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HomeMy WebLinkAbout10-06-09~-1$2~1~ IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PA ORPHANS COURT DIVISION NO.08-1069 FIRST ACCOUNT For the "Special Needs Trust" Established for George A. Gilmer Stated by Bart W. Holmes, Esq. trustee Purpose of Account: The Trustee offers this Account to acquaint interested parties with the transactions that have occurred during the Administration. It is important that the Account be carefully examined. Requests for additior~ ~ .~ information, question or objection can be discussed with: ~ Ca `° ~ ~~~~ ,_T~ ~~ ~ c~ ~, ~ ~ fw ~ Lei Huang Esq. ~ ~ ~ ~ :~ ~", ~, `' f -~,-, , 310 Saddle Ridge Court _~ - ~:.} 1 ~-~. .}. ,..~ t Harrisbur PA 17110 ~ `~ ~ ~~~ ~' ~ ' Cell Number: (732)-277-5866 ~-' ~~^ ~~'~_ ` ~~' Supreme Court LD. 210252 - .. ~. r , ; co Please note that After 10/15/2009, Lei Huang's new address is 2225-a Prior Rd Wilmington DE 19809 SUMMARY OF ACCOUNT PRINCIPAL PAGES Receipts 2 $45,763.18 Distributions to Beneficiaries 2 -$23,711.62 Principal Balance on hand 2 $22, 051.56 n~~n~~rF Receipts 2-3 $788.97 Less Disbursements 3 -$760 Income Balance on Hand 3 $28.97 COMBINED BALANCE ON HAND 22 080.53 1 Verification 4 PRINCIPAL RECEIPTS Settlement collected from Gilmer v. Paige Longstreth, $45, 743.18 Initial deposit into the Trust account 20.00 TOTAL PRINCIPAL RECEIPTS $45, 763.18 DISTRIBUTIONS OF PRINCIPAL TO BENEFICIARIES To: George A. Gilmer 01/12/2009 Cash for the purchase of handicapped equipped automobile, and related handicapped motor vehicle equipment. $23,711.62 TOTAL DISTRIBUTIONS OF PRINCIPAL TO X23, 711.62 BENEFICIARIES RECEIPTS OF INCOME Northwest Savings Bank Saving and Checking Account 2008 to 2009 Interest income $628.29 $628.29 Members 1St Federal Credit Union Acct # 342887 (11 month CDC Nov 25, 2008 -Dec 24, 2008 $15.06 Dec 25, 2008 -Jan 24, 2009 $38.91 Jan 25, 2009 -Feb 24, 2009 $21.62 $75.59 Members 1St Federal Credit Union Acct # 347848 (19 month CDl Jan 29, 2009 -Feb 24, 2009 $1 72 Feb 25, 2009 -Mar 24, 2009 $12.01 Mar 25, 2009 -- Apr 24, 2009 $13.31 Apr 25, 2009 -May 24, 2009 $ 8.59 May, 25, 2009 -June 24, 2009 $ g gg Jun 25, 2009 - Ju124, 2009 $ 8.60 Jul 25, 2009 -Aug 24, 2009 $14.89 2 Aug 25, 2009-Sept 24, 2009 $17.09 $85.09 TOTAL RECEIPTS OF INCOME 782.14 DISBURSEMENTS OF INCOME 9/25/2009 Legal fee/cost of filing account and petition of disbursement $760 TOTAL DISBURSEMENTS OF INCOME 760 VERIFICATION I, Bart W. Holmes, the trustee of the George A. Gilmer Special Needs Trust hereby declares under oath that the foregoing First Account is true and correct and fully discloses all significant transactions occurring during the accounting period that all known claims against the Trust have been paid in full; that, to his knowledge, there are no claims now outstanding against the Trust; and that all taxes presently due from the Trust have been paid. This statement is made subject to the penalties of 18 Pa. C.S.A. Section 4904 relating to unsworn falsification to authorities Bart W. Holmes Date: 4 CERTIFICATE OF SERVICE I, Lei Huang, Esquire, attorney for Petitioner, Bart W. Holmes, hereby certify in accordance with Rule 6.3-1 of the Cumberland County Orphans Court Rules and Sect. 3503 of PEF Code that notice of Account has been mailed by US Mail to the underlying parties at their addresses. They are the only parties in interest. Commonwealth of Pennsylvania Governor's Office of General Counsel 3rd Fl. West, Health and Welfare Bldg. 7th & Forster Streets Harrisburg, PA 17120 Social Security Regional Office III PO BOX 8788 Philadelphia PA 19101 George A. Gilmer 550 Brown Lane Enola, PA 17025 Bart W. Holmes 17 Logans Run Enola, PA 17025 t 310 Saddle idge Harrisburg PA 17110 Dated: Oct 5, 2009 N c `~'~ - ~--; ~ /'1 . ~ 4 J c a .....~ r '"'y l"'~ TRUST ~ ~ ' ~-- ~.' -~~-` t ~ .,, ~ ~yS..y' OU T O COMMON PLEAS OF C -l --~ -' ~~. .~- ' - ~ ~:~ ~, Q. c~ ~e- `~ COUNTY, PENNSYLVANIA ~' ORPHANS' COURT DIVISION NAME OF TRUST (TRUST UNDER WILL OF or r---, TRUST UNDER DEED OF ~ /V ~~~5 /~(S o ~ ~-~i y ~. ~ r /~y ~,~~ DATED d 3o Z o ---~ PETITION FOR ADJUDICATION / STATEMENT OF PROPOSED DISTRIBUTION PURSUANT TO Pa. O.C. Rule 6.9 This form may be used in all cases involving the Audit of Trust Accounts. If space is insufficient, riders may be attached. INCL UDE ATTACHMENTS AT THE BACK OF THIS FORM. Name of Counsel: ~! l"(l.~Q Supreme Court LD. No.: Z/a 2 ~ Z- Name of Law Firm: / Address: ~ L~ s~`Q ~~ ~ ,~ arr ;csd ~ ~ ~ 7//0 Telephone: ~3 Z _ Z~ ~ - ~ ~~~ e ~ ~o ~ e Fax: f Form OC-02 rev 10.13.06 /~~ ~~l ~ ~ /,~ ~ 'Z 2~-~ ~(/ t7 r C( Page 1 of 10 /'~ r Name of Trust: ~~dY _ l -/ I YY/ ~/ e S 1. Name(s) and address(es) of Petitioner(s): Name Address: Petitioner: ' ~" ! J ~~ S n o~~ 2. Check if any of the following issues are involved in this case: A. Appointment of Trustee ........................................... B. Interpretation ... ................................................ ~ C. Discharge of Truste e .......... . .................. . D. Transfer of Situs ................................................. E. Appointment of Ad Litem .......................................... F. Minor, Unborn or Unascertained Beneficiary(ies) ...................... G. Principal Distribution .............................. H. .............. . Partial/Full Termination of Trust I. .................................... Missing BeneficiarY(ies) .......................................... J. Cy Pres ............ ...................................... K. ...... WilliamsonIssue* ............................................... ~ L. Other Issues .. .................................... List: .............. Please note: A detailed explanation of issues checked should be set forth at item 13 below. ~` See Williamson Estate, 368 Pa. 343, 82 A.2d 49 (1951), if Trustee was also Executor of the settlor/decedent's estate and received commissions in such capacity. Petitioner: r~ / V E~Ky Form OC-02 rev 10.13.06 Page 2 of 10 N cD~ . ame of Trust: ~' ~ / ~`Y1e ~ ~ ~~ ` ~ ~ 3. Testamentary Trust: ~~ Decedent's date of death: Date of Decedent's Will: Date(s) of Codicil(s): Date of probate: or Inter Yivos Trust: Date of Trust: ~(',~ Z ~~ 2 ~~ Date(s) of Amendment(s): /(/(~ /`T ~ ~~i-~~h fs 4. A. If any other Court has taken jurisdiction of any matter relating to this Trust, explain: ./~ ~ d ~ r ~~P ~~ ~ ~ ~ ~s ~ ~n ~ i~~f ~ J - B. Identify all prior accountings and provide dates of adjudication. ~Vl lS lS (~ ~1 rS' f ~CC~u~ f 5. A. State how each Trustee was appointed: 7~~ den erica r ~ o = ' ~ ~ ~ B. If a Petitioner is not a Trustee, explain: Q~~oj/ (S' ~ ! r~S Q~ . ~~f~ w H/ ;~ Form OC-02 rev 10.13.06 Page 3 of 10 Name of Trust: v r ~ yh / S ~°C~ f " ~ °G~s /Y(~ S 6. State how and when the present fund was awarded to Trustee(s): w - ~f ~~ ~~~ 7. Period covered by accounting: / / C~ Z ~~ zoos to ~~'~ 8. Current fair market value of the Trust principal is $ of Account.) 9. State concisely the dispositive provisions of the Trust: Se~ ~f~~~ti~~ A ~e ~xy ti~f a . (See page 10. Explain the reason for filing this Account (if filed because of the death of a party, state name of person, relationship to Trust and date of death): ~~ ~ o ~ / ~ ~ ~ r ~ ~~~/ 7~ ~~ ~~- ~ ~ l~ YG ~ ~~ ~ /~ee~s ~ a~ ru S ~~~e~~ ~ ~ Form OC-02 rev 10.13.06 Page 4 of 10 Name of T ~~~ r --/ rust. l ~`~/~'t'" S ~~ ~ /~'~ T;~ 11. State why a Petition for Guardian/Trustee Ad Litem has or has not been filed for this Audit (see Pa. O.C. Rule 12.4): ~~ff ah ~OV C-ua~~p,,~ ~TUsfPe ftq' Li fPin %S ha'L ~~`~l PCL~ e ~ l~'u S''tfe / S ~ CcC~~ ~ ~ ~uQrK~o,1 `~GY ~Q ~2 ~CfA.rv~ , ~I 12. A. State the amount of Pennsylvania Transfer Inheritance Tax and Pennsylvania Estate Tax paid (including postponed tax on remainder interests), the dates of payment and the interests upon which such amounts were paid: Date !V ~Q ' Payment r i fb VE'Cd/or Interest B. If any such taxes remain unpaid or are in dispute, explain: ~~ ~~ ~ ~~ aSS~ ~ ~n~ ~ _la ~ /~ 13. Describe any questions requiring Adjudication and state the position of Petitioner(s) and give details of any issues identified in item 2: ~C'f~f 0/I~/ QS~S ~ ~~/~ f ~iwr~f /~ Tu~ 7`0 ~5~~(,ge ~, ~a ,~`700~700 ~ year ~/m ~rin~%"~ ~ l Fo,,,,oaoz .e,.io.is.o6 Page 5 of 10 T~sf ~~,a~~_ ~- Name of Trust: / e~~ Cr n? e ~ / - ~' ~'~..~ /f'(.~ 14. Written notice of the Audit as required by Pa. O.C. Rules 6.3, 6.7 and 6.8 has been or will be given to all parties in interest listed in item I S below. In addition, notice of any questions requiring Adjudication as discussed in item 13 above has been or will be given to all persons affected thereby. A. If Notice has been given, attach a copy of the Notice as well as a list of the names and addresses of the parties receiving such notice. B. If Notice is yet to be given, a copy of the Notice as well as a list of the names and addresses of the parties receiving such Notice shall be submitted at the Audit together with a statement executed by Petitioner(s) or counsel certifying that such Notice has been given. C. If any such party in interest is not sui juris (e.g., minors or incapacitated persons), Notice of the Audit has been or will be given to the appropriate representative on such party's behalf as required by Pa. O.C. Rule 5.2. D. If any charitable interest is involved, Notice of the Audit has been or will also be given to the Attorney General as required under Pa. O.C. Rule 5.5. In addition, the Attorney General's clearance certificate (or proof of service of Notice and a copy of such Notice) must be submitted herewith or at the Audit. 