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HomeMy WebLinkAbout09-09-13 J EX 101*111IFI}REV-1 15Q561ii65 600 Vt! OFFICIAL USE ONLY PA Department of Revenue Bureau of hMMduel Tenet, County Code Year File Number PO Box 280601 INHERITANCE TAX RETURN 21 12 0264 Hatdsburg,PA 17128-0501 _ RESIDENT DECEDENT ENTER DECEDENT INFORMATION BELOW Social Security Number Dale of Death MMODYYW Dale of Birth MMDDYY" 02262012 07311947 Decedent's Lest Name Suffix Decedent's First Name M I DELL CHERYL A (if Applicable)Enter Surviving Spouse's Information Ballow Spouse%Last Name Suffix Spouse's First Name MI Spouses Social Security Number THIS RETURN MUST BE FILED IN DUPLICATE WITH THE REGISTER OF WILLS PILL IN APPROPRIATE BOXES BELOW ® 1.Original Return ❑ 2. Supplemental Return ❑ 3. Remainder Return(Date of Death Prior to 12-13.82) ❑ 4.Limited Estate ❑ 48. Future Interest Compromise(date of ❑ 5. Federal Estate Tax Return Required death after 12.12.82) OR 6. Decedent Died Testate 7. Decedent Maintained a Living Trust 0 8, Total Number of Safe Deposit Boxes (Attach Copy of Will) (Attach Copy of Trust.) n ❑ 9.Litigation Proceeds Received ❑ 10.Spousal Poverty Credit(Date of Death ❑ 11..El bon to Tex ur1li SecxCt-Ofe Between 12-31.91 and 1-1-M (A�ch Schedule W rrn c,> - CORRESPONDENT- THIS SECTION MUST BE COMPLETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFO&A=N SHOURIME D15 RECITED TO: Name Daytime Tlfwpb&tecrdumbw=� `.{ ° ELIZABETH B. PLACE 717-2A-DA co ° >- NE CK *LLS170EONLY' -n ty O ri 3 rr First Una of Address }1 ~ r— C 17 S SECOND ST y t9 N r Second Lone at Address City or Post Once State ZIP Code DATE FILED HARRISBURG PA 17101 Corraapondears a-mall address: EBP{7 SS'KARLATOSZONARIDH•COM Under penalties of perjury,I declare that I he"examined this return,Including scoompanylntl schedules and statements,and to the best of my knowledge and belief. It Is We.com%t and complete.Declaration of preparer other then the personal representetha Is based on all information orwhich prepamr has any IawrMM9e. SIGN4TUREOF PERSON RESPONSt FOR FILING RETtf N DATE JAMES GRAHAM 21 WEST ST., GRAN Y MA 01033 SL;NATURE PREP ESENTATNE DATE ADD ELIZA H B. PLACE, ESQUIRE 17 S. 2ND ST., HARRISBURG PA 17101 PLEASE USE ORIGINAL FO ONLY Side 1 1505611185 OM48473.0e0 1505611165 J 1505611285 REV-1500 EX(FI) Decedent's Social Security Number Decedent's Name, D E L L CHERYL A RECAPITULATION 1. Real Estate(Schedule A) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 0 . 00 2. Stocks and Bonds(Schedule B) . . . . . . . . . . . . . . . . . . . . . . . . . 2 0 .00 3. Closely Held Corporation,Partnership or Sole-Proprietorship(Schedule C). , . . . 3 0 • 00 4. Mortgages and Notes Receivable(Schedule D) . . . . , . . . . . - q 0 • 00 5. Cash,Bank Deposits and Miscellaneous Personal Property(Schedule E) . . , . . 5. 71472 • 00 6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested , 6. 0 • 00 7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property (Schedule G) F-1 Separate Billing Requested . . . . 7. 8 4,3 3 3 • 0 0 8. Total Gross Assets(total Lines 1 through 7) . . . . . . . . . . . . . . . . 8 911805 - 00 9. Funeral Expenses and Administrative Costs(Schedule H). . . . . . . . . . . . . 9. 161613-00 10. Debts of Decedent, Mortgage Liabilities,and Liens(Schedule 1) . , , . . . , . . 10 32,942 - 00 11. Total Deductions(total Lines 9 and 10), , , , , , , , , , , , , , , , , , , , , 11 491555- 00 12. Net Value of Estate(Line 8 minus Line 11) . , , . . . . . , . . , 12 421250 - 00 13. Charitable and Governmental Bequests/Sec 9113 Trusts for which an election to tax has not been made(Schedule J). . . . . . . . . . . . . . . . 13 0 . 00 14. Net Value Subject to Tax(Line 12 minus Line 13) . 14. 421250-00 TAX CALCULATION - SEE INSTRUCTIONS FOR APPLICABLE RATES 15. Amount of Line 14 taxable at the spousal tax rate,or transfers un�er Sec.9116 (a)(1.2)X.06 0 . 00 15. 0 . 00 16. Amount of Line 14 xable at lineal rate X � -4 0 . 00 16. 0 . 00 17. Amount of Line 14 taxable at sibling rate .12 42 ,250 - 00 17. 5,070 - 00 18. Amount of Line 14 taxable at collateral rate X.15 0 . 00 18. 11 - 00 19. TAX DUE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19. 51070 . 00 20. FILL IN THE BOX IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT Side 2 1505611285 1505611285 OM464e 3.000 REV-1500 EX(FI) Page 3 File Number Decedent's Complete Address: 21 12 0264 DECEDENT'S NAME DELL CHERYL STREET ADDRESS 304 BAHAMA CIRCLE CUMBERLAND CITY STATE 7JP CARLISLE P 0 5- Tax Payments and Credits: 1. Tax Due(Page 2,Line 19) (1) 5,070 . 