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IN RE:
APPROVAL OF SPECIAL NEEDS TRUST No. 21-09-397
FOR TAMMY LEIGH DOUGHTERY, AN
ADJUDICATED INCAPACITATED PERSON
PETITION TO AUTHORIZE THE CREATION AND FUNDING OF THE
IRREVOCABLE SPECIAL NEEDS TRUST FOR THE BENEFIT
OF TAMMY LEIGH DOUGHERTY OF MECHANICSBURG,
CUMBERLAND COUNTY,PENNSYLVANIA PURSUANT
TO 42 U.S.C. SECT. 1396p(d)(4)(A)
TO THE HONORABLE JUDGES OF THE SAID COURT:
And now comes, MILTON M. DOUGHERTY,JR., and DEBORAH DOUGHERTY
KNAUB and SANDRA L. DOWNEY, the daughters of the aforesaid MILTON M.
DOUGHERTY, and the sisters of TAMMY LEIGH DOUGHERTY, the adjudicated
incapacitated person and the beneficiary of the special needs Trust herein referenced, by and
through their attorney, CHARLES E. SHIELDS,III, who files this PETITION TO
AUTHORIZE THE CREATION AND FUNDING OF THE IRREVOCABLE SPECIAL
NEEDS TRUST FOR THE BENEFITOF TAMMY LEIGH DOUGHERTY OF
MECHANICSBURG, CUMBERLAND COUNTY, PENNSYLVANIA PURSUANT
TO 42 U.S.C. SECT. 1396p(d)(4)(A)
RE: JURISDICTION
1. Jurisdiction lies in the Orphans' Court Division under 20 Pa. C. S. Sect. 711(3) referring
to Inter Vivos Trusts and 20 Pa. C.S. § 711(10), which states that the administration and
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distributions of the real and personal property of the estates of incapacitated persons is to be
exercised through the Orphans' Court Division.
RE: PREVIOUS ADJUDICATION
2. Previously, hereto, upon petition and hearing, the beneficiary herein, TAMMY LEIGH
DOUGHERTY was adjudicated an incapacitated person by a FINAL DECREE dated the 101'
day of June 2009 signed by the HONORABLE JUDGE BAYLEY. By same said DECREE,
MILTON M. DOUGHERTY, JR., and DORIS S. DOUGHERTY, his wife, and DEBORAH
DOUGHERTY KNAUB and SANDRA L. DOWNEY were appointed permanent Plenary
Guardians of the estate of TAMMY LEIGH DOUGHERTY with broad powers. Said DECREE
reads in pertinent part: "IT IS ALSO ORDERED AND DECREED THAT [the Plenary
Guardians] are authorized and empowered to ... c. Establish a Special Needs Trust or similar
Trusts." The said DORIS S. DOUGHERTY has been suffering from severe illness of late and
is currently residing in a nursing home; she therefore does not join in this PETITION.
RE: PETITIONERS
3. Petitioner, MILTON M. DOUGHERTY, JR., residing at 220 West Keller Street, in the
Borough of Mechanicsburg, Cumberland County, Pennsylvania 17055, is an adult individual,
having a birthdate of May 8, 1925, aged eighty-nine (89) years, and is the natural father of
TAMMY LEIGH DOUGHERTY, an adjudicated incapacitated person and the beneficiary of
the Special Needs Trust herein referenced. Petitioner is also the Plenary Guardian of the said
TAMMY LEIGH DOUGHERTY and a Co-Trustee of the proposed Trust. Said Petitioner is a
United States citizen and is able to speak, read and write in the English.language.
4. Petitioner DEBORAH DOUGHERTY KNAUB, residing at 225 Indian Creek Drive, in
the Township of Hampden(Mechanicsburg), Cumberland County, Pennsylvania 17050, is an
adult individual, having a birthdate of September 27, 1954, aged fifty-nine (59) years, and is the
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natural born sister of the whole blood of TAMMY LEIGH DOUGHERTY, an adjudicated
incapacitated person and the beneficiary of the Special Needs Trust herein referenced. Petitioner
is also the Plenary Guardian of the said TAMMY LEIGH DOUGHERTY and a Co-Trustee of
the proposed Trust. Said Petitioner is a United States citizen and is able to speak, read and write
in the English language.
5. Petitioner SANDRA L. DOWNEY, residing at 127 Victoria Drive, in the Township of
Lower Allen (Mechanicsburg), Cumberland County, Pennsylvania 17055, is an adult individual,
having a birthdate of July 3, 1957, aged fifty- seven(57) years, and is the natural born sister of
the whole blood of TAMMY LEIGH DOUGHERTY, an adjudicated incapacitated person and
the beneficiary of the Special Needs Trust herein referenced. Petitioner is also the Plenary
Guardian of the said TAMMY LEIGH DOUGHERTY and a Co-Trustee of the proposed Trust.
Said Petitioner is a United States citizen and is able to speak, read and write in the English
language.
RE: THE BENEFICIARY
6. TAMMY was born with severe mental retardation and lacks any real capacity to
communicate. She suffers from other severe limitations including the inability to handle toilet
facilities, feed, bathe or dress herself. Additionally, she suffers from scoliosis, osteoporosis, and
exceptionally brittle bones. As a result, she occasionally suffers from fractures.
7. TAMMY resides with her said father and requires assistance of virtually every type and
variety.
8. TAMMY is currently receiving benefits and assistance through Cumberland County and
Social Security.
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9. TAMMY currently receives approximately six hundred thirty-three ($633.00) dollars
monthly from Social Security. She also has an Access Card for prescriptions.
RE: POTENTIAL FUNDING FOR THE SPECIAL NEEDS TRUST
10. The gross value of any single name property in the sole name and absolute ownership of
TAMMY is zero. However, based on a legacy received under the Last Will and Testament of
Ethel R. Brubaker, as is set forth more fully at large in Paragraph 1 of the Special Needs Trust
attached hereto, TAMMY has a direct beneficial interest in a fund of approximately twenty
thousand eight hundred ($20,800.00) dollars.
11. FOR PURPOSES OF ADDITIONAL INFORMATION, DISCLOSURE,AND
CLARIFICATION: In the original PETITION FOR THE APPOINTMENT OF
PERMANENT PLENARY CO-GUARDIANS filed on April 24, 2009, in Paragraph 35,
Petitioners averred and disclosed as follows:
"35. TAMMY's parents currently hold a number of accounts and
financial instruments in fully revocable "IN TRUST FOR," designations "for the
benefit of TAMMY LEIGH DOUGHERTY," as follows, to wit:
(A.) Citizen's Bank:
(i.) Six (6) month Certificate of Deposit: $32,436.30
(ii) Three(3) year, increasing rate, Certificate of Deposit:
$27,718.61
(iii) Three (3) year, increasing rate, Certificate of Deposit:
$17,509.08
(iv) Statement Savings Account: $13,079.66.