15. List all parties of whom Petitioner(s) has/have notice or knowledge, having or claiming any interest in the Trust, whether such interest is vested or contingent, charitable or non-charitable. This list shall: A. State each party's relationship to the Settlor/Decedent and the nature of each party's interest(s); _ Name and Address o Each Parry in Interest ~ Relationship and Comments i ar ~S~ ~~~ ~~f-- 2 ,~~~~~cr~ l--h alb , /~ l ~~ ~' ~aCl' ~ ~`r`~ Q~°hez~rC~~ e ~Q q~ ~~t i cry ~e~~ v ~,J Ss~ pro 1 ~ ~ /~~~.~C ~o~~s 1 ~S~ r~ f Form OC-02 rev 10.13.06 Interest Trcc sf Qene f c~a~ y /~nef c!a~ ~-eCP! vP SS.Z ~o~` Sc~c ~~ .~r,~ r,~~ Page 6 of 10 Name of Trust: (J-'2°, _ Name and Address orEach Party in Interest ~~ vNC~/~ lf~ j~h~is /r,~. ~ ~ C ~~ ~o/C'~1 o~'S ~f C~o C i s .k~~P-~' .~ ~.SI~G~I. f C ~r G( ~- ~~ ~r c S Gc. r ~,~- ~ ~ z o ~~'r f w / 7~ Eh D'~ ~a Yh ~' > L- S , ,,.~ ~ ~~ ~~02~ ~r ~~~~ Ketationship and Comments i ,~ I~ec~~ vas ~ - ~e~~~a rc~ I ~~-f,~~i /~P~~ ~~, Interest ~~~~C~ ~~~ ~~ 7r~~~/ ~-Pf f, ahPr B. Identify each party who is not sui juris (e.g., minors or incapacitated persons). For each such party, give date of birth, the name of each Guardian and how each Guardian was appointed. If no Guardian has been appointed, identify the next of kin of such party, giving the name, address and relationship of each; and /~iDf a~l~bl~ C. If distribution is to be made to the personal representative of a deceased party, state date of death, date and place of grant of Letters and type of Letters granted. ~va~ ~p/,~d/e 16. If Petitioner(s) has/have knowledge that a Trust share has been assigned or attached, provide a copy of the assignment or attachment, together with any relevant supporting documentation. ~a ~~ l ~~ 17. If a trustee s principal commission s claimed: A. If based on a written agreement, attach a copy thereof. ,/~~-f 1 ~ ~ ~b~~ Form OC-O2 rev 10.13.06 Page 7 of 10 Name of Trust: c i~~P~ B. If a principal commission is claimed, state amount. ~~ ~ C. If a principal commission is claimed, state the amounts and dates of any principal commissions previously paid in prior accounting periods. Amount Date Paid /~O ~ // ~i7 I~ /~'/l ~PO r 18. If a reserve is requested, state amount and purpose. Amount: ~©~ ~,p~~CJ, Purpose: If a reserve is requested for counsel fees, has notice of the amount of fees to be paid from the reserve been given to the parties in interest? ........................................ ® es o 'Y N If so, attach a copy of the notice. 19. Is the Court being asked to direct the filing of a Schedule of Distribution? ............... Yes ' No Form OC-02 rev 10.13.06 Page 8 of 10 Name of Trust: S ~C ~ ~~_S ru Wherefore, your Petitioner(s) ask(s) that distribution be awarded to the parties entitled and suggest(s) that the distributive shares of income and principal (residuary shares being stated in proportions, not amounts) are as follows: A. Income: Proposed Distributee(s) ~~~ I-1~~~.~.. ~g B. Principal: Proposed Distributee(s) Amount/Proportion Amount/Proportion Submitted By: (All petitioners must sign. Add additional lines if necessary): r ~ ~ Name of Petitioner: Name of Petitioner: Form OC-02 rev 10.13.06 Page 9 of 10 Name of ~~~ r Trust: ~ ._-- ~ / yn S I ~1~ C >, Verification of Petitioner (Verification must be by at least one petitioner.) The undersigned hereby verifies * [that~i~ is title f1 -~ ~ of the above-named name of corporation 0 ~ '",~t~ .~ and] that the facts set forth in the foregoing Petition for Adjudication /Statement of Proposed Distribution which are within the personal knowledge of the Petitioner are true, and as to facts based on the information of others, the Petitioner, after diligent inquiry, believes them to be true; and that any false statements herein are made subject to the penalties of 18 Pa. C.S. § 4904 (relating to unsworn falsification to authorities). Signature of Peti 'o er * Corporate petitioners must complete bracketed information. Certification of Counsel The undersigned counsel hereby certifies that the foregoing Petition for Adjudication / Statement of Proposed Distribution is a true and accurate reproduction of the form Petition authorized by the Supreme Court, and that no changes to the form have been made beyond the responses herein. .~- Signature of Counsel for t Toner Form OC-02 rev 10.13.06 Page 10 of 10 In re. George A. Gilmer Special 1Veeds Trust ) A Petition in the Orphan's Court, ) Court of Common Pleas, ) SS: Cumberland County, Pennsylvania ) Parties in Interest: George A. Gilmer 550 Brown Lane Enola, PA 17025 Social Security Regional Office III c~~ ^; - Attn: Mandy Stokes, SSI Program Expert ` } ~; _~ ~_ ;:.