00 2. Credits/Payments A. Prior Payments 0 . 00 B. Discount 0 .00 Total Credits(A+B) (2) 0 .00 3. Interest (3) 118 . 00 4. If Line 2 is greater than Line 1 +Line 3,enter the difference.This is the OVERPAYMENT. Fill in box on Page 2,Line 20 to request a refund. (4) 0 . 00 5. If Line 1 +Line 3 is greater than Line 2,enter the difference.This Is the TAX DUE. (5) 51l88 - 00 Make check payable to: REGISTER OF WILLS, AGENT. PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS 1. Did decedent make a transfer and: Yes No a. retain the use or income of the property transferred . . . . . . . . . . . . . . . . . . . . . . . . ❑ ❑ b. retain the right to designate who shall use the property transferred or its income . . . . . . . . . . X❑ El c. retain a reversionary Interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❑ d. receive the promise for life of either payments,benefits or care? . . . . . . . . . . . . . . . . . . ® ❑ 2. If death occurred after Dec. 12, 1962,did decedent transfer property within one year of death without receiving adequate consideration? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ® ❑ 3. Did decedent own an"in trust for"or payable-upon-death bank account or security at his or her death? ❑ 4. Did decedent own an individual retirement account,annuity,or other non-probate property,which contains a beneficiary designation? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ❑ ERI IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN. For dates of death on or after July 1, 1994, and before Jan. 1, 1995,the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 3 percent(72 P.S.§9116(a)(1.1)(i)]. For dates of death on or after Jan. 1, 1995, the tax rate imposed on the net value of transfers to or for the use of the surviving spouse is 0 percent [72 P.S.§9116 (a)(1.1)(it)].The statute does not exempt a transfer to a surviving spouse from lax,and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if the surviving spouse Is the only beneficiary. For dates of death on or after July 1,2000: • The tax rate imposed on the net value of transfers from a deceased child 21 years of age or younger at death to or for the use of a natural parent, an adoptive parent or a stepparent of the child is 0 percent 172 P.S.§9116(a)(1.2)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's lineal beneficiaries is 4.5 percent,except as noted in[72 P.S.§9116(a)(1)]. • The tax rate imposed on the net value of transfers to or for the use of the decedent's siblings is 12 percent(72 P.S.§9116(a)(1.3)]. A sibling is defined, under Section 9102,as an individual who has at least one parent in common with the decedent,whether by blood or adoption. OM4621 2.000 REV-15M EX-(11-10) pennsylvania SCHEDULE E RETURN DEPPRTMENiT REVENUE INHERITANCE TPX CASH, BANK DEPOSITS, & MISC. RESIDENTDECEDENT PERSONAL PROPERTY ESTATE OF: FILE NUMBER: Cheryl A. Dell 21 120264 Include the proceeds of litigation and the date the proceeds were received by the estate. All property jointly owned with right of survivorship must be disclosed on Schedule F. ITEM VALUE AT DATE NUMBER DESCRIPTION OF DEATH Sovereign Checking Account 2,931 2 Proceeds from sale of 1985 Zimmer Mobile Home VIN 37354205602 DE - NADA evaluation report attached 4,230 The value reported is decedent's one-half interest in the asset, which was owned as tenants in common with Thomas Donmoyer 3 Arizona Mail Order Refund 11 4 Household goods and personal property 300 TOTAL Also enter on line 5,Recapitulation) $ 71472 OW46AD 2.000 If more space is needed,use additional sheals of paper of the same size. REV-1510 EX+(08-09) SCHEDULE G pennsylvania DEPARTMENT OF REVENUE INTER-VIVOS TRANSFERS AND INHERITANCE TAX RETURN URN ED MISC. NON-PROBATE PROPERTY INHERITANCE M DE ESTATE OF FILE NUMBER Cheryl A. Dell 21 12 0264 This schedule must be completed and filed if the answer to any of questions 1 through 4 on page three of the REV-1500 is yes. DESCRIPTION OF PROPERTY ITEM MILOET .EDFT1ETRNGFEREE TEIRREITDNjWP TO DECEDENT AND DATE OF DEATH %OF DECD'S EXCLUSION TAXABLE NUMBEF TEDATEDFTRA^SFA ATTACH A COFV OF TW DEED FOR RE ESTATE VALUE OF ASSET INTEREST IFAPPLICABLE VALUE 1. Cheryl Dell Special Needs Trust U/A dated April 26, 2011 87,333 100.0000 3,000 84,333 