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HomeMy WebLinkAbout07-19-11,, John J. Connelly, Jr., Esquire Attorney I.D. No. 15615 Christine Taylor Brann, Esquire Attorney I.D. No. 82204 James Smith Dietterick & Connelly, LLP P.O. Box 650 Hershey, PA 17033 r,., .•~. ~ , r~r-~ ~`' _, - _ r =,; - - ~,: ~. ~ .~ ~; .___. ~ ~ .~ ~? .. --r z <_ ~.: IN RE: : IN THE COURT OF COMMON PLEAS ESTATE OF :CUMBERLAND COUNTY, PENNSYLVANIA BRANDON V. LIDDICK, Minor ACCOUNT OF BETSY J. SUGGS, : NO. ,~ ~ - ~ ~ - C~ .1 Guardian ORPHANS' COURT DIVISION PETITION FOR THE APPOINTMENT OF A GUARDIAN OF THE PERSON AND ESTATE OF A MINOR UNDER THE AGE OF 14 YEARS IN ACCORDANCE WITH 20 Pa. C.S.A. ~ 5111(a) TO THE HONORABLE JUDGES OF SAID COURT: AND NOW, comes Betsy J. Suggs, by and through her attorneys, John J. Connelly, Jr., Esquire, Christine Taylor Brann, Esquire and the law firm of James, Smith, Dietterick & Connelly, LLP, and files the within Petition for the Appointment of a Guardian and in support thereof, respectfully represents as follows: 1. Petitioner, Betsy J. Suggs, is the maternal aunt of Brandon V. Liddick, a minor, age 7, born on November 6, 2003. . 2. Brandon V. Liddick currently resides with Petitioner at 275 Walton Street, Lemoyne, Cumberland County, Pennsylvania 17043. The minor also occasionally resides with Connie L. Royer and Robert P. Royer, maternal grandparents, who reside at 922 Willcliff Drive, Mechanicsburg, Pennsylvania 17050. 3. Brandon V. Liddick is the son of Wendy K. Royer and Robert A. Liddick, both of whom died on June 15, 2011. Copies of the Death Certificates are attached hereto as Exhibit «A» 4. No other guardian has been appointed for the person of the minor. 5. The proposed guardian is Petitioner, Betsy J. Suggs, maternal aunt of the minor, who is 38 years of age, and resides at 275 Walton Street, Lemoyne, Cumberland County, Pennsylvania 17043. Her consent is attached hereto as Exhibit "B". 6. The proposed guardian has no interest adverse to the minor. 7. The religious persuasion of Brandon V. Liddick is Methodist. The religious persuasion of the proposed guardian is Methodist. 8. The minor is anticipated to receive monies as a result of the death of the minor's parents. A comprehensive listing of benefits is set forth in Exhibit "C". 9. The minor is a child of a veteran and as such notice has been given to the United States Veterans' Administration. 10. Consistent with the Affidavit of Service, a copy of the instant Petition has been served upon the regional office of the Department of Veterans' Affairs. A copy of the transmittal correspondence to the regional office of the Department of Veterans' Affairs is attached hereto as Exhibit "D". 11. Notice of the instant Petition has been provided to Connie L. Royer and Robert P. Royer, maternal grandparents of the minor, who consent in the relief requested. A copy of their consent is attached hereto as Exhibit "E". 2 12. Notice of the instant Petition has been provided to Kathy J. Irvin, paternal aunt of the minor, who also consents to the relief requested. A copy of her Consent is attached hereto as Exhibit "F". WHEREFORE, Petitioner, Betsy J. Suggs, respectfully requests that this Court appoint Betsy J. Suggs as guardian of the person and the estate of Brandon V. Liddick, a minor. Respectfully submitted, JAMES, SMITH, DIETTERICK & CONNELLY, LLP Dated: ~ J ~ ~ ~ B ~ ~`, ~;c Y~ John J. Connelly, Jr. ,,.- Attorney LD. #1561 Christine Taylor Brann Attorney I.D. #82204 P.O. Box 650 Hershey, PA 17033-0650 (717) 533-3280 Attorneys for Petitioner, Betsy J. Suggs 3 VERIFICATION The undersigned hereby verifies that the facts set forth in the foregoing Petition for the Appointment of a Guardian of the Person and Estate of a Minor under the age of 14 years in Accordance with 20 Pa. C.S.A. § S ll l (a), which are within the personal knowledge of the Petitioner true and as to facts based on the information of others, the Petitioner, after diligent inquiry, believes them to be true; any false statements herein are made subject to the penalties of 18 Pa.C.S. § 4904 relating to unsworn falsification to authorities. /~ Date: / ~ ~-~ ~~ etsy J. S ggs, etitione IUAR6V9NG: It is iBlegal t® duplic~t~ this ~®Py by ph®t®stat ®r Ph®t®gr~ph. gee; for this certificate, $6.00 _ P 17668488 _ This is to certify that the information here given correctly copied from an original Certificate of Dea duly filed with me as Local Registrar. The origin certificate will be forwarded to the State Vit Records Office for permanent filing. . Local Registrar Date Issued COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS .CORONER'S CERTIFICATE OF DEATH (See Instructions and examples on reverse) ,,..~ ... _ ......___ W 3 s r i 1: Name a Oecedem (RRI, midrib, lea). aulfoc) 2. Sex 3. Soda) Secwny Number 4. Date a Death (Month. day; yearf Robert A Liddick Male 182- 58- 0544 June 15, 2011 S. Ape (~ SIrNWey) Under 1 year tAtder 1 day 6. Dste d Bimr (Month. day. year) 7, l3kdlplece (Ciy and stele or foreign ea. Place d Deatn (Lxredt only one) esoaaw Dap norss eYaaes ~~ Other. ~~ . 