~ -;~ ~~' ~ P.O. Box 8788 ~ ~~~ ~:_ ~~~ ~ ~' ~ Philadelphia, PA 19101 _ r ~ ~ : ~ ~' ~~ ~ _ ` ~' ~ ~' ~ ~~ :; ~ W ~ . ~ '~~ Commonwealth of Pennsylvania ~ 1 ; .... ~. ~ ~ ~~ = - ~ ~ =? ~ ~ --= - - ~ Governor's Office of General Counsel ~_-J -; ~ ; _ ~-;-= ;.; Attn. Lisa B. Dees, Assistant Counsel l ~a ~ ; <~~ . _ 3`~ FL. West, Health and Welfare Bldg. .,,, '~" ~. , ~ 7`~ & Forster Streets Harrisburg, PA 17120 O~'~~URT DIVISION No._ C~8-- i~(Q~ Petition to Settle Special Needs Trust for the Exclusive Benefit of George A. Gilmer, a disabled person, to appoint Bart W. Holmes, Esquire Trustee, and to authorize withdrawal of twenty-five thousand dollars ($25,000.00) from principal for a handicapped equipped automobile and for handicapped equipment for same. To he Honorab! ,the JudPes of the Said Orphan's Court Division: Facts relied uyon: Petitioner, George A. Gilmer, a resident of Cumberland County, Pennsylvania, at 550 Brown Lane, Enola, 17025, who is an adult, disabled individual, as defined in Title XVI of the Social Security Act, 42 U.S.C. Section 1832(c)(a)(3), hereinafter referred to as "Beneficiary," was injured in an automobile accident and collected a settlement from the tortfeasor at Gilmer v. Paige Longstreth, Lehigh County Docket No. 2003-C-2711, said money now deposited in an interest bearing account at Northwest Savings Bank, in the amount of $45,723.18, account number 2656005408 (October 2, 2008 statement of account attached as Exhibit A). Beneficiary seeks to establish a Special Needs Trust with the settlement proceeds, to exempt these assets from being included in the determination of Beneficiary's eligibility for, or amount of, medical benefits under a State Plan under the Act (Petitioner's Consent attached at Exhibit B). The Trust is established in accordance with a special provision of Title XIX of the Act, specifically 42 U.S.C. Section 1396p(d)(4)(A), as amended by the Omnibus Budget Reconciliation Act of 1993 (and any federal or state regulations or other rules promulgated pursuant to that provision) and 62 P.S. Section 1414 Special Needs Trusts, and therefore, the property directed to this Trust shall in no way be deemed to be available to Beneficiary for purposes of determination of benefits. Request for Relief: 1) Beneficiary, having no living mother or father as otherwise required by Statute to establish a Special Needs Trust (Trust), requests the Orphan's Court to act as Settlor for said Trust (Trust Instrument attached as Exhibit C, in accordance with Cumberland County Rules of Orphan's Court Rule 12.6-1, Exhibits to Petition), ordering the deposit of an initial $20.00 dollars into the Trust account (check attached at Exhibit D)(Trust account location to be determined); and, 2) Appoint Bart W. Holmes, Esquire, of 17 Logans Run, Enola, PA 17025, Cumberland County, to act as Trustee (Trustee), without compensation (Trustee's written consent to act as Trustee is attached as Exhibit E), and; ---------- 3) To authorize disbursement from the principal of the Trust, for the purpose of -`---` purchasing a handicapped equipped automo ei~`T and related equipment, the amount of up to $25,000.00 (Social Security Administration and Commonwealth of Pennsylvania Department of Public Welfare consents are attached as Exhibits F and G, respectively). By: Bart W. Holmes, sq ire Attorney for Petitioner 17 Logans Run, Enola, PA 17025 717-802-5756 (cellular) ID# 85071 Dau: / D 9, O c9 ~` PROPOSED DECREE In re. George A. Gilmer Special Needs Trust) .~ A Petition in the Or han's Cou ~~ p ~~, ) Court of Common Pleas, ) SS: Cumberland County, Pennsylvania ) And now, this ~o 'day of ~ ~~-~- , 2008, the Orphan's Court of Cumberland County, Commonwealth of Pennsylvania, in the matter of In re. George A. Gilmer Special Needs Tnist, finding the attached Trust at Exhibit C in order and permissible under law, decrees and orders the following: The Court hereby settles the Trust attached at Exhibit C of this Petition, having signed same as settler, and hereby transfers to Trustee a $20.00 cashiers check attached at Exhibit D of this Petition, to be deposited in a Trust account to be determined and established at the sole discretion of Trustee; The Court orders that Bart W. Holmes, Esquire, of 17 Logans Run, Enola, PA 17025 (717-802-5756), is hereby appointed original Trustee (to serve without compensation), who shall sign said Trust, and who shall have all of the powers and duties set forth in the Trust attached at Exhibit C of this Petition; The Court orders that Bart W. Holmes, Esquire, Trustee, at his sole discretion, shall be authorized-ts. w-iihdraw up to twenty-five thousand ($25,000.00) from the principal of the Trust, to purchase a haiidicagp~~quipped automobile, and related handicapped motor vehicle equipment, for the benefit of