The amount shown reflects the date of death value; the trust has paid the expenses of trust administration listed on Schedule H and the lifetime debts of the decedent listed on Schedule I. See Trust statement showing date of death and current value after payment of debts and expenses of trust administration. The remainder beneficiary of the trust is James Graham, the decedent's brother. TOTAL(Also enter on line 7,Recapitulation)$ 84,333 If more space is needed,use additional sheets of paper of the same size. 9W46AF 2.000 REV-151 Ex+(,009) SCHEDULE H pennsylvania DEPA EWOF REVENUE FUNERAL EXPENSES AND PINERITANCE TAX RETURN ADMINISTRATIVE COSTS RESIDEWDECEDENT ESTATE OF FILE NUMBER Cheryl A. Dell 21 12 0264 Decedent's debts must be reported on Schedule I. ITEM NUMBER DESCRIPTION AMOUNT A. FUNERALEXPENSES: None B. ADMINISTRATIVE COSTS: 1. Personal Representative Commissions: Name(s)of Personal Representative(s) Street Address City Stale ZIP Year(s)Commission Paid: 2. Attorney Fees: 3. Family Exemption: (If decedent's address is not the same as claimant's,attach explanation) Claimant Street Address City State ZIP Relationship of Claimant to Decedent 4. Probate Fees: 105 5. Accountant Fees: 6. Tax Return Preparer Fees: 7. 1 SkarlatosZonarich - legal fees Attorney fees relative to size of estate are higher than normal due to complexities of obtaining clear title to mobile home,addressing issues related to co-ownership of mobile home by deceased co-tenant with unknown heirs, and issues relating to Trust 12,000 Total from continuation schedules . . . . . . . . . 4,508 TOTAL(Also enter on Line 9,Recapitulation) $ 16,613 9W40AG 2.000 If more space is needed, use additional sheets of paper of the same size. Estate of: Cheryl A. Dell 21 12 0264 Schedule H Part 7 (Page 2) 2 Cumberland County Law Journal - Estate Advertising 75 3 The Sentinel - Estate Advertising 232 4 James Graham - travel to probate, attorneys office, decedent's residence (1090 miles @ .555 605 5 James Graham - notary reimbursement 10 6 James Graham - postage reimbursement 22 7 James Graham - death certificate reimbursement 18 8 INA - investigation of heirs of co-tenant 33 9 NADA - valuation report on mobile home 20 10 Jeffrey Noss - lawn care 690 11 Leiby's MHC, LLC - mobile home lot rent, , water, sewer, trash, fees 1,980 12 PPL - electric 211 13 Tax Claim Bureau of Cumberland Cc - real estate taxes 91 14 Postage 14 15 Pennsylvania Department of Revenue - 2011 trust tax due 47 16 Thompson Reuters - 2011 trust tax preparation fee 224 17 Thompson Reuters - 2012 trust tax preparation fee 236 Total (Carry forward to main schedule) 4,508 REV-1512 Ex I(12-M) pennsylvania SCHEDULE I DEPAMMENTOF REVENUE DEBTS OF DECEDENT, INHERITANCE TM RETURN MORTGAGE LIABILITIES 8r LIENS RESIDENTDECEDENT ESTATE OF FILE NUMBER Cheryl A. Dell 21 12 0264 Report debts incurred by the decedent prior to death that remained unpaid at the date of death,including unreimbursed medical expenses. ITEM NUMBER DESCRIPTION VALUE OF DEATH DATE EATH t. Capital Cardiovasular Associates 26 2 Credit Collection Services - Liberty Mutual 54 3 Verizon 199 4 Roamans - credit card debt 150 5 Julia Gaie - attendant care 428 6 Janet Foreman - care manager mileage reimbursement 40 7 Janine Davis - pet care 100 8 Marsha Garman - attendant care 1,800 9 SkarlatosZonarich - legal & care management fees 2,040 10 PA Department of Public Welfare payment from irrevocable Special Needs Trust £bo Cheryl Dell (listed on Schedule G) for medicaid services provided to decedent while Trust was in existence. 28,105 TOTAL Also enter on Line 70.Rew itulation $ 32 942 ew46AH 2.000 If more space is needed, insert additional sheets of the same size. REV-1513 EX+(01-10) pennsyivania SCHEDULE J DEPA EWOF REVENUE BENEFICIARIES INHERITANCE TAX RETURN RESIDENT DECEDENT ESTATE OF FILE NUMBER: CherVl A. Dell 21 12 0264 RELATIONSHIP TO DECEDENT AMOUNT OR SHARE NUMBER NAME AND ADDRESS OF PERSON(S)RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE I TAXABLE DISTRIBUTIONS[include outright spousal distributions and transfers under Sec.9116(a)(1.2).] 