HomeMy WebLinkAbout04-25-08
THE MATTER OF CLAIRE R. WELDON:
AN ADJUDICATED
INCAPACITATED INDIVIDUAL
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLV~IA
ORPHANS COURT DIVISI~O g
NO. 21-07-0606 . 2:!. ~
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PETITION FOR COURT APPROVAL TO PAY PREPAID_~I~
)] N
TO THE HONORABLE JUDGES OF SAID COURT: ~
AND NOW, this 21st day of April 2008 comes the guardian,
Constance E. Stoneroad, of Keystone Guardianship Services, of
the
above-captioned incapacitated individual,
petitions
as
follows:
1. Claire R. Weldon is presently a resident of the Sarah
A. Todd Memorial Home, located at 1000 West South Street,
Carlisle, Cumberland County, Pennsylvania.
2. Claire R. Weldon is receiving a monthly social
security payment paid directly to the representative payee,
Sarah A. Todd Memorial Home in the amount of $545.00 toward her
care and housing.
3. Keystone Guardianship Services was appointed Guardian
for Claire R. Weldon, an alleged incapacitated person by the
Cumberland Country Orphans Court by order dated August 6, 2007.
4. There is no burial reserve set up for the funeral
expenses of Claire R. Weldon.
5. There is a life insurance policy held with ING
ReliaStar Life Insurance Company with a cash surrender value of
$3,415.10 as of April 19, 2007.
Page 1 of 2 Pages
)r
Estate
Claire R. Weldon
An Incapacitated Person
6. Funeral arrangements have been completed with the
Myers Funeral Home, Inc., 37 Main street, Mechanicsburg,
Pennsylvania 17055. (see copy of Statement of Funeral Goods and
Services and Forethought Life Insurance Company contract
attached as Exhibit "1").
WHEREFORE, the aforementioned guardian respectfully requests
this Honorable Court enter an Order directing the following:
1. Keystone Guardianship Services authorization to pay
$4,995.00 to Forethought Life Insurance Company for
the prepaid burial arrangements for Claire R. Weldon
from the proceeds of the ING Life Insurance Policy and
the difference from the proceeds of the sale of her
real estate.
Da t e: ~ <--?~ ,tlc::?t::J 7
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KEYSTONE GUARDIANSHIP SERVICES
129 Market Street Suite "1"
Millersburg, PA 17061
Office (717) 692-2345
Cell (717) 265-4056
Page 2 of 2 Pages
'THE MATTER OF CLAIRE R. WELDON:
AN ADJUDICATED
INCAPACITATED INDIVIDUAL
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS COURT DIVISION
NO. 21-07-0606
VERIFICATION
I verify that the averments in this Petition for court
approval to pay the prearranged burial expense for Claire R.
Weldon are true and correct. I understand that false statements
herein are made subject to the penalties of 18 Pa. C.S. 4904,
relating to unsworn falsification to authorities.
KEYSTONE GUARDIANSHIP SERVICES
~
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Date: ~,--:1~ 6!.OtJg
~dr4<L~Lt ~#zt!/;rL
Constance E. stoneroad
Four Generations...
~RS
~~lInera-l cYet7me, @nc.
STATEMENT OF FUNERAL GOODS AND SERVICES SELECTED
Charges are only for those items that you selected or that are required. If we are required by law or by a cemetery or crematory to use any items, we will
explain in writing below.
If you selected a funeral that may require embalming, such as a funeral with viewing, you may have to pay for embalming. You do not have to pay for embalming
you did nOI approve if y~u selecte arr ngewnts such as a dire t cremat" n or immediare burial. If we charged for embalming, we w: 1 explain why belo~. ,-
For the Service of C I c.. .. __do C
BOYD L. MYERS, JR., Supervisor
37 E. MAIN STREET
MECHANICSBURG, PENNSYLVANIA 17055
(717) 766-3421
Charge to:
Name
Address
City
Other clothing
State
A. CHARGE FOR SERVICES SELECTED:
I. PROFESSIONAL SERViCES 11 q. ll. S
~~~~:i~~ ~~ne~J ~i~e~to~/S~f : : : : :i1td
Other preparation of body
$_
S
......S~
Cremation urn
(Description)
OTHER
5_
S_
S_ _
TOTAL MERCHANDISE SELECTED.................. B S~
C. SPECIAL CHARGES:
Forwarding of remains to
SUB-TO~A~ 'OFPROFESSIONA~ SERVI~~. . .. Al 5.