Beneficiary, hereunder. By the Court: `""~~ ~ ~~~ ~~'`'' Date: c~] t` r:~ +:~ ~i:l E~ ~ - _ _, _~ .. ~~~ `. ~~ • `~_) ~~ --i ~~ , .:~ c:- r,,: C :` (' : 7 r, ; C"'. ~`r~ Attachment A (question 9) The trustee, Bart Holmes, has sole and absolute discretion to disburse the net income and principal of the trust solely for the special needs of the disabled Beneficiary, George Gilmer. The trustee's discretion is subject to the Declaration of the Trust. (see Exhibit B) Distribution from the principal does need approval from the Settlor, the Orphans' Court Division of the Court of Common Pleas or other appropriate court, following due notice to all interested parties including the Department of Public Welfare and the Social Security Administration. All payments for the Beneficiary's special needs shall be reasonably and rationally related to the disabled Beneficiary's individual disabilities. The Trustee must also consider the resources and sources of funds available to Beneficiary through any state or federal public assistance program in exercising this discretion. Any income which is not distributed shall be accumulated and may be (but is not required to be) added to the principal. 1)ECL~~R~~TION ()H' ()BRA '9.~ SPECI~~L NEEDS DIS~~1iILITY TRUST 1G'OR THE BENEFIT OF GEORGE A. GIL;~IER This Declaration of Trust (the "Trust") is established by the Orphan's Court of the Court of Cummun Pleas, Cumberland County, Pennsylvania, hereafter rcfrrred to as "Settlor," and Bart W. Nolmcs, Esquire, as original Trustee, who shall hereafter be referred to ax "Trustee," for the benc:tit of George A. Gilmer, a disabled person, and by Decree dated the day of , 2008, Settlor, upon signing of this Trust Agreemc;nt and without consideration on Settlor's part, transfer and deliver to the Trustee the sum of twenty dollars ($20.00 dollars), receipt of which is acknowledged, and other certain assets which, together with the interest thereon, shall constitute the trust estate. The trust estate shall be held, managed, administered, and distributed by the Trustee as hereinafter provided solely for the benefit of George A. Gilmer, who resides at SSO Brown Lane, Enola, Cumberland County, Pennsylvania 17023, who is an adult, disabled individual as defined in Title XVI of the Social Security Act (the "Act"), 42 U.S.C. Section 1832(cxax3), hereinafter referred to as "Beneficiary." This Trust is established in accordance with a special provision of Title XIX of the Act, specifically 42 U.S.C. Section 1396p(dx4xA), as amended by the Omnibus Budget Reconciliation Act of 1993 (and any federal or state regulations or other rules promulgated pursuant to that provision) which exempts the assets held in the Trust from being included in the determination of Beneficiary's eligibility for, or amount of, medical _ « benefits under a State Plan under the Act, and in accordance with 62 P.S. Section 1414 ~~`.._` Special Needs Trusts, and therefore, the property directed to this Trust shall in no way be deemed to have been or to be availabk..to~B~eueficiary, Bart W. Holmes, Esquire, shall serve hereunder as trustee, for no fee, and hold the sum awarded pursuant to the Orders and any other property acceptable to the trustee which is added to this Trust, and shall manage, invest and reinvest said property, shall collect the income therefrom and shall distribute the net income and principal in accordance with the following provisions: FIRST: A. During disabled Beneficiary's lifetime, all distributions from the Trust must be for the sole benefit of the disabled individual in compliance with 62 P.S. Section 1414. Payments shall be made of such parts or all or none of the net income and principal as the tn~stee shall determine in the trustee's sole and absolute discretion, solely for the special needs of the disabled Beneficiary, subject to the provisions of Item Second herein, except that any distribution from principal shall require obtaining approval from the Scttlor, the Orphans' Court Division of the Court of Common Pleas or other appropriate court, following due notice to all interested parties including the Departm~;nt of Public Welfare and the Social Security Administration. All payments for the Beneficiary's special needs shall be reasonably and rationally related to the disabled Beneficiary's individual disabilities. Any income which is not distributed shall be accumulated and may be (but is not reyuired to be) added to the principal. B. Upon the tint to occur of Be~lcficiary's death or the ~•arlicr termination cif this Trost, tl~e trustee shalt pay to the State of Pennsylvania, Department of Pty V~'ctfare, or a~ly successor agency, and/or any other state which has rovided genblic with medical ~•are under a state medical assistance program, as a beneficiar ~ hcr,`rlc~ary an amount which is equal to the lesser of the amount paid to Beneficiary unclcr such I ' or plans from the time of creation of this Trust until his death or earlier termination pan this Trust (as tinully dctcrrnined by such state or states), or the balance rcmainin of Trust, in accordance with 42 U.S.C. Section 1396 d 4 A . An rtion of th 8 in the ~ )( )( ) Y Po a Trust estate remaining after reimbursement to the Commonwealth as required under this Item shalt be paid to Margaret Swab, of SSO Brown Lane, Enola, Cumberland Coun Pennsylvania 17025, or if Ms. Swab should predecease Beneficiar , to Benefic ~~ at law under the taws of the Commonwealth of Pennsylvania. Upon the Benefici ry• heirs death the Trustee shall notify in writing the 'T'hird party Liability Unit of the p ary's Department of Public Welfare: ennsylvania Department of Public Welfare Third Party Liability Casualty Unit Special Needs Trust Repository P.O. Box 8486 Harrisburg, PA 17105 SECOND: A. The trustee has discretion to determine whether or to what principal or income shall be distributed to or used for the benefit of Benefici extent to the limitation in section First. A. involving limitations on distribution of nn (sub~eet without leave of court), without further leave of Court after the initial establs cipal r~ ~ Trust, and the trustee shall consider the resources and sources of funds av hmen~ ~__ Beneficiary through any state or federal ublic assis ailab a tl` o " discretion. In making this determination, the trustee sh li pro~am in exercising this p rpose of the Trust is not to supplant public assistance benefit, but to su o lemer that the u providing only for Beneficiary's needs, that is, to provide the extrat those benefits by for Beneficiary which will not disqualify him from any local, state or f supplemental care ederal benefits. B. The term "special needs" refers to the maintenance of Benefici 's good health, safety and welfare when, in the discretion of the trustee, such n ~ provided by any public assistance agency or other public or private source. Sins are not may include but are not limited to extra and supplemental medical and dental ~ h needs physical and mental health care, nursing and custodial care, theca ies nutr' ' are, socialization, transportation, maintenance, education, equipment, theca utic n, recreation and the like over and above the amount of benefits he otherwee re eavcl and any local, state or federal government or from any other prig ate ~r ublic sou i es from p rce. C. The payments authorized in paragraphs A. and B. of this Item shall specifically include the following: (l) Payments fc~r tl~~ improvement and/or maintrnuiice of a residence suitable for B~~iet'iciary's special i~teds, such payments to include atl reasonable erpcnses of insuring, improving, modifying and/or maintaining said residence ur of otherwise improving Beneficiary's physical living enviro~lment. (2) Payments for the purchase, modification a~ld/or maintenance of a specially equipped van or other vehicle for Beneficiary, with title to such vehicle to be held by the Tn~st, such payments to include the reasonable costs of purchasing, financing, insuring, maintaining and operating .said vehicle for Beneficiary's benefit. THIRD: The trustee and Settlor are expressly authorized to receive additional property or monies from Beneficiary or any other person and to administer and distribute it as part of this Trust. FOURTH: This is a discretionary, non-support trust. No principal or income of the Trust shall be anticipated, assigned or encumbered. The Trust shall not be liable for any debt, contract or engagement of any beneficiary nor subject to any Legal process. No part of this Trust estate shall be construed as being subject to the claims of the beneficiary's voluntary or involuntary creditors. The trustee shall deny any request by any public or private entity to disburse Trust funds to support or other care that such entity has the obligation to provide to the Trust beneficiary. Any discretion under this document, if exercised or not exercised, shall be conclusive upon all persons concerned so long as such discretion is exercised in good faith. FIFTH: If Beneficiary's testamentary estate, exclusive of his residence and r r......