1. James Graham 21 West Street Granby, MA 010-33 Remainder interest in Cheryl Dell Special Needs Trust) : 42,250 Brother 42,250 ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18 OF REV-1500 COVER SHEET,AS APPROPRIATE. [[ NONTAXABLE DISTRIBUTIONS A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN: 1. B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS: 1. TOTAL OF PART II-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET. $ 0 9W4eAl 2.000 If more space is needed,use additional sheets of paper of the same size. NAUA NADAguides.com Value Report cubes (THIS IS NOT AN APPRAISAL FORM) Date 02/15/2013 Reference Number 336713 Office Location Costa Mesa Guide Edition Jan-Apr 2013 Year Mfg'd Manufacturer Trade Name State Region 1985 1 ZIMMER Unknown PA MA Floor Areas: Single-Wide Width Length Total Value Main Floor Area: 12 x 60 $4,116.70 1. Base Structure Value $4,116.70 2. State Location Adjustment x 102 % 3. Total Guide Book Retail Value (in average condition) $4,199.03 4. Condition Adjustment Excellent ❑ Good ❑ Fair ❑ Poor x 61 % 5. Condition Adjusted Value $2,561.41 6. Total Adjusted Value of Home $2,561.41 7. Total Additional Features + $4,362.52 8. Total Adjusted (Retail) Value of Home and Optional Equipment $6,923.93 Completed By:Online Summary Comments:This is a base retail value(without inspection)based on information supplied by the customer. Copyright©2013 National Appraisal Guides Inc.All rights reserved. Page 1 of 3 NADQi NADAguides.com Value Report ® cu,coes (THIS IS NOT AN APPRAISAL FORM) Date 02/15/2013 Reference Number 336713 Office Location Costa Mesa �— Guide Edition Jan-Apr 2013 Year Mfg'd Manufacturer Trade Name State Region 1985 ZIMMER Unknown PA MA ADDITIONAL FEATURES Description Unit of Quantity Measure Age Unit Price Total Value Components BATH FIXTURES Fiberglass Tub-Combo 1 ea. 5+Yrs $191.00 $191.00 Total BATH FIXTURES DOORS $191.00 Storm Doors-Single-wide 1 all 5+Yrs $71.00 $71.00 Total DOORS ELECTRICAL $71.00 Electric Home-Total 1 ea. 5+Yrs $363.00 $363.00 Total ELECTRICAL FAN $363.00 Ceiling Paddle Fan 1 ea. 5+Yrs $78.00 $78.00 Total FAN HOUSE TYPE ROOFING $78.00 Single-wide 1 home 5+Yrs $396.00 $396.00 Total HOUSE TYPE ROOFING HOUSE TYPE SIDING $396.00 Single-wide 1 home 5+Yrs $397.00 $397.00 Total HOUSE TYPE SIDING MISCELLANEOUS $397.00 Clothes Washer 1 ea. 5+Yrs $190.00 $190.00 Clothes Dryer 1 ea. 5+Yrs $145.00 $145.00 Total MISCELLANEOUS $335.00 Copyright©2013 National Appraisal Guides Inc.All rights reserved. Page 2 of 3 NA!DA NADAguides.com Value Report ® r, (THIS IS NOT AN APPRAISAL FORM) Date 02/15/2013 Reference Number 336713 Office Location Costa Mesa ---__ Guide Edition Jan-Apr 2013 Year Mfg'd Manufacturer Trade Name State Region 1985 State Unknown PA MA Components PLUMBING Stainless Steel Sink 1 ea, 5+Yrs $92.00 $92.00 Total PLUMBING $92.00 Total Components $1,923.00 Accessories CENTRAL AIR CONDITIONING SYSTEM (By Ton, 12,000 BTU = 1 Ton) 2 Ton Electric 1 ea. 5+Yrs $703.00 $703.00 Total CENTRAL AIR CONDITIONING SYSTEM (By Ton, 12,000 BTU= 1 Ton) PORCHES/DECKS (Measure Width x Length Including Carpet&Rails) $703.00 Wood w/Rails 100 sq. ft. 5+Yrs $9.55 $955.00 Total PORCHES/DECKS (Measure Width x Length Including Carpet&Rails) SKIRTING TO 30"HIGH (Measure Around Perimeter) $955.00 Metal or Vinyl(Vertical) 144 lin. ft. 5+Yrs $2.08 $299.52 Total SKIRTING TO 30" HIGH (Measure Around Perimeter) STEPS $299.52 Wood-3 Steps 2 ea. 5+Yrs $241.00 $482.00 Total STEPS $482.00 Total Accessories $2,439.52 Total Additional Features $4,362.52 Copyright©2013 National Appraisal Guides Inc.All rights reserved. Page 3 of 3 x ® COPY IRREVOCABLE SPECIAL NEEDS TRUST FOR ✓✓✓"` THE BENEFIT OF CHERYL DELL THIS AGREEMENT is made thisl t 5 day of MARQU, 2011, by CHARLOTTE RIDDERVOLD, (hereinafter called "Settlor"), and ACHIEVA FAMILY TRUST (hereinafter called "Trustee") on behalf of CHERYL DELL (hereinafter called "Beneficiary"). This trust is established pursuant to 42 U.S.C.A. §1396p(d)(4)(A), 62 P.S. §1414 and 55 Pa. Code §178.7(f)(1). This trust shall be known as the "CHERYL DELL SPECIAL NEEDS TRUST." Trustee shall ascertain whether there are any claims or liens by the Department of Public Welfare and the Social Security Administration before payment into the trust. A copy of the Special Needs Trust should be directed to: The Special Needs Trust Depository Attention: Manager, TPL Section P. O. Box 8486 Harrisburg, PA 17105-8486 SSI Program Support Team Attention: Team Leader Mid-Atlantic Program Service Center 3rd and Spring Garden Streets Philadelphia, PA 19101 After payment of any claims or liens, Settlor is authorized to transfer, assign and convey unto Trustee the property listed in Schedule "A" annexed