41 Yr~ October 9, 1969 "Harrisburg, Pa ^ ^~/~~ ~~ ^~~ ^ she.-speaty: 6b, Courtly a Death fit: City. Twp. Death tld. FaeBty Name N not irMnukan, P'A stied and nunber) 9. Was Decedent or HLspaNc Odght7 ~ No ^ Vas 10. Face: Arrrukren Ndlan, ehdc WNh, ek. ~: Cumberland East Pennsboro West Fairview Point Park M yes. ray crd,arl, Hexicerr,PrrerroWcan.ete.l ( White 11. Decedars Usud d work d one mass d He. Do rat able 12. Was Deoadwa ever in Ow 13. Deeederd's Edueatbn (Spedty Doty tdgMat grade camp hted) 14. Medial Statue: Married Never Herded 15 Survivk S I il i id ~ US. Amted Farces? ~n~Y p Secondary (0-12) Cdlepa (1-4 or 5+) , , Widowed Diaorced (SpacNy) . rg pouse Q w e, g ve ma en name) Clerk State Government pJ~a ^No 12 Never Married • 1G Demdad's Manap Address (Street, dty /ban. elate, zip nodal DecederrYs DW Decaderd A d R ld PA L; i 940 $. 30th $t. aW ee eras na. seta ae n e t 7c. ^ Yes, Decedem twee kr Tom, Camp Hlll PA 17011 Tz 17b.County Cumberland 1Yd•~(Io,oeadentlhredwNldrt Camp Hill , ~l~a Cpy / Borg t& Falhr'sNeme (Fire), mode, Iasi wll6c) ~ 19. N4o0rers Name (F4st mWde, maiden annente) - Arthur Liddick Barbara Miller . 20a. bdarrtrent's Dlame (Type /Print) 20b. bdornrard'e MaNkrg Address (Street, arY / bartt, aleie, ZP coda) ' Kathy Irvin 217 Belle Vista Marysville, PA 17053 21e. HeOrod d Dhpoaidan • 6p j~~ya,r ^ pa„m;p, 21b. Date a DiaQoerNOn (MOa4 day, year) 21c. Place d tHepoaiuon (Name a amalary, aematay «dMr place) 21d. Location (Gry / bMm. ems, zip toes) ~ ~~ ~ 'f0m stab • ^ 'corer • spednc Mrn °"""'O" ~ 0~0n Mrtt101~d w twacal ExrNner / c«onen ~I ra ^ Na June 19, 2011 .Hoffman Cremato ry Carlisle, PA 17013 Sgrotue a Purace) Service l kensee « z2b. Lberme Number 22c. Name ant Address or FadNty 1` F0.13845•L Sullivan.Funeral Home 51 N. Enola Dr, Enola, PA 17025 Compleb Items'23ec aNy when ceANykp 23a. To the best d my bawledpe, deadr oocurted at tlw kme, date end phce Baled (Sigrubae end nNel 23b. l.icemne Number 23c pate Si ned (Madh da ear) plryaictat h not avaNebh at Nrne d deem to . g , y, y artlly orrse a death Ildne 24.26 semi be eonrphled by perms 24. Tare a Death 25. Date Prararrced Dead (MaNh, day, Y~1 26. Was Case Raerred b Medical Examrrer / Corarrer br a Reason ONrer than Cremetlon or Dorretton7 "('°a°'"'"`~sd~"` A rx. 10:00 A. H~ June 15, 2011 Y~ ^~ CAUSE OF DEATH (See Mstrucdona and examples) , Appradmale irderval: Part N: Eaer 28.OW Tobacco Use Cordrrbrde b Dealh9 Nam 27. Pert I: Enter the {~jp„pJ,t1ylt0~ - deeases, kquries, « - tFlet d:ecny sauced Ore dedh DO NOT eder termnal evens suds as carduc arrest, m Oroel b Deanr but rat N Nre 9 9 recces tl~n n Pert L ^ Yes ^ Pratady k b t ri h Gb ihd a resp ry arres , «vard cu r r on wNhaA strowkrp the aliobgy. List any one cause an sadt Wre. r r ^ No ^ lhdeawn r IINAE0IATE CAl1SE fFard deease w wrrdganraeAlingin ) _~ a. Gunshot to Head ; 29.nFameh: Due b (ar as a corrsequ&rce a): i ^ Na prepmwm wNhki past year $aprre ^ Pfeprmrtl a1 Ome a deelh e~ d ~Y~ b. r Ift I~dsq b Cerse Neled an Nrre a r ErNx Ula u"DER~rwtc CAUSE Due b (w ea a aoraegrbnae or): r - ^ Nd prepnamd, Dui pregnenl wihin 42 days ' ' yiseffie « , rtM NrNhled Ina ererss resrtNry death) LAST. c' r of death Due b (or as a mrgegtrence a): ^ pre gra rd, but pregrran143 days l0 1 year ~ ~ • d. ; ^ lMlaawn n pragnad within me pact year 30a. Was an Autopsy 30b. Were Autpsy FNdkrgs 31. Manner d Deatlr 32a. pale a Mljury (Month, day. Year) 32b. Describe lbw ~ry (learned 32c. Place d byury. Nonce. Farm. Street, Fagory, Perlamad7 AvaNade Prior b Completion I n t eiht io na l Self - dcaueeetpealh9 ^N80~' ^'+a^ri°da June 15 2011. Inflicted Gunshot- Lon Gun onseB'~~(s~ry) Woods ^ Yes No ^ Yes [] No ^ Acddent ^ Perrdrrg ~ ~• 1Lrw d Irgtrry 32e. b1uY e1 Work? 321. N Trernparteiicrt Injury (SpecylyJ 32p. Location a hWY (Street, sty / form, alele) rX ~ A M Drirer~ rabr ^ Passertper ^Padestrien ~srrdde ^ could Nd be Determined ^ Yes ~ IVo ^ ~ r 10 • 0 A Front Street West Fairview PA 33a. Certifier (rhedc oNy me) 33b. sigrrea,re and TNIe • ~Mrq PDYs~ ( certdrkrg awse d death when aratlwr phyeidan has prorautcad deaur and corryleled ihm 23) To the Bart a m bawhd e deetlt oaeumd d t th y g ue . o e cause(s) and manner u peted_ _ _ _ - _ _ _ _ _ _ - --------------------- ~ COrOner • PtormounebrgandoartNyingphyskian(Ptryaiden~oth To Nre best a mY loawriedge, death acurrrad at the t~e~dste ~tlealh and ceNlykq b wuee d deeN) 33c. Licence Number gn {MOrdh, day, year) - - 33d. Dam S' ed Place, and due to tlms aarwe(q ant mamer as aleted_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ^ ~as'E~"/cOr°~r June 16 2011 On the bash a nwkrtlon and 1 ar hvestlgadon, in my opinbn, demlt occurred et the thrte, dale, and plea. and dw to nra ause(s) end msnrrer as ehhd_ 34. Name end Address d Parson Who ConmPleted Cause d Death (Item 27) Type /Price Todd C. Eckenrode, Coroner ;Fk,ghlreYa Iuraand r~re~Der ~ I ~a'~I~'~ ~ e ~~„~) ~~ 6375 Basehore Rd., Suite ~~1 l ~ Dispositbn Pemdt No. ~ ~ ~ ~ ~ gs f~,~€i~ItV~: 0t is if8~€~a! to el~~iic~~e t~'li¢s ~~i~~ ~~s ~hc~t~s~~lt gar pi~~~c~~l•~~E~s. ~ee for this certificate, $fi.00 _ P 1755607 _ Certification Number ~1 REV 11/2006 PRINT IN 1ANENT ~K INK /,~~~~~~~tF! OF p~=~ ?:, - - ~ - - •9 C 1 = .m ~j v, ,,~ -,r -;' ,~ ~, - '~. .,, ~. ~~9\ Y- : ~~,~titt,, This is to certify tll~lt the infornu(lion here ~~ivi:n i earl-ectly cttpied f~r~:~l~~ an ol-i~inal Cel-tificate of Der~tl dilly filed with me as Local Registrar. The origir)~i certificate will be forwarded to the State Vit~i )ecorcls Office for pern)anent filing. ~~ ~ JUN 2 1 2011 G Local Registrar- Date Issued COMMONWEALTH OF PENNSYLVANIA • DEPARTMENT OF HEALTH • VITAL RECORDS CORONER'S CERTIFICATE OF DEATH 1. Name of Decadent (Flrat, middle, lest, aulRx) 5. Age (Lest Birthday) Ma>s16 Deye Maas MtaMa 36 YB. De 6b. County of Death fk. CRy, Bo 'Twp of Death Cumberland Ham den 1i. Decedem's Uauel tbn Kind of work done moat of die. Do rat ate' Office ~"orker ax~`~a`~rix ~" 16, Decederd'e Melling Address (Street, city I town, state, rip code) 940 S. 30th Street Camp Hill, PA 17011 i6. Fathers Name (Fhat, middle, last, sulfbc) Robert P. Royer 20a Infonnent'e Name R ! Pdnt) lave msrtvcnons ana examp~es on reverse) STATE FILE NUMBER 2. Sex 3. social Security Number 4. Date of Death (Month, day, year) Female 536 - 72 ,^ 7310 3une 15, 2011 oMh, day, year) 7. Birthplace (C end stele or loralgn casd) Ba Place of Daelh (Check ony one) Hoaptlak Own r 2 0 19 7 4 Kodiak , AK ^ lrtpeHent ^ ER / outlmtlem ^ Dos ^ Nursing Hame Residence ^oter - Speclty. Bd. FedlNy Name (H not InetlRdkm, gNe street end nunber) . 9. Wee Decedent of Hlepenk; OdginT ®No ^ Yes 10. Race: Amertcen,lndien, Bkck, Whtle, etc, (tl ye8' ap~Y fin' ISPe~r) 3924 Brookrid a Drive Mexlcan,PuertoRkren,etc.) White 12. Wea Decedent ever In Itra 13. Decederd's Educefbn (Speclly ortty highest grade completed) 14. Marital Slahut: Mertled, Never Martled, 15. SuMving Spouse (II wtle, give maiden name) U.S. Armed FaroeaT Elementary / SecorWary (0.12) Coll (1-4 or 5t) Wklowed, ~~ rsP~,'1 ^Yae ®rw ~ Never Married Decedent's Did Decedent Actual Realderae 17a State PA o~wrelnhl T 17c. ^ Yea, Deca~M Lived in Twp. ,m,~,,,,ty Cumberland P 17d.~No,DecederdLivedwllhin Camp Hill Actual UmRa of City / Bern 19. Mother's Name (Flret, mld~e, rtteMen wrtterrie) i Robert P. Royer 20b. Irdorrrtartra McNrtg Address (stree4 qty /town, state, zip code) 922 Willcliff Driv • 21a Method of Dispasltlon ^ Burial ^ Removal tram Stale 1$Gematbn ^ Donation 21b. Date of DlepoaNbn (Mardh, day, year) 21c. Piece of Olepoeltbrt (Name of rx+rnetery, crematory cr other placel 21d. Location (CNy /town, state, code ) ^ Other • Spedty: Was Cremation or Donation Authortrad ran by Medical Examiner /Coroner? t ~3 Ves ^ No June 21 2 O 1 1 ~ H o 1 1 i n g e r Crematory Mt . Ho11y Springs, PA 17065 22e. Signature d Funeral 5enk:e Ucanaee (or person actlng as such) 22h. Ucanae Number 22c. Name end Address of Facility - FD 012774-L Richardson )l~neral Home Inc. 29 South Enola Drive Enola, PA 17025 Complete Items 23e•c ony when cerftlylrg 2 the beat of my knowk3dge, death occurred at the Itme date artd late staled (Sk aW re d titl phyek;lart b not available at tlme of deaM to , p . pt an e ) 23b. Lk:ense Number 23c. Date Signed (Month, day, year) certify cause of death. Rama 24.26 moat be com leted b o 24. Time of Death 25 Date Proraunced De M d dh d p y pars n "diopronoin~~e'~ . ( a a , ay, year) 26. Was Case Referred to Medical Examiner /Corone r for a Reason Other than Cremation or DonakonT A rx. 1:00 A. M• June 15, 2011 Yea ^No- CAUSE OF DEATH (See Inatruetlons and examples) r Approxhneta frnervel: Item 27. Pert I: Enter the dteln of evems - diseases, ktjudes, or complbetbns -that dkectly caused the death. DO NOT enter terrrHnel evarda such es cardiac ertesl, r Onset to D th Part II: Eller other rdttoMlcant conditions contrtb „Inc to deem 28. Dkl Tobacco Uae Qonmbute to DeethT ea resptreary arrest, or ventrialar flbrllletlon wRhout showing the etiology. Llat ony one cause on escR line, r but not resu ht the undo N"9 rM n9 cause given b Pert I. ^ Yes ^ Prebebty IMMEDIATE CAUSE Final disease cr r condition resultlrtg In ~eth) ~„ a Multiple Gunshots ' ^ No ^ Unknown t Due to (ar 9a a consequence of): r r 29. II Female: ^ Not pregnant wtlhin pest year Sequentialy Hat rxmdllions, R any, kadng to the cause Ilsled on tine a. b. i Due to (or s a E f ^ Pregnem et lime of death a consequence o ,~: r nter the UNDERLYING CAUSE (~Ly ~ ~ry ryree~ a~s g1B o i ^ Not pregnaN, put pregnant w'Rhin 42 days e 1 ' Due to (or as a consequence oQ: r of death ~ d ^ Not pregnant, but pregnant 43 days to 1 year . r before death 3()e. Was an Autopsy P l dT 30b. Were Autopsy FlrcYngs 31. Manner of Death 32a. Dale of Injury (Month, day, year) 32b. Describe How Injury Occurted ^ Ur~ravm II pragnam vdthm the pest year er ame AvaHeble Prar to Completlon olCauseolDeathT ^NaWrel ~Manldda !