_... ... ~ tangi le personal property, shall be insnffi~~is debts, funeral expenses, and expenses of the administration of his estate, uT- t`only after the satisfaction of the requirements of FIRST (B)(reimbursement of the State of Pennsylvania, Department of Public Welfare, or any successor agency), the trustee may in the sole discretion of the trustee pay any, part or all of such debts and expenses out of the principal of this Trust but none of said debts or expenses shall be enforceable against the trustee by reason of this provision. SIXTH: All estate, inheritance and other death taxes and any interest and penalties thereon imposed by reason of Beneficiary's death on property forming the principal of this trust at Beneficiary's death shall be paid out of the principal of the trust without apportionment or reimbursement. In addition the trustee shall have the power but not the duty to pay from the principal of such trust, either directly or to the personal representative of Beneficiary's estate, as much of such taxes, and interest and penalties thereon, cm the balance of his gross estate for tax purposes as the trustee may determine in order to facilitate the s~;ttlement of B~:neticiary's estate. But no part of SIXTH shall be permitted until after the satisfaction of the requircmeiits of FIRST (B)(reimbursement of the State of Pennsylvania, Department of Public Welfare, or any successor agency). No beneficiary shall be required to refund any part of such taxes, interest or penalties. i SEVENTH: ;III ine•uitle dcciv~d from assets rcr~ivc~d as pri~lcip;il of chi, Trust Turin Beneficiary's lifeti~l~e which has accrued when su~•h assets become subject to this Trti but which is received by the trustee thereafter, whether the same is legally pri~tci al ur income, shall be applied in accordance with the provisions herein scat forth for the distribution ut' income. EIGHTH: The trustee shall hove the following powers during the administration and until the completion of this Trust and any trusts hereunder in addition to any powers given the trustee by law which the trustee may exercise in the sole discretion of the trustee and without court approval: A. To retain and invest in all forms of real and personal property, including stock, common trust funds and mutual funds of any kind, and includin real property to be used as s residence suitable for Beneficiary's special needs g notwithstanding the fact that such property is non-income producing, without restriction to investments authorized bylaw. B. To sell at public or private sale for cash or credit, to exchange, or to lease for any period of time, any real or personal property, to give options for sales exchanges or leases and to allocate premiums from the sale of options to income or principal. C. To take any and all action which the fiduciary deems necessary to prevent, abate, "clean up" or otherwise respond to any actual or potential violation of an federal, state or local law, rule or ordinance affectin an y ~~ ~; - `~~~atbd-to. the generation, use, treatment, storage, disposayl,preie~asey d1sl~ in this Trust contamination by, any materials or substances that barge of, or state or local law or that pose a hazard to the enviror meat orb related by federal, the expense thereof to the principal or to income or aril to a omen health, and to charge p y ach. D. To compromise or settle claims without obtaining Beneficiary's consent. L. To make distribution in kind and to cause any share to be composed of cash, property or undivided fractional shares in property different in kind from any other share, giving consideration to such extent as the trustee determines to federal income tax basis of such ro rt the P Pe Y• F. Subject to the limitations in section First A., in the sole discretion of the truster to apply payment of income or principal to which Beneticiar is entitled hereunder directly for his benefit or to pay it to his natural guardian or le all a oint guardian or such othc;r person as the trustee selects to disburse it fur Beneficiar [?P ed benefit. The receipt of the person so selected shall be a complete disrhar a for the trus therefore. g tee G. To repair and maintain any real or personal prupe~~ty and to ~~l~arge the expense to income or pri~lcipal. H. To arrange For the services of airy public or private organization established to assist disabled persons, to monitor Beneficiary's li~•ing co~iditions, evaluate his needs and identify available social, financial, developmental or other programs, and to charge the expense thereof.either to principal or to income or partly to each, without liability for any act or omission of any such individual or organization or For any act or omission made in reliance on the advice of such individual or organization provided such person or organization was retained with reasonable care and prudence. 