(B.) Sovereign Bank Certificate of Deposit: $18,643.39
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(values are based upon the most recent data readily available at the time of the
preparation of this Petition.)"
Milton M. Dougherty, Jr. and Doris S. Dougherty, his wife, are currently in the process of
undertaking general estate planning with particular attention to Medicaid planning. As a result
thereof, additional and more detailed financial research was undertaken as to the nature and
source of the above-referenced funds. Of the above funds, the vast majority thereof were the
funds of the said Milton and Doris Dougherty and of several well wishers who had given funds
to Milton and Doris with the idea that they could be used from time to time by Milton and Doris
Dougherty to buy gifts or other small amenities from time to time. Said funds are legally those
of Milton and Doris Dougherty and until the deaths of both of them are considered as originally
disclosed to be the funds of Milton and Doris Dougherty held in a fully revocable "IN TRUST
FOR STATUS."
As above-referenced there is a sum of twenty thousand eight hundred ($20,800.00)
dollars which is TAMMY'S and which is to be placed into the proposed SPECIAL NEEDS
TRUST.
A part of the other referenced funds, to the extent allowed by law and consonant with
current governmental regulations, will be placed in an alternate type of trust or trusts for the
benefit of TAMMY LEIGH DOUGHERTY.
RE: CREATION OF THE SPECIAL NEEDS TRUST
12. Petitioners by, and through their counsel, have drafted an IRREVOCABLE SPECIAL
NEEDS TRUST FOR THE BENEFITOF TAMMY LEIGH DOUGHERTY OF
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MECHANICSBURG, CUMBERLAND COUNTY, PENNSYLVANIA, which is attached
hereto, made a part hereof, and marked as "Exhibit A."
13. TAMMY's father, and two (2) sisters, as above related, shall be the Co-Trustees of the
Trust.
14. 42 U.S.C. §I396p(d)(4) explicitly permits the creation of certain inter vivos trusts for the
benefit of disabled individuals who meet the requirements of 42 U.S.C. §1382c(a)(3)(A).
15. The said SPECIAL NEEDS TRUST shall be an irrevocable Trust for the sole benefit of
TAMMY LEIGH DOUGHERTY.
16. The primary purpose of the said SPECIAL NEEDS TRUST is to supplement, but not to
supplant, whatever benefits and services TAMMY LEIGH DOUGHERTY may from time to
time be eligible to receive by reason of age, disability, or other factors, from federal, state, and
local governmental and charitable sources.
17. The secondary purpose of the Trust is to provide a system of financial management, asset
protection, advocacy, and guidance for TAMMY LEIGH DOUGHERTY.
18. The said Co-Trustees shall have sole and absolute discretion to apply, or refuse to apply
resources of the Trust for the benefit of TAMMY LEIGH DOUGHERTY, the Trust
beneficiary, as is set forth more fully at large in the attached Trust document in Item 5 therein.
19. Distributions from the Trust shall not be used for food or shelter unless the Trustees, in
their sole and absolute discretion, deem that it is advisable and consonant with then applicable
statutes, rules and regulations regarding Special Needs Trusts.
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20. Upon the death of TAMMY LEIGH DOUGHERTY, the Trustee shall distribute an
amount of the remaining Trust assets, principal and accumulated income, as required under 42
U.S.C. §1396p(d)(4)(A), or any regulations promulgated thereunder, or the corresponding
provisions of any subsequent federal law, to any state providing medical assistance on TAMMY
LEIGH DOUGHERTY'S behalf, equal to the total medical assistance paid on TAMMY
LEIGH DOUGHERTY'S behalf under the State's plan under Title 42 U.S.C. §1396 et seq.,
and shall forthwith distribute the balance of the Trust in equal shares to TAMMY LEIGH
DOUGHERTY's two (2) aforementioned sisters as is set forth more fully at large in the Trust
document attached hereto in Item 9 therein.
21. A Special Needs Trust under 42 U.S.C. §1396p(d)(4)(A) must be established by the
beneficiary's parents, guardians, or a court.
22. Petitioners herein also hereby seek permission to establish a prepaid funeral account,
according to the attached Malpezzi Funeral Home Pre-Arrangement Worksheet, for the benefit
of TAMMY LEIGH DOUGHERTY with the Malpezzi Funeral Home in the amount of Nine
Thousand Nine Hundred Eighty-One and No/100ths (9,981.00) Dollars, to be paid from the
approximately Twenty Thousand Eight Hundred and No/100ths ($20,800) Dollars to be
deposited into TAMMY LEIGH DOUGHERTY'S Special Needs Trust. (See Malpezzi
Worksheet attached hereto as Exhibit B.)
23. The TRUST has been submitted to the Department of Public Welfare for approval. A
copy of the approval letter is attached hereto as Exhibit C.
24. TAMMY LEIGH DOUGHERTY does have living parents and living court appointed
Plenary Guardians as is above set forth. She has been adjudicated an incapacitated person by
your Honorable Court. In an abundance of caution and at the suggestion of the Commonwealth,
Petitioners have nevertheless sought and do hereby seek and pray for an ORDER from your
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Honorable Court to officially establish the IRREVOCABLE SPECIAL NEEDS TRUST FOR
THE BENEFIT OF TAMMY LEIGH DOUGHERTY attached hereto.
WHEREFORE, Petitioners respectfully request that your Honorable Court grant the
following reliefs:
(a.) That a Court Order be entered establishing a SPECIAL NEEDS TRUST funded
with TAMMY LEIGH DOUGHERTY's currently held assets and property which the current
Co-Guardians are amenable to transferring, assigning and setting over to the proposed Co-
Trustees of the said SPECIAL NEEDS TRUST for the benefit of TAMMY LEIGH
DOUGHERTY; and,
(b.) That MILTON M. DOUGHTERY JR., DEBORAH DOUGHERTY KNAUB,
and SANDRA L. DOWNEY, be named as Co-Trustees of the said SPECIAL NEEDS TRUST;
and,
(c.) That no bond need be filed at present. In the future, if additional assets sufficient
to increase the corpus to one hundred thousand($100,000.00) dollars are added to the Trust,
Petitioners Co-Trustees are to promptly notify the Orphans' Court at which time the issue of the
need for a bond will be re-addressed.
(d) Establish a prepaid funeral account, according to the attached Malpezzi Funeral
Home Pre-Arrangement Worksheet, for the benefit of TAMMY LEIGH DOUGHERTY with
the Malpezzi Funeral Home in the amount of Nine Thousand Nine Hundred Eighty-One and
No/100ths (9,981.00) Dollars, to be paid from the approximately Twenty Thousand Eight
Hundred and No/100ths ($20,800) Dollars to be deposited into TAMMY LEIGH
DOUGHERTY'S Special Needs Trust.
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(e) Any other relief your Honorable Court deems appropriate.