2. FACILITIES AND SERVICES
Use of facilities and services for .' /)
viewing (VisitationlWake)......... 5~
Use of facilities and services _ /)
for funeral ceremony. . . . . . . . . . .. S~
Use of facilities and services for . n
Memorial Service ............... S~
Use of equipment and services . f)
for graveside service............. S~
Other use of facilities
(Funeral Home)
Receiving of remains from
.--.
'-
(Funeral Home)
Immediate Burial........... ... s_
Direct Cremation. . . . . . . . . . . . . . . .. s---==---
s_ _
SUB.TOTAL OF SPECIAL CHARGES '" . . . . . . . . . . . . . C s_
D. CASH ADVANCED
S Opening Grave ...... ... s_
SUli-TO~A~ OF FACi~iTIESiEQ'uipMENT ~.... A2 r-- Cemetery Equipment.............. s~
Lot and Deed...... .............. 5--=-
3. AUTOMOTIVE EQUIPMENT Newspaper Notices-Local......... S-.:::::::::....
~:~i~le .to. tr~~~fe~ re~ai~ .to .~~~eral ~~me. /J Newspaper Notices-Out-of-town. . .. S""':::::'"
~ Telephone & Telegrams ........... S~
Hearse (Casket Coach) _ Airbee . . . . . . . . . . . . . . . . . . . . . . . .. S ~
Loca!...................... . ... . S_ Clergy/Mass Offering....... ....... S--==---
Limousine _ Pallbearers .. .. .. .. . . .. .. .. .. .... S -
Local.... ...... S_ ~~::~~~t~OPie~ .O.f.th~. Deat~. ...... S ~ (I)
~~;~:~ .c~r.. .. .. . .. .. .. .. .. .. .. .. S w.cR Police Escort .. .. . .. .. .. . .. .. .. .. S ~
Flower car or floral disposition _ Flowers....... ............... S~
Local.. ........... ........ ... S_ Vault Service Charge............. 5-=-
~~~~c~r~Ckrgy car ....... S ~ :==
Car for pallbearers S_
Loca!............ .... S_ S_
Our of town transportation. . . . . . . .. S ~ 5_
5 5_
5== _ SUB.TOTAL OF ADVANCES..................... D S_
SUB-TOTAL OF AUTOMOTIVE EQUIPMENT. . . . . . .. A3 S_ We charge you for our services in obtaining:
TOTAL OF PROFESSIONAL SERVICES. (specify cash advances that are marked-up)
~~~I:;~~;/N.D .AUT~M~T~~.. . . . . .. . . . .. .. .. . . A s!hJ{
s~
B. CHARGE FOR MERCHANDISE SELECTED:
Casket......................... S-=:::..
(Description)
SUMMARY OF CHARGES
A. Professional Services, Facilities and
~~:::~::' .and Auto~.oti~e. . . . . . . .. s!Jij~
B. Merchandise.. . .. .. .. .. .. .. .. .... S ~
C. Special Charges. . . . . , . . . . . . . . . . .. 5""::::::"--'
D. Cash Advances....... ............ '-=--- '-'t"q ---J2S1.,
TOTAL OF ALL SECTIONS. , . . . . . . . . . . . . . . . . .. S :l ~
PAID AT TIME OF OR PRIOR TO
ARRANGEMENTS. . . . . . . . . . . . . . . .. . . . .. . .. .. ,_
BALANCE DUE..................... ........... S_
RE~ON FOR Er.y}ALMING '" f) J , .
~~ 1\~I1r:~I<; (vP:,i.A,(..... lIlbvfU~
If any law. ce etery, or crematory requirements have required the purchase
of any of the items listed above the law or requirement is explained below.
Other Receptacle .. . . .. .. . . . .. . , ., S"::::::
(Description)
Outer burial comainer..........,.. S~
(Description)
Acknowledgement cards . . . . . . . . S ~
Register book(s) .. ................ S-=-
Memory folders .. . . . . . . . S _
Prayer cards ................ .. S~
Temporary grave marker. . . . . . . S-=:::::....
Burial clothing. . . . .. ............ 5-=..