//~~~C June 15, 2011 Shot b known assailant 32c. Place of lrqurY. Home, Ferm, Street Factory, OffEe Buiklin , etc. S 1 g /mar. ,i~Yes ^ No ~y ~Q Ves ^ IJo T'` ^ ~~n' ^ P~"9 Imastigatlon 3Zd. Tone of Injury P X 32e, Injury at WorkT 32(. If Transportation ktJury /Spsdly) Home 32g. Lncatlon al lnlury (Street dry /town, state) ^ Sulfide ^ Could Not be Delemdned 1 M ^ Yes ~ No ~Ddver /Operator ^ Passenger ^Padestrian 33a. Cartlfler (check ony one) ~ o o A ^ Brookrid e Dr., Mechanicsbur PA • Certtiying phyelchn (Physician certHykg cause of death when erafher ptrysidan has prorauncad death end cortrpleted Item 23) 33h. signature and TPo To the beat of my knoarkdge, death occunad due ro the cause(s) and manner as atated_ _ _ _ _ _ _ _ _ _ _ _ _ ^ _ _ _ _ _ _ _ _ _ _ _ _ ~ _ _ _ - • Pronouncing and caMtying physkdart (PhyslGan both pronouraing death end certMyktg to cause of death) _ - _ _ o r one r To the beat of my Ioawlsdge, death occurred et the tlme, date, end pleee, end due to the cause(s) and manner ee eteted_ _ ^ 33c. Lkenae Number 33d. Dots Signed {Momh, day, year) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ • Medical Examiner I Coroner . On 1M bole m exeminedon and / or imnsadgsUon, In my opinion, death occurted at the tlme, data, and place, and due to the cause(s) and manner ac atated_ ~( June 16 2 011 34 Name and Addres of P W S.. Registrar'sSlgnature ~stlk;tNumber ~ ~ ~ Date ~( '~y'yBBfI . s eraan ho Completed Cause Todd C. Eckenrode, 6375 B h of Death (Item 27) Type / Prtnl Coroner - ' - f I I .~l ~ I r I ase ore Rd. , Suite i ~1 .~ Disposltlon PertnR No. U,6 ~ V C.~l~ Consent of Betsy J. Suggs 275 Walton Street Lemoyne, Pennsylvania 17043 I, Betsy J. Suggs, maternal aunt of Brandon V. Liddick, born November 6, 2003, consent to the appointment of guardian of the person and the estate of Brandon V. Liddick. Pursuant to Cumberland County Orphans' Court Rule Nos. 12.5-2 and 12.5-3, the following information is provided: 1. My current occupation is Physical Therapist Assistant. 2. I speak, read and write the English language. 3. I am a citizen of the United States of America. 4. I am not a fiduciary or an officer or employee of a corporate fiduciary of an estate in which the minor has an interest. 5. I have no interest adverse to the minor. 6. It is not my intention to apply for an allowance for the support or education of the minor during minority. 7. The estimated net value of the entire real and personal estate of the minor does not exceed statutory limitations. 8. The name of an insured financial institution in Cumberland County as the suggested depository is Members First Federal Credit Union. ,~'~J~ ~ Date: Zn ~( etsy J. ug s 275 Walton Street Lemoyne, PA 17043 COMMONWEALTH OF PENNSYLVANIA `~ ss. COUNTY OF , ~ ;..~t.-'~,~ ~~~ ~~ On this, the ~ ~ day of ~ , 2011, before me, a notary public, the undersigned officer, personally appeared Betsy J. Suggs, known to me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument, and acknowledged that she executed the same for the purpose therein contained. IN WITNESS WHEREOF, I have hereunto set my hand and seal. My Commission Expires: r f ~~. ~i • l1 to ~.. .j Notary Public ~OMMONVtfEALT4i OF PENNSYLVAfVIr~ Notarial Seal Maria B. LaRue, Notary Punic perry Twp., Dauphin County Commission Expires Nov. 8, 2013 Memi~r, pannayivanla Association of Notaries DEPARTMENT OF THE AIR FORCE 193D SPECIAL OPERATIONS WING (AFSOC) 81 CONSTELLATION COURT MIDDLETOWN PENNSYLVANIA 17 Jun 2011 MEMORANDUM FOR Beneficiaies - MSgt Rodert A. Liddick SUBJECT: Explaination of Benefits 1. This is to provide a comprehensive listing of benefits for Robert A. Liddick: a. Servicemembers' Group Life Insurance, $400,000, Beneficiary: Brandon V. Liddick b. Pennsylvania's National Guard Assiociation, $1,000, Beneficiary: Brandon V. Liddick c. Survior's Benefit Plan Beneficiary: Brandon V. Liddick d. GI~BiII School Benefits Transfer to Child 2. To complete claims filing for all of the above items a copy og the Guardian appointment form and 2 Copies of the Death Certificate will be required. 3. Once the required forms have been completed, we will meet to obtain required signatures and provide additional program guidance for each item. 4. For questions or concerns please contact any of the following Lt Col Kris Kollar, 193 Communication Squadron Commander Work: 717-861-8689 Ce11:717-306-8576 -~ ~ SMSgt Chris Hinton, Family Liasion Officer Work:717-948-2406 CeI1:717-586-4801 MSgt Suzanna Apeman, Casualty Assistance Representative Work:717-948-2288 Ce11:717-856-923 The Voice of the Quiet Professionals of AFSOC Never Seen -Always Heard ~, '.r ~ r~ AMERICAN GENERAL LIFE Insurance Company 2727-A Allen Parkway, Houston, Texas 77019 1-800-487-5433 American General Life Insurance Company, a stock company, referred to in this policy as we/us/our, will pay the benefits of this policy subject to its provisions. This page and the pages that follow are part of this policy. Signed at our home office at 2727-A Allen Parkway, Houston, Texas 77019. Secretary . ~~- -~--~- President READ YOUR POLICY This policy is a legal contract between the owner and American General Life Insurance Company. Read your policy carefully. RIGHT TO RETURN POLICY The owner may return