Respectfully submitted,
Charles E. Shields III
Counsel for Petitioners
Attorney ID No. 38513
6 Clouser Road
Mechanicsburg, PA 17055
717-766-0209
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COURT OF COMMON PLEAS
OF CUMBERLAND COUNTY,PENNSYLVANIA
ORPHANS' COURT DIVISION
IN RE:
APPROVAL OF SPECIAL NEEDS TRUST No. 21-09-397
FOR TAMMY LEIGH DOUGHTERY, AN
ADJUDICATED INCAPACITATED PERSON
VERIFICATION
I, MILTON M. DOUGHERTY,JR., Petitioner in the attached Petition concerning
PETITION TO AUTHORIZE THE CREATION AND FUNDING OF THE
IRREVOCABLE SPECIAL NEEDS TRUST FOR THE BENEFIT OF TAMMY LEIGH
DOUGHERTY OF MECHANICSBURG, CUMBERLAND COUNTY, PENNSYLVANIA
PURSUANT TO 42 U.S.C. SECT. 1396p(d)(4)(A), hereby verify that the facts recited are true
and correct to the best of my knowledge, information and belief. I make this verification subject
to penalty for unsworn falsification to authorities (18 Pa. C.S.A. Section 4904).
Witness MILTON M. DOUGHE Y, JR.
1
COURT OF COMMON PLEAS
OF CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
IN RE:
APPROVAL OF SPECIAL NEEDS TRUST No. 21-09-397
FOR TAMMY LEIGH DOUGHTERY, AN
ADJUDICATED INCAPACITATED PERSON
VERIFICATION
I, DEBORAH DOUGHERTY KNAUB, Petitioner in the attached Petition concerning
PETITION TO AUTHORIZE THE CREATION AND FUNDING OF THE
IRREVOCABLE SPECIAL NEEDS TRUST FOR THE BENEFIT OF TAMMY LEIGH
DOUGHERTY OF MECHANICSBURG, CUMBERLAND COUNTY, PENNSYLVANIA
PURSUANT TO 42 U.S.C. SECT. 1396p(d)(4)(A), hereby verify that the facts recited are true
and correct to the best of my knowledge, information and belief. I make this verification subject
to penalty for unworn falsification to authorities (18 Pa. C.S.A. Section 4904).
.
Witness U U DEBORAH DOUGHEr KNA
2
COURT OF COMMON PLEAS
OF CUMBERLAND COUNTY, PENNSYLVANIA
ORPHANS' COURT DIVISION
IN RE:
APPROVAL OF SPECIAL NEEDS TRUST No. 21-09-397
FOR TAMMY LEIGH DOUGHTERY, AN
ADJUDICATED INCAPACITATED PERSON
VERIFICATION
I, SANDRA L. DOWNEY, Petitioner in the attached Petition concerning PETITION
TO AUTHORIZE THE CREATION AND FUNDING OF THE IRREVOCABLE
SPECIAL NEEDS TRUST FOR THE BENEFIT OF TAMMY LEIGH DOUGHERTY OF
MECHANICSBURG, CUMBERLAND COUNTY, PENNSYLVANIA PURSUANT TO 42
U.S.C. SECT. 1396p(d)(4)(A), hereby verify that the facts recited are true and correct to the best
of my knowledge, information and belief. I make this verification subject to penalty for unsworn
falsification to authorities (18 Pa. C.S.A. Section 4904).
Witness ANDRA L. DOWNEY
3
IRREVOCABLE SPECIAL NEEDS TRUST FOR THE BENEFIT
OF TAMMY LEIGH DOUGHERTY OF MECHANICSBURG,
CUMBERLAND COUNTY, PENNSYLVANIA
IN RE: TAMMY LEIGH DOUGHERTY
DOB: DECEMBER 8, 1961
SSN: 166-46-3339
COUNTY ASSISTANCE RECORD NO.:21-01-09217
CIS NO.: 7001878458
MILTON M. DOUGHERTY, JR. currently of 220 West Keller Street, in the Borough
of Mechanicsburg, Cumberland County, Pennsylvania, the natural father, next of friend, natural
guardian and court appointed Plenary Co-Guardian of the person and estate of TAMMY LEIGH
DOUGHERTY, an adult individual fifty-two (52) years of age, an Adjudicated Incapacitated
Person, who is considered "disabled" as defined by 42 U.S.C. §1382c(a)(3)(A); DEBORAH
DOUGHERTY KNAUB, currently of 225 Indian Creek Drive, in the Township of Hampden
(Mechanicsburg), Cumberland County, Pennsylvania, natural sister, next of friend and court
appointed Plenary Co-Guardian of the person and estate of the said TAMMY LEIGH
DOUGHERTY; and SANDRA L.DOWNEY, currently of 127 Victoria Drive, in the Township
of Lower Allen (Mechanicsburg) Cumberland County,Pennsylvania,natural sister,next of friend
and court appointed Plenary Co-Guardian of the person and estate of the said TAMMY LEIGH
DOUGHERTY; and the said TAMMY LEIGH DOUGHERTY by and through her said
natural father, and sisters, acting pursuant to specific court authorization and approval as per that
certain court order dated the 10`h day of June, 2009, and signed by the Honorable Edgar B.
Bayley, J., a true and correct copy of which is attached hereto as "Exhibit A" do hereby in such
capacities and as "Settlors" transfer, assign, set over, and deliver unto the said MILTON M.
DOUGHERTY, JR., DEBORAH DOUGHERTY KNAUB, and SANDRA L. DOWNEY, as
Co-Trustees ("Trustee"), all those certain assets, property, and estate described in that certain
inventory attached hereto as "Exhibit B", to constitute, together with any other assets or property
that may become subject to this Trust; the Trust Estate of an express trust, to be held,
administered and distributed by the Trustee as provided herein.
ADDITIONAL PROPERTY
I. The initial assets and property being currently transferred into this Trust are the
assets and property of TAMMY LEIGH DOUGHERTY. The said assets and property are hers
by virtue of a pecuniary legacy given to her by close family friend, Ethel R. Brubaker, in her Last
Will and Testament,dated May 30, 1995 and duly probated in the Office of the Register of Wills
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EXHIBIT A
R
in and for Cumberland County, Pennsylvania, docketed to No. 21-96-0778. Said Last Will states
in pertinent part in Item 3d:
"I give and bequeath the sum of Ten Thousand ($10,000.00) Dollars to . . .
TAMMY L.DOUGHERTY . . ."
Said legacy has not been expended. With accumulated interest it.has a current
value of approximately Twenty Thousand Eight Hundred($20,800.00) Dollars.