I agree that I have examined the items of goods and services selected above and found them to be correct and according to the arrangements I have requested. I acknowledge
receipt of a copy of this Slatement of Funeral Goods and Services Selected. I represent that I have sufficient funds available for payment of the cash price for the goods
and services selected. 1 also agree to make payment of S within days. I agree to be jointly and severaliy liable with anvone else who
signs
from
Those
be co
(Seal)
below. A late charge of per month a ... ..... be applied to the unpaid balance beginning' days
the date of this agreement. I will also pay to Ihe Fune EXHIBIT eral Director to coliect amounts I owe under this agreement.
costs may include attorneys' fees, court costs and 0 ise ordered or requested after the date of this agreement will
nsidered part of this agreement and tbe cost tbereof I K I f/
x:.
(Purchaser) (Date)
(Purchaser) (Licensed Funeral Director)
(Seal)
_.~..----------~-- --- ~ --- -- -- -- --~-~ --- --------- ----- - ~,-- ,-- ------
GROUP INSURANCE ENROLLMENT FORM - FORETHOUGHT LIFE INSURANCE COMPANY
FORETHOUGHT CENTER,BATESVlllE, INDIAN~ 47006 (Please print) 7311994
FBRE
TH8UGHT@
Proposed Insured 0 Mr. rs. 0 Ms.
C)-~ \ (t.t ~ . vJ E-l":Do ,..j
First Name! Middle Initial! Last Name
o Miss
I I
Age I l. 4.
Date of Birth
I t-l 1'lJ/ I I~t I
Social Security Number
o Male ~ Female
( S8) 13~ - Cf~/i
Area Code Telephone Number
tYJ,u.ef!SBJ~ fA- j'7CJ<e I
City State Zip Code ,/
Health Questions (Optional) - Multi-Pay Plans ONl",:Y.
TO BE COMPLETED ONLY BY THE PROPOSEV
SURED. Please answer each question to the besff
y knowledge and belief. /
,.
1) Are u currently confined to a hospital, hospicelursing home
(including stodial care) or other such faCility;. oo~r, ithin the past
twelve months, ave you been told by a medical p~:titioner that you
should be confin but have chosen not to folIo that instruction?
I understand I will ualify for coverage ich provides for full
benefits fromince on, if the answer to both he thquestions is "no."
If either answer' "yes," or if the Proposed Insu d is physically or
mentally una to answer the questions, a certifi te with limited
death benefi during the first one or two years (depen . ng on age and
plan) will e issued.
Author ation By completing the Health Questions a: d signing
this E ollment Form, any medical practitioner or facility, r other
per n is authorized to give Forethought Life records or info ation
r arding the Proposed Insured's health. This authorization is Ii . ted
irst Name! Middle Initial! Last Name 0 matters related to the Health Questions.
The above information is true and complete to the best of my knowledge and belief. Any person who knowingly and with intent to
defraud any insurance company or other person files an application for insurance or statement of claim containing any materially
false information or conceals for the pur ose 0 . leading, information concerning any fact material thereto commits a fraudulent
insurance act, which is a crime and subje son to criminal and civil penalties. No insurance will take effect until the premium
has been paid and.a certificate has been. the Insured i living.
o Mrs. 0 Ms.
Mailing Address for Insured or Certificateholder
(Where to send information about this insurance)
, 2"1 IY1 Allar
S,.
ST~ ff .1
Single Premium
Payment Mode
o Annual 0 Semi 0 Quarterly 0 Monthly 0 APA*
Initial Premium
Multi-Pay Premium
Check is for $
Make check payable to Forethought Life Insurance Company.
* Automatic Payment Authorization - Attach completed authorization form if selected.
Replacement Is the insurance applied for intended to replace
or change any existing life insurance or annuity policy?
o Yes .~No
If yes, please provide name of insurance company(s) and policy
num~r(s).