this policy to us at the above. address or to the agent from whom it was purchased within 30 days after receipt. This policy will then be cancelled as of its date of issue and any premium paid will be refunded. Renewable Level Benefit Term Life Policy Premiums Payable During Term Insurance Payable in Event of Death Prior to Expiry Date New Policy Option Adjustable Premium No Dividends Re-Entry Option LTG 2000AG YME0700253 Page 1 ' ~ ~ ~ ~ t ' r ~ r ' , r 'POLICY SPECIFICATIONS Insured ~ Wendy K Royer Policy Number YME0700253 Face Amount $250,000 Date of Issue January 8, 2007 Sex FEMALE - Age at Issue 32 Underwriting Preferred Class Non-Tobacco SCHEDULE OF BENEFITS AND PREMIUMS Years Benefits Benefit Amounts Annual Premium Payable Life Insurance $250,000 $260.00 30 Years* Total Initial Annual Premium $260.00 Premiums payable other than annually are equal to a percentage of the annual premium. These percentages are shown on page 4. Premiums for this policy are initially payable at Monthly intervals. The first Monthly premium is $22.75. *Annual renewal premiums are shown in the table of premiums on page 4. On the thirtieth policy anniversary and any later policy anniversary we have a right to change the premium. See the Right To Change Premium provision. Expiry dates. The initial expiry date is January 8, 2037. Subsequent expiry dates will occur at the end of each one year renewable term period. The final expiry date is January 8, 2070. New Policy Option. This policy may be exchanged for a new policy as specified in the New Policy Option provision. This option is available until the thirtieth policy anniversary, provided the insured is age 75 or less on the date of exchange. - Re-Entry Option. This policy may be exchanged for a new policy as specified in The Re-Entry Option provision. This option is available only on the thirtieth policy anniversary, provided the insured is age 50 or less on the date of exchange. LTG 2000-3.430 YME0700253 Page 3 `Y1V-I~9pp37~~ Term Insurance Application Part A Pennsylvania Version American General Life Insurance Company, Mauston, TX D The United States Life Insurance Company hfember companies of American lnternationa! Group, Inc. in the City 4f New York, New York. NY The insurance company checked above is so[eiy responsible #orthe obligation and payment of benefits under any policy that it may issue. No other company is responsible for such obligations or payments. 1. Proposed Insured Name ~e-'n~~-i k ~OV~~f Social Security # .~J3~`"~-"7~~ ~ Sex ^ M ~ Birthplace (state, cauntryJ_ AIRS Ct . SSA _ Date of Birth l~,-2©- 1~ ~'-~ Age Tobacco Ilse Have you ever used any form of tobacco or nicotine products? ^ yes ~i'o If yes, date of last use If yes, type and quantityaf tobacco or nicotine products used p Driver's License e. ~ ~J' ~~ ~ ~~ License State T ~c 7. A. B. C. D. Employer. 1~X Duties Persona Income $ U.S. Citizen ~! es Ono If no, Date of Ent - Type of Visa Y ~,.~-~-, ry ` Address ~~~ ~yt ~~' ' ~~~ City, State ~m ~`i ~~ ~ ~A ZlP ~ ~4 ~ t l Home Phone (~j~) 73v " ~ ~ 1~ Work Phone ~ ~~) X15 ~ csly ~ E-mail Address ~.L f ~~t 2~'~'~~-Q?C~0.-ri i 7~ .~~ Occupation oc.ltc~~lC~~r1QI4S Length of Employment ~ (9 !ho Household Income $° c~5,ooo t~.a o~U Net Worth $ ,~o 000 2. Owner O Proposed Insured O Trust O Someone other than Proposed Insured or Trust A. Complete if other than the proposed insured is owner (1f contingent owner is required, use Remarks section.) Name Social Security or Tax ID # Address City, State Home Phone ( ) Relationship to Proposed Insured ., a. Complete if owner is a trust {lftrustee is premium payor also complete section 7 part D.} Exact Name of Trust Current Trustee(s) Trust Tax 1 D # Date of Trust 3. Plan of Insurance Product N me L-~' ~ V ~ ~'~- ~ 3o mount Applied Por $ Zed ~ 0 Ott -~ '~ t- Reason for Insurance ~.,~ ~ ` Premium Class Quoted - Hiders Cl Waiver of Premium [Child $ ~a o c~ o r-' EComplete Child Rider Attachmer+t) O N current children 4. Primary Name ~`~~I~_~aS Relationship_~i~s~-~` Share ~,% Beneficiary Name ~~~C~i'"+~ 1~c ~ ~~>~CC~i1~C~ Relationship ms`s ~caa-~M~ Share 5C`~ ~a 5. Contingent Name ~~ i-Y e b Ll-2.~' _ Relationship ~~~4 ~. Share ,.~~% iBeneficiary Name ~ ff1CIC-~ ~ ~ ~~C~ . Relationship .~+Oll Share 6, Trust Information (if Beneficiary} Exact Name of Trust Trust Tax ID # _ Current Trustees} Date of Trust Premium Payment l~ Modal $ ~`1 ~ l~j Cl Single $ Frequency of modal premium: ^ Annual ~ Semi-annual O Quarterly Method: D Direct Billing Clank Draft (Complete Bank Draft Authorizatiorr.J ^ List Bill: ^ Other (Please explain.) Amount submitted with app(icatian $ ~?. I~ Premium payor (Complete if other than owner.) Name Address City, State ZIP 8. Health and Age Questions (If the proposed insured answers yes to either question, temporary insurance is not available, the agreement wil! be void and any payment submitted will be refunded) A. Has the proposed insured ever had a heart attack, stroke, cancer, diabetes, or disorder of the immune system, or during the last two years been confined in a hospital or other health care facility or been advised to have any diagnostic te~st~r surgery not yet performed? ^ yes hdno B. Is the proposed insured age 79 or above? ^ yes ~o AGLCl0U240-PA - Pagn 1 of 5 L~onthly (Bank Draft) Number Social Security or Tax ID # Home Phone { Date of Sirth ZIP Other life Insurance or Annuities (Indicafe life insurance policies or annuities in force or pending for the proposed insured(s~~).)