She is an adjudicated Incapacitated Person and a"disabled"person as above set forth and
defined. For all initial purposes, she is herein referred to as the Settlor. In its broadest sense
herein the term Settlor can also be used to refer to her above named Plenary Co-Guardians. The
said Settlor, the said Settlors, or any other person or persons, shall have the right at any time,
either during his or her or their life'or lives or by a Last Will and Testament or any other similar
grant, transfer, assignment or conveyance, to add other assets or property acceptable to the
Trustee to this Trust. Any additional assets, or property, when received and accepted by the
Trustee, shall become a part of the Trust Estate of this Trust. CAVEAT: However,no additions
may be made to this Trust after TAMMY LEIGH DOUGHERTY reaches the age of sixty-five
(65)years.
IRREVOCABLE
2. This Trust shall be irrevocable and shall not be altered, amended, revoked, or
terminated by the Settlor or any other person.
EXPRESS PURPOSES
WHEREAS, TAMMY LEIGH DOUGHERTY, bom December 8, 1961, is currently a
fifty-two (52) year old female who has been Adjudicated an Incapacitated Person and is
considered a"disabled" person as above set forth and defined;and
WHEREAS,.the said TAMMY LEIGH DOUGHERTY currently suffers from a variety
of maladies including but not limited to: severe and"profound"mental retardation, Scoliosis,and
Osteoporosis; and
WHEREAS,the prognosis for improvement in her various conditions is virtually nil; and
WHEREAS, the said TAMMY LEIGH DOUGHERTY is most likely currently eligible
to receive and may be, at the time of finalizing this Trust receiving governmental subsidies,
assistance and/or the like;
3. It is the express purpose and intent of the parties herein involved that TAMMY LEIGH
DOUGHERTY receive all government entitlements to which she would be entitled. The parties
hereto recognize that in view of the vast costs involved in caring for a disabled person a direct
distribution would be rapidly dissipated. The purpose of this Trust is to permit the use of Trust
assets to supplement and not to supplant, impair or diminish any benefits or assistance of any
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Federal, State, or other governmental entity for which TAMMY LEIGH DOUGHERTY may
otherwise be eligible or which she may be receiving and also to satisfy the requirements of Title
42 of the U.S.C. § 1396p(d)(4)(A) and the Program Operating Manual System (POMS) of the
Social Security Administration including, but not limited to, POMS S.I. 01 120.200.D2. It is also
intended that this trust will be treated as a grantor type trust for federal and state income tax
purposes and that the funding of the trust will not he subject to federal and state gift taxation.
Any provision of this Trust which may prevent this Trust from satisfying full compliance
with Title 42 of the U.S.C. § 1396p(d)(4)(A) and the POMS shall be deemed and considered to
be and shall be null and void and of no force or effect.
This Trust shall be initially funded with the assets described in Paragraph I and also
described in"Exhibit B" attached hereto.
One of the several important purposes of this Trust is to enable TAMMY LEIGH
DOUGHERTY to qualify for Medical Assistance under the Medicaid program as provided for
by Section 1396p(d)(4)(A) of Title 42 of the United States Code as enacted by the Omnibus
Budget Reconciliation Act of 1993 ("OBRA 1993"); the Supplemental Security Income ("SSI)
Program; and any other governmental program. This Trust is created pursuant to § 3257.6 of the
Health Care Financing Laws (HCFL) and of the Health Care Financing Administration (HCFA)
Transmittal No. 64. In the administration of this Trust, Trustee shall do all acts necessary to
establish and maintain TAMMY LEIGH DOUGHERTY's eligibility for Medicaid Assistance
under the HCFL then in effect.
A. Although this Trust is an Irrevocable Trust, if there is any change in relevant
federal or state taws, rules, regulations or policies concerning Disability Annuity
Trusts, or other similar Trusts which may have an effect upon this Trust, its
purposes, intentions and/or administration, the Co-Trustees are instructed to
administer and distribute the Trust assets and income according to such revised
laws, rules, regulations and policies, unless such change is more restrictive than
current law and if this Trust instrument would be exempt from such change.
B. Further, to the extent permissible and reasonably necessary, the Co-Trustees are
authorized to amend this Trust document to conform with changes made,
subsequent to the execution of this Trust, in federal or state laws, rules,
regulations or policies, to effect the purpose of this Trust, if this Trust is not
"grandfathered" from such changes or to make the Trust comply with
interpretations of federal or state laws, rules, regulations or policies so that the
Beneficiary's eligibility for Medical Assistance and the like is preserved.
4. The Trust Estate shall NOT be used to provide basic food, clothing and shelter,
nor be available to TAMMY LEIGH DOUGHERTY for conversion for such items, unless all
local, state, and federal benefits have been filly expended for such purposes. It is the express
purpose of the Settlors / Trustors to establish the Trust in accordance with 42 U.S.C. §1396p
(d)(4)(A),and any provisions herein shall be construed accordingly.
Page 3
f
EXPENDITURES
5. During the lifetime of TAMMY LEIGH DOUGHERTY (hereinafter, the
"Beneficiary"), the Trustee may expend for her benefit, so much of the net income and, if
necessary, principal of the Trust Estate to carry out the purposes set forth in the above recitals, as
the Trustee, in its sole and absolute discretion, considers advisable, in view of other funds or
benefits available from governmental or other sources, both public and private, of which it has
knowledge. CAVEAT: Any and all distributions and expenditures from this Trust must be and
shall be for the sole benefit of TAMMY LEIGH DOUGHERTY.