hereto and made a part hereof, and Trustee agrees to hold such property, together with any other real or personal property that may be added to this Trust, such proceeds and additions constituting the principal of Trust, upon the following terms and conditions: FIRST: Beneficiary is a disabled individual who is 63 years old. Beneficiary is disabled as defined by the SSI criteria in 42 U.S.C.A. §1382c(a)(3). The extent of 1 Beneficiary's disability has been documented as: Beneficiary's chronic conditions include osteoarthritis, depression and high blood pressure. In addition, she is being treated for a neuroendrocrine tumor. Osteoarthritis has resulted in broken bones, leading to surgery and resulting significant complications that have included removal of replacement knee and removal of left femur. Beneficiary has a Foley catheter and is not ambulatory. SECOND: Settlor declares this Trust to be a Special Needs Trust for the sole benefit of Beneficiary. All distributions from this Trust shall be for her sole benefit. The purpose of the Special Needs Trust shall be to maintain and support Beneficiary's health, safety, welfare, education and treatment when such items, products, or services are not provided by a public agency or government program. A. Special needs shall mean those requisite items, products or services that can be provided to Beneficiary to assist in the treatment of Beneficiary's disability and to increase Beneficiary's quality of life. B. Special needs shall include but not be limited to medical expenses, dental expenses, nursing and custodial care, care management expenses, psychiatric/psychological services, recreational therapy, occupational therapy, physical therapy, vocational therapy, durable medical needs, prosthetic devices, special rehabilitative services or equipment, programs of training, education, transportation, home modifications and disability- required travel expenses, dietary needs and supplements, and related insurance. 2 THIRD: No public assistance or Social Security benefits Beneficiary shall be added to the Trust. Any additions to the trust must be approved by the Trustee. No additions shall be accepted by Trustee after Beneficiary attains the age of sixty-five (65) years. FOURTH: Trustee shall seek support and maintenance of Beneficiary from all available public resources, including but not limited to Supplemental Security Income program (SSI), Old Age Survivor and Disability Insurance program (OASDI), the Medicare program and Medical Assistance (Medicaid) program or similar or successor programs. Trustee shall take into consideration applicable resources and income limitations of any of these public programs or any private agency program for which Beneficiary is eligible in determining whether to make any discretionary distributions hereunder. FIFTH: Trustee shall have the power to distribute to, or apply for the benefit of, Beneficiary such amount of income as Trustee may from time to time determine, in Trustee's sole, absolute and unfettered discretion, to be necessary or appropriate for Beneficiary's special needs and comfort. Expenditures of income from the Trust fund must have a reasonable relationship to the disability of Beneficiary. Any income not so distributed or applied shall be added to principal. SIXTH: Trustee shall have the power to distribute to, or apply for the benefit of, Beneficiary such amount of principal as Trustee may from time to time determine to be necessary or appropriate for Beneficiary's special needs and comfort. Expenditures of principal from the Trust fund must have a reasonable relationship to the disability of Beneficiary. Except as provided in ITEMS ELEVENTH and TWELFTH below, Trustee 3 shall provide due notice to all interested parties, including the Department of Public Welfare and Social Security Administration, for any such expenditure that exceeds $10,000. Notice to the Department of Public Welfare and Social Security Administration should be directed to: The Special Needs Trust Depository Attention: Manager, TPL Section P. O. Box 8486 Harrisburg, PA 17105-8486 SSI Program Support Team Attention: Team Leader Mid-Atlantic Program Service Center 3rd and Spring Garden Streets Philadelphia, PA 19101 SEVENTH: It is further the intent of this Trust that no part of the Trust established hereunder shall be used to supplant or replace public assistance benefits