi
1655 South Holly Pike, Carlisle, Pennsylvania 17013
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Columbia-Montour Area Agency on Aging (Attention: Annie Reilly)
702 Sawmill Road (Suite 201), Bloomsburg, PA 17815
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Bruce G. Baron, Esquire
Attorney for Petitioner
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EXHIBIT C
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Received:
.JAH-23-2008 13:58 FROM: 1+570+389+5621
Jan 23 2008 02:21pm
TO: 917172334103
P:2/2
.
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IN THE COURT OF COMMON PLEAS
OF THE 26TH JUDICIAL DISTRICT
PENNSYLVANIA
~N RE:
BETTY R. VALENCIK
COLUMBIA COUNTY
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CASE NO: 4-0C-Oa
CIVIL ACTION LAW
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BRUCE G. BARON, ESQUIRE, ATTORNEY FOR THE PETITIONER
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AMENDED
OlUlER OF COURT
AND NOW, this 22nd day of January, 2008, it is hereby
Ordered that a pre-hearing regarding the guardianship of the
.
.
above captioned case be held on Monday the 31st day of March,
2008, at 2:00 P. M. in the Chambers of the Columbia County
Courthouse, Bloomsburg, Pennsylvania before the
.
.
Honorable Thomas A. James, Jr.
BY THE COURT:
.
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cc; ~12/e$ter Valencik
!nda d. Valencik
helly Valencik Capozzi
Columbia Montour Area Agency on the Aging
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Bruce G. Baron, Esquire
Attorney I.D. No. 28090
Capozzi & Associates, P.c.
2933 North Front Street
Harrisburg, P A 17110-1250
Telephone: 717-233-4101
FAX: 717-233-4103
Attorneys for Respondent
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ESTATE OF BETTY R. V ALENCIK : IN THE COURT OF COMMON PLEAS
: CUMBERLAND COUNTY,
: PENNSYL VANIA
.
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: ORPHANS' COURT DIVISION
CHESTER L. V ALENCIK, JR.,
: No. 21-08-0120
Petitioner,
.
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TROY A. V ALENCIK,
Respondent.
.
.
CERTIFICATE OF SERVICE
:
I, Bruce G. Baron, Esquire, do hereby certify that I have served a true and correct
copy of the foregoing PETITION TO DISMISS DUE TO JURISDICTION OVER
THIS MATTER HAVING PREVIOUSLY BEEN ASSUMED BY THE ORPHANS'
COURT IN THE 261" JUDICIAL DISTRICT (COLUMBIA COUNTY) upon the
following below-named individuals by U.S. Mail, first class postage prepaid, at
Harrisburg, Pennsylvania, thisr day of February, 2008:
SERVED UPON:
Neil Warner Yahn, Esquire
JAMES SMITH DIETTERICK & CONNELLY, LLP
P. O. BOX 650
Hershey, P A 17033
[Attorneys for Petitioner]
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Bruce G. Baron, Esquire
Attorney I.D. No. 28090
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