Beneficiary Death proceeds are to be paid to the Beneficiary
which is the estate of the insured. If another Beneficiary is desired,
provide the informatiop b~low. Th~s designation is su.b~ect to any
assignment or other dIrectIons receIved from the Certlflcateholder
during the Insured's life. S
. .5TDIJ - G LJA/l-i). t f IIC~
5
I
I
Social Security Number
Yes ~o
2) During the last five ears have you be n diagnoki as having, or
have you received active eatment fr a medical practitioner for
any of the following:
AIDS/ARC
Blood Disorder
Brain Disorder
o Yes ONo
Kidney Disorder
Liver Disorder
Lung Disorder
X
Signature of Proposed Insured Signature of Certificateholder (only if other than Insured)
Al-75-39 J
Agent's Statement Is the insurance app Ie or mtended to replace or change an existing life insurance or annuity policy? -0
_ If ~e Health Questions are completed, I c~.!I that the information ~as provided directl~ the Proposed Insured. '- 0 ~J.\,,,Oi'!o n
IVtECt-lANiJfJUIlCi,P4 -S/~~ AIlAIJJ Sf.. /70,55 ~.mr.r.ll'ml.Jfl'"
A ~entJ..t:Jca~n I ". 1_ . ~ Q Address, F r ~ til'l'/~~
. V-./ // . _ J ,ar-""-LLI --"'--"7 "....- 1\ If C. 1.1 _I /f'llll'\.
Change of Policy/Certificate/Annuity
Ownership to The Forethought Trust
(Permanent and Irrevocable)
F8RETH0UGHT LIFE INSURANCE COMPANY
P.O. BOX 216
BATESVILLE, INDIANA 47006-0216
IMPORTANT: Both sections of form must be completed.
C L.-Ai (t.C a... &J EJ-i)BAi
Name of Insured
'72> f7cr'iL/
Number of Policy/Certificate/Annuity
Irrevocable Assignment of Ownership to Funeral Firm
I hereby irrevocably assign ownership of the Forethought Life insurance policy/certificate or annuity to the Funeral Firm
identified below in return for the promise to deliver funeral services and merchandise, and for the promise of the Funeral
Firm to immediately transfer ownership of the policy/certificate/annuity to The Forethought Trust on my behalf.
By assigning ownership of the policy/certificate/annuity to the Funeral Firm, it is understood:
1. This is permanent and irrevocable, and except as stated below, I renounce my power to control the policy/certificate/
annuity; and
2. Ownership of the policy/certificate/annuity will subsequently be transferred by the Funeral Firm to The Forethought
Trust which shall assure payment to the Funeral Firm, or any subsequently designated funeral firm, for the provision
of funeral services and merchandise; and
3. I waive all rights under the policy/certificate/annuity to surrenderit for cash and to obtain a loan against the policy/
certificate/annuity. I do not assign these rights to any other person; and
,
4. I understand that it is my personal obligation to pay all premiums due on the policy/certificate/annuity identified
.. above; that I retain the right to change the designated funeral firm; and that I retain the right to change the named
beneficiary .
Signature of Owner
Date
Transfer of Ownership to The Forethought Trust
On behalf of the Funeral Firm, I accept the above assignment, and hereby transfer ownership of the policy/certificate/
annuity to The Forethought Trust. I understand that any right to receive payment of the proceeds is contingent upon delivery
of funeral services and merchandise.
rS rv~ MOMf:
of Funeral Firm (Please Print Name)
Signature of Authorized Representative
Date
-,~-- --- -- -- ------- ----"------ -- - -- -- --- -- - -~-- -- ._-~ ~ --,,- --'-- ------~-
-- - ~--- --~ -------- - --
REVOCABLE ASSIGNMENT OF DEATH BENEFIT
FORETHOUGHT LIFE INSURANCE COMPANY
P.O. BOX 216
BATESVILLE, INDIANA 47006-0216
Please print all information
Insured (j VtII2.[ R.~ ()~'bt-l POlicy/CertificateNumberl6 "1'1 q L{
Owner (lfother than Insured) Kr;V~7lJ^,e GUAlU;>i~H' f S \/c-S
I
I, the Owner, hereby assign the death benefit of the numbered policy/certificate to the Funeral
Home identified below, in an amount equal to the retail price of any goods and/or services provided
by the Funeral Home. If the death benefit exceeds the amount due the Funeral Home, the excess
death benefit proceeds will be paid to the beneficiary of the policy/certificate.
Funeral Home:Jl1 Frs hnverA:<...-- 4aw..r;
Address (City & State): -3(. E., At1AuJ S /- /Ill r7! UANtCSf>Ute..q
Telephone Number (if known): 4l1- {4z~ -- "3 tt"'Z...-- t
.#I I 7()S~
~'
t
I understand that I may revoke this assignment at any time by notifying Forethought Life Insurance
Company at the above address.
_arure of Policy owner/Certificate holder
Date
A 7043-01
@ 2005 Forethoull;ht