of any county, state, federal or governmental agency. For these purposes, in determining Beneficiary's eligibility for such benefits, no part of the principal or income of the Trust established hereunder shall be considered available to Beneficiary. In the event Trustee is requested by any department or agency to release principal or income of the Trust to or on behalf of Beneficiary, in order to pay for equipment, medication, or services that other organizations or agencies are authorized to provide; or in the event that any department or agency administering such benefits petitions the Orphans' Court for these same purposes, Trustee shall deny such requests and is directed to defend and contest these request at the expense of the Trust. Trustee shall have complete discretion with regard to any such claims including management of all litigation which may result. Trustee shall also have 4 sole and absolute discretion to settle, in whole or in part, or otherwise compromise any such claim or litigation. EIGHTH: If Trustee determines that it is impractical to administer the Trust because it has become too small to justify maintaining the Trust, or because it is no longer suitable for Beneficiary's needs, Trustee shall obtain Orphans' Court approval to terminate this Trust and to distribute the principal and income of the Trust as set forth in ITEM NINTH. NINTH: This Trust shall terminate upon the earlier of the death of Beneficiary or Order of Court upon petition thereto. A. Upon termination of the Trust during the lifetime of Beneficiary, Trustee shall obtain a determination from the Department of Public Welfare of its claim, if any, for Medical Assistance payments which had been made on behalf of Beneficiary. After payment of taxes, administrative expenses and costs attendant to terminating this Trust, Trustee shall distribute to the Department of Public Welfare from the remaining principal and accumulated income, if any, an amount equal to the amount of Medical Assistance paid on behalf of Beneficiary during the time the Trust was in existence. If more than one state is entitled to reimbursement for Medicaid expenditures, each state shall receive its proportionate share of the total amount of Medicaid to be reimbursed. If any principal and accumulated income remains after distribution to the Department of Public Welfare, Trustee shall distribute the remainder in accordance with an Order of Court terminating the Trust upon petition thereto, 5 B. Upon the termination of the Trust at the death of Beneficiary, Trustee shall obtain a determination from the Department of Public Welfare of its claim, if any, for Medical Assistance payments which it has made on behalf of Beneficiary. After payment of taxes and administrative expenses and costs attendant to terminating this Trust, Trustee shall distribute to the Department of Public Welfare from the remaining principal and accumulated income, if any, an amount equal to the amount of Medical Assistance paid on behalf of Beneficiary during the time the Trust was in existence. If more than one state is entitled to reimbursement for Medicaid expenditures, each state shall receive its proportionate share of the total amount of Medicaid to be reimbursed. C. If any principal and accumulated income remains after said distribution to the Department of Public Welfare and the payment of all expenses of any last illness, funeral and burial costs and enforceable debts, Trustee shall distribute the remainder to such persons in such amounts, and upon such terms, Trusts and conditions as Beneficiary shall appoint under the terms of Beneficiary's Last Will and Testament, making specific reference to this power. However, this power of appointment shall not be exercisable in favor of Beneficiary, Beneficiary's estate, Beneficiary's creditors or creditors of Beneficiary's estate. If Beneficiary has not validly exercised this power to appoint by Will, the remaining principal and accrued income, if any, shall be distributed to JAMES ROBERT GRAHAM. 