1. To retain legal or professional assistance in establishing and administering this Trust and accomplishing its purpose, and to charge the expense thereof either to principal or to income or partly to each, and without liability for any act or omission of any such individual for any act or omission made in reliance on the advice of such individual provided such person or organization was retained with reasonable care and prudence. J. To register investments in nominee name or to hold investments in bearer form. NINTH: All reasonable expenses in establishing, maintaining, administering, and defending this Trust, including but not limited to reasonable attorneys' fees, accountin fees, and costs shall be proper charges to the Trust. g TENTH: The silos of this Trust is Pennsylvania and all questions pertaining to the validity; ,interpretation and administration of this Trust shall be determined in accordance with the laws of Pennsylvania and the applicable laws of the United States. ELEVENTH: A. This Trust shall be subject to the continuing jurisdiction of the Orphans' Court Division of the Court of Common Pleas of Cumberland County, Pennsylvania. B. The Court having jurisdiction of this Trust and the trustee with the approval of said Court may amend this Trust so that it conforms with 42 U.S.C. Section 1396p(d)(4)(A), 62 P.S. Section 1414 Special Needs Trusts, and any related statutes or regulations, consistent with the provisions and purposes of OKRA '93 and any amendments thc;reto. C. Anything hereicibefore to the contrary notwithstanding, the tru~tce with the approval of said Court, shall have the discretion to terminate this Trust at an time if the trustee in its sole and absolute discretion determines that the continuance of the Tn~st is impractical, uneconomical or for other reasons unwise. Upon such earl termination the trustee shall make any distribution required under Item FIRST, paragra h P 5 B• :end :uly cem:ltlllllg principal `Fall he cii~tributed dirc~•tly to Bencfiriar , ur if Beneficiary is legally inrupacitated, to the guardian of his estate or other Ic al represciitative in accordance with the Order of said Court. g TWELFTH: This Trust shall be irrevocable. Notwithsta~lding any summon law statutury provisions to the contrary, neither Bcne~ciary's nor a~iy legal represcntave acting for Beneficiary shall have the right to alter, amend or revoke an rovision ' Trust, or to withdraw any funds from this Trust. y p of this THIRTEENTH: A. The guardian of BeneEciary's estate shalt have the power to remove the trustee, provided that the said guardian appoints another trustee, bank or t company to serve in its place. Any successor trustee may likewise be removed and rust replaced. There shall at a!1 times be a trustee serving hereunder. B. The original trustee, Bart W. Holmes, Esquire, declines to be compensated for his services, but this shall in no way prevent a future trustee from receiving compensation for the performance of its functions as trustee hereunder accordance with its schedule of fees in effect from time to time Burin the riod in which its services are performed. g ~ n C. All trustees shall be required to enter bond or other securit in this jurisdiction, and the cost of said bond shall be paid out of the income or rinc' y trust. p ipal of the ._~-_. IN WITNESS WHEREOF, the Settlor and Trustee hav Y of Trust to be executed, a paused this Declaration Attest: Orphans' Court Judge, Settlor By: Attest: Bart W. Holmes, Trustee ~~. ~r ~a~~~ By. 6 Exhibit C (question 9) CONSENT OF BART W. HOLMES THE TRUSTEE FOR A SPECIAL NEEDS TRUST ESTABLISHED FOR THE BENEFIT OF GEORGE A. GILMER I, Bart W. Holmes, request and consent that the Orphans Court authorize the disbursement of up to $7,000.00 a year from the principal of the Trust, for the maintenance of the Beneficiary's good health, safety and welfare. I also authorize the disbursement of $600.00 plus expenses from the interest income of the Trust, for the legal fee and expense of preparing this Account and Petition. Social Security Administration, Commonwealth of Pennsylvania Department of Public Welfare and Mr. George A. Gilmer are notified of this etition and accounting. Bart W. Holmes, Petitioner and Trustee `~ Notary Public: Dc~Ob-u- ~, a oU9 --__.__ NOTARIAL SEAL Jackie L. Buffington, Notary Public _ Susquehanna Township, Dauphin County My commission expires September 30, 2010 CERTIFICATE OF SERVICE I, Lei Huang, Esquire, attorney for Petitioner, Bart W. Holmes, hereby certify in accordance with Rule 6.3-1 of the Cumberland County Orphans Court Rules and Sect. 3503 of PEF Code that notice of a Petition for distribution of the trust assets has been mailed by US Mail to the underlying parties at their addresses. They are the only parties in interest. Commonwealth of Pennsylvania Governor's Office of General Counsel 3`d Fl. West, Health and Welfare Bldg. 7th & Forster Streets Harrisburg, PA 17120 Social Security Regional Office III PO BOX 8788 Philadelphia PA 19101 George A. Gilmer 550 Brown Lane Enola, PA 17025 Bart W. Holmes 17 Logans Run Enola, PA 17025 310 Saddle g Court Harrisburg P 1 110 Dated: Oct 5, 2009