6. ILLUSTRATIVE EXAMPLES OF TRUST EXPENDITURES AND
DISTRIBUTIONS: Distributions by Trustee for the benefit of TAMMY LEIGH
DOUGHERTY, which are not required but may be appropriate and are consistent with the terms
of this Trust and pursuant to POMS SI 01120.201.1,include but are not limited to the following:
A. Any and all reasonable expenses incident to the implementation of a "life care
plan" for TAMMY LEIGH DOUGHERTY, as recommended by certified life
care planners, physicians, care managers, therapists, counselors, technicians,
rehabilitation specialists, nutritionists, home modification and accessibility
specialists, or other care providers;
B. Medical, dental, rehabilitative, therapeutic and diagnostic treatments, therapies,
interventions, evaluations, care and equipment, whether or not experimental,
necessary or life-saving, including but not limited to vision care, prosthetic and
orthotic devices, mobility and adaptive aids, stabilizers, monitors, appliances,
braces, wheelchairs (powered or manual), adaptive tools and instruments, and the
cost of maintaining, repairing and periodically replacing or updating same, except
for that care that would be provided by any benefits or assistance of any Federal,
state, county, city, or other governmental entity for which TAMMY LEIGH
DOUGHERTY may otherwise be eligible or receiving;
C. Professional therapy and behavior management programs, including but not
limited to occupational, speech, music, art, language and communication,
physical, psychological, audiological, recreational, social skills, emotional and
behavioral therapy and counseling and all related costs, including but not limited
to the equipment or tools used in connection with such therapies and the related
cost of training TAMMY LEIGH DOUGHERTY, to maximize the benefits to
TAMMY LEIGH DOUGHERTY, except for that care that would be provided
by any benefits or assistance of any Federal, state, county, city, or other
governmental entity for which TAMMY LEIGH DOUGHERTY may otherwise
be eligible or receiving;
D. Medical, physical, and mental health care needs of TAMMY LEIGH
DOUGHERTY, including but not limited to physicians' office visits, prescription
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medications, evaluations, treatments, injections, surgeries, laboratory tests,
procedures, hospitalizations, and diagnostics, including experimental procedures,
treatments and visits related thereto, except for that care that would be provided
by any benefits or assistance of any Federal, state, county, city, or other
governmental entity for which TAMMY LEIGH DOUGHERTY may otherwise
be eligible or receiving;
E. Reasonable compensation and appropriate expenses for TAMMY LEIGH
DOUGHERTY's care givers, professional, rehabilitative, vocational, attendant,
respite or custodial, as well as for the services of a "case manager," or other
advisor who is experienced in overseeing the implementation of life care plans for
individuals such as TAMMY LEIGH DOUGHERTY, and who is familiar with
related governmental or private entitlement or assistance programs, except for that
care that would be provided by any benefits or assistance of any Federal, state,
county, city, or other governmental entity for which TAMMY LEIGH
DOUGHERTY may otherwise be eligible or receiving;
F. Attendant care and adaptive aids and equipment for TAMMY LEIGH
DOUGHERTY's personal needs, including but not limited to bathing, dressing,
grooming, hygiene, skin care, nutrition and meal preparation, and other activities
of daily living, as well as domestic services and other household maintenance
services, except for that care that would be provided by any benefits or assistance
of any Federal, state, county, city, or other governmental entity for which
TAMMY LEIGH DOUGHERTY may otherwise be eligible or receiving;
G. Private insurance coverage for TAMMY LEIGH DOUGHERTY, including but
not limited to premiums attributable to health, life, disability, and accident
insurance, as well as co-payments and deductible amounts with respect to any
insurance covering TAMMY LEIGH DOUGHERTY;
H. Travel costs for TAMMY LEIGH DOUGHERTY as are necessary or
appropriate, associated with access to medical, physical and/or mental health care
services of all types;
1. Tuition, fees, costs and expenses related to educational and training needs and
opportunities of all types, at private or public institutions, and all expenses related
thereto, whether vocational, elementary, undergraduate, professional or graduate
schools, including special education aides and assistants as well as private tutoring
outside of the traditional educational setting, including educational or workshop
programs specializing in serving persons with disabilities or impairments such as
those of TAMMY LEIGH DOUGHERTY;
J. Travel and transportation costs for TAMMY LEIGH DOUGHERTY, to and
from any school or residential accommodation removed from the residence of
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TAMMY LEIGH DOUGHERTY's;
K. Purchase of a residence for TAMMY LEIGH DOUGHERTY, customized and
adapted to accommodate her special needs, with title to such real estate to be held
by the Trustee as an asset of the Trust Estate, as well as the expense of securing,
insuring (at replacement cost), and maintaining such residence, and the land
adjoining same, in good condition and repair, and the cost of additional household
assistants to accommodate the limitations and needs of TAMMY LEIGH
DOUGHERTY while living in the residential setting;
L. Structural and/or non-structural alterations or adaptations to a residence, which
are necessary or appropriate to accommodate TAMMY LEIGH
DOUGHERTY's special needs or disabilities, as well as the expense of securing,
insuring(at replacement cost), and maintaining such alterations or adaptations;
M. Appropriate modes of transportation for TAMMY LEIGH DOUGHERTY, or
for her benefit, including but not limited to vans or automobiles specially
equipped and adapted for TAMMY LEIGH DOUGHERTY's particular
disability, and the cost of insuring, maintaining, repairing and periodically
replacing such transportation. CAVEAT: However, any improvements or
upgrades to such vehicles must be for the sole benefit of TAMMY LEIGH
DOUGHERTY.
N. Appropriate home-based and community-based recreational opportunities and
social initiatives, and the expenses and travel costs of TAMMY LEIGH
DOUGHERTY associated with access to such opportunities and social
initiatives;
O. Appropriate furniture and furnishings required for the care of TAMMY LEIGH
DOUGHERTY, customized and adapted to her use, and periodic replacements of
such items;
P. Expenses associated with periodic vacations and sabbaticals for the benefit of
TAMMY LEIGH DOUGHERTY;
Q. Such technological. equipment as may enhance TAMMY LEIGH
DOUGHERTY's quality of life or education or training, including but not limited
to television, audio and video recording equipment, computers, augmented
communication systems, related software and hardware, including the cost of
training TAMMY LEIGH DOUGHERTY, in the proper use of such equipment
to maximize the benefit to TAMMY LEIGH DOUGHERTY;
R. Professional services rendered for the benefit of TAMMY LEIGH
DOUGHERTY, including but not limited to, the legal fees and costs associated
with the preparation, execution, funding, administration and termination of this
Page 6
Trust Agreement, as well as ongoing fiduciary, legal, accounting, bookkeeping
and other services as may be necessary or appropriate for the Trustee in
administering this Trust for the benefit of TAMMY LEIGH DOUGHERTY;
S. Improvements to a vehicle to protect the safety of TAMMY LEIGH
DOUGHERTY. Any such improvements must be for her sole benefit; and
T. A funeral Trust fund for burial and a suitable gravestone or marker. CAVEAT:
The expenses for these must be reasonable as per TAMMY LEIGH
DOUGHERTY'S station in life.
7. EARLY TERMINATION PROVISIONS
The provisions of this Article govern Early Terminations, defined as a provisions or clause that
would allow a trust to terminate before the death of the beneficiary as provided in the Social
Security Administration's Program Operations Manual System ("SSA POMS") Section SI
01120.199. Under no circumstances may TAMMY LEIGH DOUGHERTY have the power to
cause an Early Termination.
A. Early Termination if Eligibility Terminates
The Trustee, in the Trustee's sole and absolute discretion, may terminate the trust
if TAMMY LEIGH DOUGHERTY's eligibility for either Supplemental
Security Income or Medicaid is terminated.
B. Early Termination if Insufficient Assets
The Trustee, in the Trustee's sole and absolute discretion, may terminate the trust
if the trust assets have been reduced to the point that continued administration is
not financially justified.
C. Disposition of Trust Assets Upon Early Termination
In the event of an Early Termination,the Trustee will dispose of the trust assets as
follows:
(i) first, the Trustee may pay the expenses allowed in SSA POMS
Section SI 01120.199F.3, as amended, which are specified in D under this
Section 7, entitled "Allowable Administrative Expenses Paid from the
Trust," being mindful of the prohibited expenses specified in Section 9.A,
entitled "Prohibited Expenses and Payments,"below;
(ii) second,the Trustee must reimburse the state as provided in Section
9.13, entitled"Reimbursement to State,"below; and
Page 7
(iii) finally, the Trustee must disburse all remaining trust assets to
TAMMY LEIGH DOUGHERTY outright.