6 TENTH: The interest of Beneficiary in both the principal and income, until actually distributed, shall not be subject to anticipation or to voluntary or involuntary alienation. ELEVENTH: Trustee shall, in addition to the powers given by law, and pursuant to the Prudent Investor Rule, 20 Pa. C.S.A. § 7201, et sea., have the following powers applicable to all property held in Trust whether principal or income, and exercisable without Court Order: A. To retain any property transferred to this Trust, and to make such investments and reinvestments and in such proportions, without limitation to what are known as legal investments, as Trustee shall consider beneficial. B. To (1) participate in any merger or reorganization affecting securities held hereunder at any time; (2) deposit stock under voting agreements; (3) exercise any option to subscribe for stocks, bonds or debentures; (4) grant proxies, discretionary or otherwise, to vote shares of stock. C. To manage, operate, or repair, real estate or other property and to lease real estate and other property upon such terms and for such period as Trustee deems advisable. D. To retain care giving and professional services for the benefit of Beneficiary, including by not limited to legal services and costs associated with the preparation, execution, funding, administration and termination of this Trust Agreement, as well as ongoing fiduciary, legal, accounting, 7 bookkeeping and other services as may be necessary or appropriate for Trustee in administering the Trust for the benefit of Beneficiary. E. To purchase a handicapped-accessible vehicle for transporting the disabled Beneficiary without prior notice to the Department of Public Welfare and Social Security Administration. F. To establish a reasonable irrevocable burial account on behalf of Beneficiary without prior notice to the Department of Public Welfare and Social Security Administration. TWELFTH: Trustee shall, in addition to the powers given by law and pursuant to the Prudent Investor Rule, 20 Pa. C.S.A. § 7201, et sea., have the following powers applicable to all principal held in trust, A. To buy or sell (and to grant options for the sale of) any real or personal property at public or private sale for such prices and upon such terms as Trustee may think proper, following due notice to all interested parties, including the Department of Public Welfare and Social Security Administration regarding property in excess of$10,000, without liability on the purchaser to see to the application of the purchase monies. B. To make necessary structural changes to the real property to accommodate the special needs of Beneficiary following due notice to the Department of Public Welfare and Social Security Administration for principal expenditures in excess of$35,000. THIRTEENTH: This Trust shall be irrevocable, and, except as provided below, Settlor shall not have the right to alter, amend or revoke this Trust Agreement, or any 8 provision hereto without the approval of the Orphans' Court Division of the Court of Common Pleas of Cumberland County, following due notice to all interested parties, including the Department of Public Welfare and Social Security Administration. Trustee may amend the Trust from time to time to ensure continuing eligibility of Beneficiary for Public Benefits programs to which Beneficiary may be entitled. If the law or regulations governing eligibility change, Trustee may amend the Trust to ensure continuing eligibility or to secure eligibility. If any provision of this original Trust fails to meet the requirements of SSI, Medicaid or any other public benefit program. Trustee may amend the trust to comply with any such provisions. If Beneficiary shall move to another jurisdiction, Trustee may amend the trust to comply with the laws of such jurisdiction in order to maintain Beneficiary's eligibility. Trustee shall notify the Department of Public Welfare and Social Security Administration each time the Trust is to be amended. FOURTEENTH: In addition to the powers given by law and pursuant to 20 Pa. C.S.A. §7761 et seq, the Trust shall be governed by the following trustee provisions: A. Any Trustee shall have the right to resign by giving notice in writing to Beneficiary, Beneficiary's natural or legally-appointed guardian, conservator or other legal representative. B. If a vacancy occurs in the office of Trustee, following due notice to the Department of Public Welfare and Social Security Administration, Settlor may appoint a successor Trustee that is not related or subordinate to any beneficiary. Such appointment shall be made in written instrument that shall be delivered to Beneficiary. In the default of such appointment, 9 JAMES ROBERT GRAHAM shall have the right, power, and authority