~~ Does any proposed insured have any existing or pending annuity or life insurance contracts? Qyes CYI"no (!f yes, indicate life insurance policies or annuities in force or pending for the proposed insured(s).J Type: i = individual, b = business, g = group, p=pending life insurance or annuity Type{sl Yaar of dace Name of Proposed Insured Policy Number Insurance Company ~ fsee above) Issue Amount Replaca* 703 Ex ^ yes ^ yes - ©ye5 ^ ye5 ^ yes ^ yes * Replace means thatthe insurance being applied for may replace, change or use any monetary value of any existing or pending life insurance policy or annuity. if replacement may be involved, complete and submit replacement-related forms. Please note: certain states require completion of replacement related forms even when other life insurance or annuities are not being replaced by the policy being applied for. 1t}. Background Information ' ~~~ A. Does the proposed insured intend to travel ar reside outside of the United States or Canada within the nexttwa years? ^ yes t.cSno (1f yes, list country, date, length of stay and purposs.) B, In the past five years, has the proposed insured participated in, or does he or she intend to participate in: any flights as a trainee, pilot or crew member; scuba diving; skydiving or parachuting; ultralight aviation; auto racing; cave exploration; hang gliding; boat racing; mountaineering; extreme spurts or other hazardous activities? (lf yes, circle the applicable activities and complete the Aviation and/or Avocation Questionnaire.) ~ ^ yes no C. Has the proposed insured; 1) During the past 90 days submitted an application for life insurance to any other company or begun the process of filling out a~* application? (If yes, list company name, amount applied for, purpose of insurance and if application will~be placed) ^ yes L~"no 21 Ever had a life or disability insurance application modified, rated, declined, postponed, withdrawn, canceled or refused for renewal (1f yes, list date and reason.) Q yes o .D. Has the proposed insured ever filed for bankruptcy? Oyes (If yes, list chapter fled, date, reason and if discharged) E. In the past five years, has the proposed insured been charged with ar convicted. of driving under the influence of atcaha~~l a/~r drugs or had any driving violations? ~ ~~O ~ $ I~1'yes O no (!f yes, lrst data, state, bcense na. and specnc~ vralatron.) ~ ~ ~ y , ~~ . $~ ~3 ~y ~ ~~~~~ r,~ F Has the proposed insured ever been convicted of or pled guilty or no contest to a fe any or does he or she have any such~r pending against him or her? (!f yes, list date, state and felony.) Q yes ~ no REMARKS 9'!. Details and Explanations AgentlAgency Information Does the proposed insured have any existing or pending annuity or life insurance contracts'f ^ yes ~o If yes, will the proposed insured replace, change, or use any monetary value of any existing ar pending life insurance policy or annuity with any company in connection with the purchase of insurance? Q yes D no (!f yes, please provide details in the Remarks section and attach all replacement-related forms. Certain states require completion of replacement-related forms even when life insurance or annuities are not being replaced by the policy being applied far.} I have ordered/obtained the fnllo~w_~~in~~requirements: ^ APS D 8{ood PrafilelUrinalysis OEKG ^ Inspection Report ^ MD Exam ^ Oral Fluids (as state permits) [~J'Parametlical Exam ^ Treadmill ^ Urinalysis Only (lfrequirements are scheduled, please provide name of examiner, clinic and date ordered:) Agent(s~ to Receive Commission Agency Number Agent Number % of Commission ,3iTDiTH B. GILBERT. Q.E.D., Z~~7 f certify thatthe information supplied bythe proposed insured/owner has been truthfully and accurately recorded on the PartA application. .tTmrrx B. G'R.BERT,I~.B,D., Lt~f'(~ ~C~~r~'3 a ~ ~ ~ O ~ g, '~ Wr' 'ng Agent iVame (please print) State License # [~` X X ~r~--~ Wr 'ng Agent Signature Countersigned {licensed resident agent if state required) Phone # ( L1 ~~1"'1^-`~~~~ E-mail Address ~ ~`V~ AGtC100240-PA Page 2 of 5 st ~1 ~~ BISYS Insurance Services ~~~~~ ~~1SU!