No entity may benefit from the Early Termination, other than payment of
expenses in accordance with SSA POMS Section SI 01120.199F.3, as amended,
which are specified in Section D, entitled "Allowable Administrative Expenses
Paid from the Trust,"below.
D. Allowable Administrative Expenses Paid from the Trust
In the event of an Early Termination, the following types of administrative
expenses may be paid from the trust prior to reimbursement of medical assistance
to Pennsylvania(or any other state):
(i) taxes due from the trust to Pennsylvania (or any other state) or the
federal government due to the termination of the trust; and
(ii) reasonable fees and administrative expenses associated with the
termination of the trust.
For example, payment for an accounting of the trust to a court, completion and
filing of documents, or other required actions associated with termination and
wrapping up of the trust.
E. Savings Clause
In the event that the mere existence of a provision giving the Trustee discretion to
terminate the Trust and make distributions would result in a reduction or loss of
TAMMY LEIGH DOUGHERTY's entitlement program benefits, regardless of
whether the Trustee actually exercises the discretion, then such provision will be
null and void,ab initio.
8. PUBLIC ASSISTANCE PROGRAMS
A. Public Resources—Trustee may, in the exercise of Trustee's best judgment and
fiduciary duty, assist in any application on behalf of TAMMY LEIGH
DOUGHERTY for all available public benefits. Trustee shall take into
consideration the applicable resource and income limitations of any public
assistance program for which TAMMY LEIGH DOUGHERTY is eligible. All
costs relating thereto, including reasonable attorneys'fees, shall be a proper charge
to the Trust. It is intended that no part of the corpus of the Trust created herein
shall be used to supplant or replace public assistance benefits of any county, state,
federal or other governmental agency.
B. Maintain Public Assistance Eligibility—If Trustee is required to release principal
or income of the Trust to or on behalf of TAMMY LEIGH DOUGHERTY to
Page 8
pay for benefits or services which such public assistance is otherwise authorized
to provide, were it not for the existence of this Trust, or if Trustee is requested to
petition the court or any other administrative agency for the release of Trust
principal or income for this purpose, Trustee is authorized to deny such request
and is authorized in Trustee's discretion to take whatever administrative or judicial
steps may be necessary to continue the public assistance program eligibility of
TAMMY LEIGH DOUGHERTY, including obtaining instructions from a court
of competent jurisdiction ruling that the Trust corpus is not available for
TAMMY LEIGH DOUGHERTY for such eligibility purposes.Any expenses of
Trustee in this regard, including reasonable attorneys' fees, shall be a proper
charge to the Trust. No Trustee shall be liable for any loss of Trust assets, except
for any loss caused by Trustee's bad faith, wanton conduct or negligence.
ADMINISTRATION OF THE IRREVOCABLE SPECIAL NEEDS TRUST FOR THE
BENEFIT OF TAMMY LEIGH DOUGHERTY UPON TAMMY LEIGH
DOUGHERTY'SDEATH
9. Upon TAMMY LEIGH DOUGHERTY'S death, all of the trust property not
previously distributed pursuant to prior Articles of this agreement will be administered as
follows:
(i) first, the Trustee must reimburse the state as provided in B under
this Section 9, entitled"Reimbursement to State,"below;
(ii) second, the Trustee may pay the expenses specified in C under this
Section 9,entitled"Payment of Expenses and Taxes,"below;and
(iii) finally, the Trustee will distribute the remainder of the trust
property as specified in E under this Section 9, entitled "Distribution of
Remaining Trust Property,"below.
A. Prohibited Expenses and Payments
The following expenses and payments are examples of some of the types not permitted
prior to reimbursement to Pennsylvania (or any other state)for medical assistance:
(i) taxes due from the estate of the beneficiary (TAMMY LEIGH
DOUGHERTY) other than those arising from inclusion of the
trust in the estate;
(ii) inheritance taxes due for residual beneficiaries;
(iii) payment of debts owed to third parties;
(iv) funeral expenses; and
(v) payments to residual beneficiaries.
Page 9
Note: For the purpose of prohibiting payments prior to reimbursement of medical
assistance to Pennsylvania (or any other state), a pooled trust is not considered a residual
beneficiary.
B. Reimbursement to State
The Department of Public Welfare, or other appropriate Medicaid entity within
Pennsylvania, and any other state, must he reimbursed for the total Medical Assistance
provided to TAMMY LEIGH DOUGHERTY during her lifetime, as is required by
federal and state Iaw. If TAMMY LEIGH DOUGHERTY received Medicaid in more
than one state, then the amount distributed to each state will be based on each state's
proportionate share of the total amount of Medicaid benefits paid by all states on
TAMMY LEIGH DOUGHERTY's behalf. In no event may any trust assets be used for
TAMMY LEIGH DOUGHERTY's funeral expenses until the reimbursement
provisions of this paragraph are satisfied. Under no circumstances may the total amount
of trust assets used to reimburse the Department of Public Welfare, and any other
appropriate Medicaid entity within Pennsylvania, and any other state, exceed the amount
of Medicaid benefits paid to TAMMY LEIGH DOUGHERTY or on her behalf during
her lifetime.
C. Payment of Expenses and Taxes
Upon full reimbursement to the Department of Public Welfare, or other appropriate
Medicaid entity within Pennsylvania, and any other state, as provided in B of this Section .
9,the Trustee may pay-
(i) any and all expenses of TAMMY LEIGH DOUGHERTY's last
illness,funeral and burial or cremation, including memorials and memorial
services in connection therewith;
(ii) any and all death taxes imposed on TAMMY LEIGH
DOUGHERTY's estate;
(iii) court fees of probate, administration, or estate proceedings related
to TAMMY LEIGH DOUGHERTY's estate; and
(iv) any and all legal and accounting fees related to TAMMY LEIGH
DOUGHERTY's estate.
D. Contingent Supplemental Needs Trust Prohibition Against Reimbursements
The provisions of this paragraph only apply if another provision of this trust agreement so
directs.
The Trustee may not make payments for expenses incurred prior to TAMMY LEIGH
DOUGHERTY's death if the Trustee determines, in the Trustee's sole and absolute
discretion, that the payments are the obligation of any county, state, federal or other
Page 10
governmental agency that has a legal responsibility to serve persons with disabilities that
are the same as or similar to TAMMY LEIGH DOUGHERTY's.