to designate a successor trustee. C. Under no circumstance shall Beneficiary or Beneficiary's spouse serve as a Trustee or Successor Trustee hereunder. D. Settlor, or in the event of Settlor's death or inability to exercise this power, then JAMES ROBERT GRAHAM by a written instrument, following due notice to the Department of Public Welfare and Social Security Administration, may remove from office any Corporate Trustee of the Trust for any reason whatsoever, and may replace such Trustee with another Corporate Trustee who is not related to or subordinate to Beneficiary (within the meaning of Internal Revenue Code ("Code") § 672(c)) to act in place of Trustee so removed. Any successor trustee shall be a bank or trust company that either (i) has at least $2,000,000 in trust assets in their management, or (ii) is obligated by law or obligates itself to post and maintain a fidelity or fiduciary bond sufficient to insure fully the value of the trust property at the expense of the successor trustee. E. Any Successor Trustee shall have the rights, powers, privileges, discretions, and duties conferred upon or vested in Trustee by the provisions of this Agreement. F. The Corporate Trustee shall be entitled to reasonable compensation for its services pursuant to its customary fee schedule. FIFTEENTH: Unless required by the Orphans' Court or a Court of competent jurisdiction, Trustee shall not be required to post a bond. 10 SIXTEENTH: All estate, inheritance, and other death taxes, including any interest and penalties with respect to those taxes not caused by negligent delay, payable to any federal, state, or foreign taxing authority imposed with respect to all property comprising the gross estate, whether or not such property passes under this Trust, shall be paid out of the principal of the Residuary Trust Estate.. SEVENTEENTH: The situs of this Trust shall be the Commonwealth of Pennsylvania and all questions as to the validity or effect of this instrument or the administration of the Trust hereunder shall be governed by the law of Pennsylvania. EIGHTEENTH: Trustee hereby accepts the Trust created by this agreement and agrees to carry out the provisions hereof according to the best of Trustee's ability. IN WITNESS WHEREOF, CHARLOTTE RIDDERVOLD, Settlor herein, and ACHIEVA FAMILY TRUST, as Trustee herein, have set there hand and seal the month, day and year first above written. ness CHARLOTTE RIDDERVOLD, Settlor Witness HIE MILY TRUST, Trustee I1 SCHEDULE "A" Schedule of Property Transferred Pursuant to the Foregoing Trust Agreement By and Between CHARLOTTE RIDDERVOLD, Settlor and ACHIEVA FAMILY TRUST, Trustee. 1 '�e10• �u ness CHARLOTTE RIDDERVOLD, Settlor vim, - _ HIE AMILY T UST, Trustee Date: 12 CELEBRATING ABILITIES. EXCEEDING EXPECTATIONS. August 14, 2013 Department of Revenue Bu ACHIEVA Bureau of Individual Taxes P.O. Box 280601 Harrisburg, PA 17128-0601 FAMILY TRUST Re: Inheritance Tax Return—Resident Decedent Cheryl A. Dell File Number 21 12 0264 Dear Sir or Madam: ACHIEVA Family Trust served as Corporate Trustee of the Irrevocable Special Needs Trust for the benefit of Cheryl Dell established April 21, 2011. The date of death balance in Ms. Dell's trust account was $87,333.25. Subsequent to Ms. Dell's death the following distributions were made from her trust account for payment of lifetime debts and costs of trust administration: 1. Capital Cardiovascular Associates $ 26.16 2. Liberty Mutual Credit Collection Services $ 53.50 3. Verizon $ 199.37 4. Ascension Point Recovery Services - credit card debt $ 150.00 5. Julia Gaie—attendant care $ 427.50 6. Janet Foreman—transportation reimbursement $ 40.05 7. Janine Davis—pet care $ 100.00 8. Marsha Garman—attendant care $ 1800.00 9. SkarlatosZonarich—legal & care management fees $ 2040.00 10. PA Department of Public Welfare—payment for Medicaid services $ 28105.15 11. PA Department of Revenue—2011 trust tax due $ 47.00 12. Thompson Reuters—2011 tax prep fee $ 224.91 13. Thompson Reuters—2012 tax prep fee $ 236.16 TOTAL $ 33449.80 The current balance in Ms. Dell's trust account available for distribution is $ 53,883.95. Please contact me at 412-995-5000 x 452 if you have any questions. Thank you. Sinc e y, L. a M. Doug' Esq ire Trust Attorney Affiliated with The Arc of-Pennsylvania and The Arc of the United States 1T�1 s a u 711 Bingham Street I _[ • _ ••• 15203-1007 �iCfCleRl:'LYIIII