°3~C£ ~er~Iices, ~~C. AUTHORIZATION AND SIGNATURE American @eneral Lifie Insurance Company, Houston, TX The United States Life Insurance Company in the City of New York, New York, NY The above listed fife insurance company as selected on page one of this applicatian is solely responsible for the obligation antl payment of benefts under any policy that it may issue. No other company is responsible for such obligations or payments. In this application, "Company" refers to the insurance company which was selected on page one. Authorization to Obtain and Disclose Information and Declaration I give my consent to any of the entities listed below to give the Company, its legal representative, or American General Life Companies, an (affiliated service company}, all information they have pertaining to medical consultations, treatments, or surgeries; hospital confinements far physical and mental conditions; use of drugs or alcohol; or any other information; forme or my minor children. I}ther information could include items such as: personal finances, habits, hazardous avocations, motarvehicle records from the Department of Motor Vehicles ar court records, foreign travel, etc. The list of entities for which I give my consent to provide the information above is as follows: any physician or medical practitioner; any hospital, clinic or other health care facility; any insurance or reinsurance company; any consumer reporting agency or insurance support organization; my employer; arthe Medical Information Bareau (MIB}. I understand the information obtained will be used by the Company to determine eligibilityfor insurance and eligibility farbenefitsuvder an existing policy. The Company may disclose any information gathered during its evaluation of my application to: its reinsurers, the MI B, other persons or organizations performing business or legal services in connection with my application or claim, me, any physician designated by me, or any person or entity required to receive such information by law ar as I may furkher consent. I, as well as any person authorized to act on my behalf, may, upon written request, obtain a copy of this cansentfrom American General Life Companies. I understand this consent may be revoked at any time by sending a written request to American General Life Companies, ATTN: Underwrfing Department at P.O. Box 1931, Houston, TX 77251-1931. This consent will be valid for 24 months from the date of this application. I agree that a copy of this consent will be as valid as the original. I authorize the Company to obtain an investigative consumer report on me.1 understand that I may: request to be interviewed for the report and receive, upon written request, a copy of such report. ^ Check if you wish to be interviewed. 1 have read the above statements or they have been read to me. They are true and complete to the best of my knowledge and belief. t understand thatthis applicatian: (1J will consist of PartA, Part B, and if applicable, related forms; and (2} shall be the basis #ar any policy issued. I understand that any material misrepresentation made in this application and relied on by the insurer issuing the policy maybe used to reduce or deny a claim or void the policy, if: (1} it is within its contestable period; and (2} such misrepresentation materially affects the acceptance of the risk. Except as may be staled in a Limited Temporary Life Insurance Agreement (LTLlA}for which all requirements are met, i understand and agree that no insurance will be in effect under this application, ar any new policy issued by the insurer, unless or until: the policy has bean delivered and accepted; the full first modal premium far the policy has been paid; and there has been no change in the health of the proposed insured that would change the answers to any questions in the application. 1 understand and agree that no agent may: accept risks or pass upon insurability; make or modify contracts; or waive any of the insurers rights or requirements. ! have received a copy of the Notices to the Proposed Insured. Limited Temporary Life Insurance Agreement- If eligible, l have received and accepted the LTLIA. This insurance is available only if; the full first modal premium is submitted with this application and "no" answers have been given by the proposed insured to the Health and Age questions in section 8. 1RS Certifcation: Under penalties of perjury, I certify: (1) that the number shown an this application is my correct Social Security or Tax ID number; (2} that l am not subject to backup withholding under Section 34Dfi(a}(t}(C} of the Internal Revenue Code; and (3} that 1 am a U.S. person (including a U.S, resident alien}. The Internal Revenue Service does not require my consent to any provisions of this document other than the certifications required to avoid backup withholding, You must cross out item (7) if you are subject to backup withholdin a ss out item (3} if you are not a U.S, person (including a U.S. resident alien}. of Otimer t}ate Proposed Insured/Owner Signatures} f Signed at (Clty, State) _ Primary Propose~nsuri;d (lfun~erage f8,slgnature ofparentorguardianJ On (Date) ~~l ~~~QO~ caner (tf other than proposed lnsured) AGLC~0~2-i'J-P.4 Pege 3 of 5 JAMES SMITH DII~";TTERIQC & CONI~~2.1 Y LLP Christine Taylor Braun ctbra,jsdc.com FAX 717.298.2021 P.O. BSX G50 HERSHEY, PA 17033 July 18 2011 ~ `~"°"~~'~~ A~drE~~ 134 SIPS AVENUE= HUMMELSTOWN. PA 17036 TEL. 717.533.3.80 WWW.JSDC.COM Department of Veterans' Affairs P.O. Box 42954 Philadelphia, PA 19101 Re: M.S.G.T. Robert A. Liddick SS# xxx-xx-0544 