E. Distribution of Remaining Trust Property
Subject to the provisions of B under this Section 9,entitled"Reimbursement to State"the,
Trustee will distribute the remaining trust property as specified in this paragraph E under
Section 9. However, if at the time of distribution a beneficiary is a Supplemental Needs
Person, then the Trustee will hold and administer the beneficiary's share as a
supplemental needs trust under the same terms as this trust (substituting the beneficiary
for TAMMY LEIGH DOUGHERTY), excluding the provisions of Section 7, "Early
Termination Provisions," and B under this Section 9, entitled "Reimbursement to State,"
but including the provisions of D under this Section 9,entitled "Contingent Supplemental
Needs Trust Prohibition Against Reimbursements."
Further, if at the time of distribution a beneficiary is not a Supplemental Needs Person,
but is incapacitated or under the age of 25, then the beneficiary's share will be held or
distributed pursuant to the terms of paragraphs 12, 13, 14 under the title "Distribution to
Any Minor."
If there is no such reimbursement due to the Commonwealth of Pennsylvania and/or any
other governmental entity, or any remaining balance after the reimbursement to the
Commonwealth of Pennsylvania and/or any other governmental entity,then the remaining
balance of the Trust Estate and any accumulated, undistributed net income after the
payment of all death and other taxes that may first be due thereon shall be distributed as
follows:
(i) All the then remaining balance shall he divided into two (2) equal
shares. One share thereof shall go to the Beneficiary's sister,the aforesaid
DEBORAH DOUGHERTY KNAUB and the other share thereof shall go
to the Beneficiary's other sister,the aforesaid SANDRA L.DOWNEY,in
their own respective rights and absolutely.
(ii) In the event that DEBORAH DOUGHERTY KNAUB has
predeceased the beneficiary,then to her issue,per stirpes. In the event she
is not survived by issue,then to SANDRA L. DOWNEY, or her issue,per
surges,as the case may be.
(iii) In the event that SANDRA L. DOWNEY has predeceased the
beneficiary, then to her issue, per stirpes. In the event she is not survived
by issue,then to DEBORAH DOUGHERTY KNAUB, or her issue,per
stirpes, as the case may be.
Page I t
SPENDTHRIFT CLAUSES
10. Notwithstanding any other provision of this Irrevocable Special Needs Trust, the
Beneficiary, TAMMY LEIGH DOUGHERTY, shall not and does not have the power to
assign,encumber,direct,distribute or authorize distribution from the Trust established hereby.
11. No other beneficiary herein, vested or contingent, shall have the power to sell,
assign, encumber, or in any manner anticipate his or her interest in the Trust Estate, or in the
income produced thereby.
DISTRIBUTION TO ANY MINOR
12. If any beneficiary who is entitled to receive a share of the principal of the Trust
Estate shall be a minor, the Trustee is hereby authorized and empowered to continue to hold and
manage such share for the benefit of the minor during his or her minority as the minor's guardian
and may use all of the income from the minor's share,together with such amounts of principal as
the Trustee deems advisable for his or her health, education, maintenance, and support. This
shall be construed as a power only and shall not operate to suspend the absolute ownership
thereof by the minor nor to prevent the absolute vesting thereof in the minor.
13. In the disbursement of the funds directed to be paid to or for the use and benefit of
any beneficiary who shall be a minor, the Trustee may make payment of the same to the parent,
guardian, or such other person who may have custody of the person of that minor at the time such
payments are made, to be used for the health, education, maintenance, and support of the minor,
but without liability on the part of the Trustee to see to the application of said payments by the
payee. The receipt of any such person shall be a full acquittance of the Trustee as to any amounts
so paid; or the Trustee may make payment of the same directly to or for the benefit of the minor
beneficiary.
14. For purposes of interpretation of this Trust, the word "minor" whenever used
herein shall mean any person under the age of eighteen(18)years, notwithstanding any law to the
contrary.
ADDITIONAL POWERS OF TRUSTEE
15. In addition to the powers conferred by law, the Trustee shall have the following
discretionary powers which may be exercised without approval of any court:
A. To retain any and all property, real or personal, without any duty of
diversification.
B. To sell any and all real estate held as a trust asset, at public or private sale, for
such prices and upon such terms as the Trustee shall believe advisable, and to
make, execute, and deliver any deed or deeds therefor, conveying title thereto in
fee simple absolute or for any lesser estate to any purchaser or purchasers, freed
and discharged of any and all trusts hereunder.
Page 12
C. To sell, grant options to purchase, exchange, and alter assets of any trust created
hereunder or of any part thereof, at any price and upon such terms which the
Trustee shall deem proper.
A. To invest and reinvest in all forms of property, including but not limited to
common and preferred stocks,or any bond or other debt security.
E. To retain the services of any financially responsible professional investment
manager, special needs advisor, brokerage service, bank,credit union,savings and
loan association or other financial institution to assist and advise the Trustee in the
management and investment of the assets of the Trust Estate,including to execute
security transactions through such institution or institutions.
F. To purchase real property whether improved or not and to lease property on any
terms and conditions and for any term of years, even though extending beyond the
period of any trust created hereunder.
G. To insure, improve, repair, alter, abandon, and partition real estate; erect or raze
improvements; grant easement; subdivide and dedicate to public use.
H. To cause any of the investments which may be delivered or acquired by the
Trustee to be issued, held, or registered in the name of the Trustee, in street name
negotiable form, in the name of the nominee, or in any form in which title will
pass by delivery. Any corporation or its transfer agent may presume conclusively
that said nominee is the actual owner of the securities submitted for transfer.
1. To vote in person or by proxy any securities held in the Trust Estate and, in such
connection,to delegate powers,discretionary or otherwise,for any purpose to one
or more nominees or proxies with or without power of substitution and to make
assignments to and deposits with committees, trustees, agents, depositories and
other representatives; to retain any investments received in exchange in any
reorganization or recapitalization; to subscribe for stocks and bonds; to grant,
obtain or exercise options; and generally to exercise all rights of security holders.
J. To settle,compromise,contest or abandon claims or demand in favor of or against
any trust created hereunder.
K. To borrow money, assume indebtedness, extend mortgages, and encumber by
mortgage or pledge.
L. 'To distribute the principal of any trust created hereunder in kind or in cash, or
parry in kind and party in cash.
M. To allocate receipts and disbursements to principal or income,or partly to each as
the Trustee deems proper.
Page 13
N. To retain a consultant knowledgeable in the subject of Medical Assistance and/or
Medicare benefits or other public or private benefits available to the Beneficiary
and to advise the Trustee concerning discretionary distributions of income or
principal so that such distributions will be made in a manner consistent with the
purpose of the Trust.
O. To deal in every way and without limitation with the representatives of any trust
or estate in which the Beneficiary has any existing or future interest, even though
the Trustee is acting as the representative of such other trust or estate, without
liability for loss resulting from said transaction.
P. To employ such agents, attorneys, accountants, investment counsel, and
professional advisors as may be required in managing, protecting and investing
the assets of the Trust Estate and to pay their reasonable compensation.