GARY L. JAMES Dear Sir or Madam: MAX J. SMITH, JR. JOHN J. CONNELLY, JR. SCOTT A. DIETTERICK JAMES F. SPADE Our office has been retained to represent Betsy J Suggs maternal aunt of the MATTHEW CHABAL, ~~~ . , surviving son of Major Sergeant Robert A. Liddick. M. Sergeant Liddick passed away June NEIL W. YAHN EDWARD P. SEEBER 15, 2011. Pursuant to the Orphans' Court Rules of Pennsylvania No. 12.5(b)(10), notice is RONALD T. TOMASKO SUSAN M. KADEL required to be given to the United States Veterans' Administration with res ect to a Petition p COURTNEY K. POWELL for the appointment of a guardian of the estate or person of a minor in the event the minor is KIMBERLY A. BONNER KAREN N. CONNELLY a child of a veteran. CHRISTINE T. BRANN JESSICA E. LOWE SEAN M.CONCANNON GREGORY A. KOGUT, JR. In com Hance with Rule 12 5 10 enclosed is a co of the Petition which i b i p ~)( ) THOMAS J. CAR . s e n ~ py g filed with the Court of Common Pleas, Cumberland County, Pennsylvania, for the RALPH M. SALVIA appointment of a guardian of the estate of and of the person of Brandon V. Liddick, the OF COUNSEL: GREGORY K. RICHARDS surviving minor child of Robert A. Liddick. BERNARD A. RYAN, JR. Should you have any questions or wish to discuss this matter, please do not hesitate to call me. Very truly yours, -~ ~ -.~~ ~hristine Taylor Br CTB/mbl Enclosure cc: Betsy J. Suggs Consent of Connie L. Royer and Robert P. Rover 922 Willcliff Drive Mechanicsburg, Pennsylvania 17050 I, Connie L. Royer, maternal grandmother and along with my husband, Robert P. Royer, maternal grandfather of Brandon V. Liddick, born November 6, 2003, consent to the appointment of Betsy J. Suggs as guardian of the person and the estate of Brandon V. Liddick. Date: ~~ ~/' ~ ~~ l Date: ~ `f l ~ I ~~c..,t- ~.- Connie L. Royer 922 Willcliff Drive Mechanicsburg, PA 17050 ~?~ P ~? Robert P. Royer 922 Willcliff Drive Mechanicsburg, PA 17050 COMMONWEALTH OF PENNSYLVANIA ss. COUNTY OF ~~~,~,~ ~~ On this, the ~ `~ day of ~ _, 2011, before me, a notary public, the undersigned ~.! officer, personally appeared Connie L. Royer, a married person, known to me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument, and acknowledged that she executed the same for the purpose therein contained. IN WITNESS WHEREOF, I have hereunto set my hand and seal. My Commission Expires: COMMONWEALTH OF PEiVNSYL1irANIA Notarial Seal Maria B. LaRue, Notary PubJ1c Derry Twp., Dauphin County My Commission Expires Nov. 8, 2013 ' ~ ~ ~~,~ a Notaiy Public Member, Pennsllvania Asso!:.iation of Notaries COMMONWEALTH OF PENNSYLVANIA COUNTY OF DAUPHIN ss. ,~ On this, the ~~ day of - , 2011, before me, a notary public, the undersigned officer, personally appeared Robert P. Royer, a married person, known to me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument, and acknowledged that he executed the same for the purpose therein contained. IN WITNESS WHEREOF, I have hereunto set my hand and seal. My Commission Expires: COMMONWEALTH OF PENNSYLVANIA Notarial Seal Marta B. LaRue, Notary Public Deny Twp., Dauphin County My Commission Expires Nov. 8, 2013 Member, Pennsliv~nia Association of Notaries 1 r` Notary Public Consent of Kathy Jean Irvin 217 Belle Vista Drive Marysville, Pennsylvania 17053 I, Kathy Jean Irvin, paternal aunt of Brandon V. Liddick, born November 6, 2003, consent to the appointment of Betsy J. Suggs as guardian of the person and the estate of Brandon V. Liddick. Date: ~~ Kathy Jean Irv 217 Belle V' a Dn e Marysville, Pennsylvania 17053 COMMONWEALTH OF PENNSYLVANIA `~,, r ss. COUNTY OF i ~ ~ ~~~,,.~ : On this, the ~ day of ~ _, 201 1, before me, a notary public, the undersigned officer, personally appeared Kathy Jean Irvin, a married person, known to me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument, and acknowledged that she executed the same for the purpose therein contained. IN WITNESS WHEREOF, I have hereunto set my hand and seal. My Commission Expires: ~OMMONVVEALTH OF PENNSYLVANIA Notarial Seal Maria B. LaRue, Notary Pubic Derry Twp., Dauphin County My Commission Expires Nov. 8, 2013 Member, Pennsv+~~rar~ia Association of Notaries ~ '~ _~ /;. n - ~ j ~._ Notary Public IN RE: : IN THE COURT OF COMMON PLEAS ESTATE OF :DAUPHIN COUNTY, PENNSYLVANIA BRANDON V. LIDDICK, Minor ACCOUNT OF BETSY J. SUGGS, : NO. Guardian ORPHANS' COURT DIVISION AFFIDAVIT OF SERVICE I, Christine Taylor Brann, Esquire, of James, Smith, Dietterick & Connelly, LLP attorney for the Petitioner, Betsy J. Suggs, hereby certify that I have served a copy of the foregoing Petition on the following on the date and in the manner indicated below: VIA U.S. MAIL, FIRST CLASS, PRE-PAID Department of Veterans' Affairs P.O. Box 42954 Philadelphia, PA 19101 Robert P. Royer and Connie L. Royer 922 Willcliff Drive Mechanicsburg, PA 17050 Kathy J. Irvin 217 Belle Vista Drive Marysville, PA 17053 JAMES, SMITH, DIETTERICK & CONNELLY, LLP ! ~ / ~ ~'~ a Dated: - ~ ~ B ,/,:;.~ ~, ~;, ;~ ~:.-:~~ Y• Christine Taylor Brann Attorney LD. #82204 P.O. Box 650 Hershey, PA 17033-0650 (717) 533-3280