Q. To pay any taxes due from or by the trust from time to time, and to file all proper
tax returns.
16. The Co-Trustees C"Trustee") may act in all matters individually or jointly; the
actions of any individual Co-Trustee shall be construed by all persons having dealings therewith
as being with the full knowledge and authority of the other Co-Trustees, unless such persons
have prior written notice to the contrary from another Co-Trustee.
SUCCESSOR TRUSTEES
17. If any of the above-named Co-Trustees, to wit: MILTON M. DOUGHERTY,
JR., DEBORAH DOUGHERTY KNAUB and/or SANDRA L. DOWNEY, ceases or cease to
act as Trustee, then the remaining individual Co-Trustees shall continue and assume jointly and
individually the rights, powers, and obligations of Trustee. Although highly unlikely given the
number of and the ages of the aforesaid Co-Trustees, if all of the said Co-Trustees cease to act
hereunder for any reason, then a suitable replacement Trustee shall be submitted upon Petition,to
the Orphans' Court for approval. Upon transfer of the assets of the Trust Estate, the predecessor
Trustee(s) shall provide an accounting to the Successor Trustee, with a copy to the Third Party
Liability Section of the Department of Public Welfare. No Successor Trustee shall he liable for
any act or failure to act of a predecessor Trustee. A Successor Trustee may accept the account
furnished, if any, and the property delivered by or from a predecessor Trustee without liability for
doing so. If no objection is made promptly by the Agency, such acceptance shall be a full and
complete discharge to the predecessor Trustee.
ACCOUNTINGS
18. The Co-Trustees shall provide a written account, annually or otherwise as may be
deemed appropriate and convenient or as may be required by then current rules and regulations,
of their activities on behalf of the Trust to the Third Party Liability Section of the Department of
Page 14
Public Welfare and may, at its option, file formal accountings with the Orphans' Court from time
to time, costs therefor to be paid from the Trust.
TRUSTEE COMPENSATION
19. Any Trustee which may be acting hereunder, shall be entitled to deduct as
compensation reasonable fees, and for any corporate trustee, if any there be, the fees shall be in
accordance with the then prevailing rate of compensation charged by it or such other Trustee for
like services at the time such services are rendered. In addition to such Trustee's normal
compensation, such Trustee shall be entitled to deduct such fees as shall reasonably compensate
such Trustee for such additional services which such Trustee may be required to perform, and to
employ and pay any other person including but not limited to accountants, attorneys, or any other
similar party employed by the Trustee in aiding and assisting Trustee in the carrying out of
Trustee's duties.
WAIVER OF BOND
20. Settlors and Co-Guardians respectfully request that no bond be required in any
jurisdiction of any Trustee or of any Successor Trustee unless required by and then only to the
extent required by the regulations or policies of the Pennsylvania Department of Public Welfare
or by any other governmental entity. Current policy of the Department of Public Welfare
requires a bond for non-corporate, non-lawyer Trustees if the Trust corpus exceeds One Hundred
Thousand ($100,000.00)Dollars. Corpus herein will be well below said threshold amount.
The rest of this page has intentionally been left blank.
Page 15
ACCEPTANCE AND APPROVALS
21. This Trust Agreement has been delivered to and accepted by the Co-Trustees in
the Commonwealth of Pennsylvania, and all questions pertaining to the validity and
interpretation of this Trust Agreement and to the management and distribution of the Trust Estate
hereunder shall be determined in accordance with the laws of the Commonwealth of
Pennsylvania,and any applicable federal law or regulation.
22. This Trust document has been submitted to and approved by counsel for the
Department of Public Welfare of the Commonwealth of Pennsylvania, which department has
indicated its consent to its establishment as is evidenced by letter of counsel attached hereto as
"Exhibit C".
IN WJ ESS WHE OF,t e Settlors,and Co-Trustees have hereunto set their hands and seals as of this 13
day of = 2013.
Settlors certify that they have read this agreement, that they understand it,and that it correctly states the provisions
and hich the„3xu t prope is to b adminis ered and distributed by the Trustee(s).
&� � .
MILTON M.DOUGHERTY,AIL,as na al father,riatural guardian,next of friend,Plenary Co-Guardian of the
person and estate of Tammy Leigh Dougherty,,and as ettlor and Co-Trustee of this Trust Estate.
DEBORAH DOUGHERTY; AUB, na 1 sister,next of friend,Plenary Co-Guardian of the person and
estate ammy Leigh ou a nd Settlor nd Co-Trustee of this Trust Estate.
fxue t4
ANDRA J..DOWNEY,as natural sister,next of nd,Plenary Co-Guardian of the person and estate of Tammy
Leigh Dougherty,and as Settlor and Co-Trustee of s Trust Esta ?
Wi ess: Witness:
ell
Address Address
COMMONWEALTH OF PENNSYLVANIA )
} Ss.:
COUNTY OF CUMBERLAND )
On this day, /'" J , 20 , before me personally appeared Milton M. Dougherty, Jr., Deborah
Dougherty Knaub, and Sandra L. Downey, personally known to me (or proved to me on the basis of satisfactory
evidence)to be the individuals whose names are subscribed to the foregoing instrument,and acknowledged that they
executed the same as their voluntary act and deed for the purposes therein contained.
Witness my hand and official seal.
[Seal]
CDWM& XMOrPBff0AVAJBA
NOTARIAL SEAL Notary Publi
REBECCA L STARK
Notary Paeik
UPPER ALLEN MR,CUMBERLAND CNTY
Atp CommWFon 6cpfree Aky 29,2077
Page 16
S
EXHIBIT B FOR
TAMMY LEIGH DOUGHERTY SPECIAL NEEDS TRUST
INITIAL INVENTORY
Assets to be used to provide initial funding for the IRREVOCABLE SPECIAL NEEDS
TRUST FOR THE BENEFIT OF TAMMY LEIGH DOUGHERTY of Mechanicsburg,
Cumberland County,Pennsylvania:
Current value of money gifted to TAMMY LEIGH DOUGHERTY by Ethel R.
Brubaker, deceased, in Item 3d of her duly probated Last Will and Testament as appears more
fully at large in Paragraph I of the said TRUST:
$20,800.00
Page 17
Malpezzi Funeral Home
Pre-Arrangement Worksheet
Pre-arranged runeral for I A. ,, Date A Zoill
Address ity/State
A. Charges For Services Selected C. Special Charges
Professional Services Forwarding of remains to
I. Services of Funeral Director&Staff S__ \
2. Embalming $ i -t (Funeral Home)
3. Other preparation of the body .� " S Receiving of remains from
i�rb,s;��,�'istrik; hf t4t6A� S-i&A— $
Immediate Burial $
Use of the Facilities Direct Cremation S
I. Use of facilities and services for Other S
Viewing(visitation/wake) S Total Special Charges.... .. ... ...S -o -
2. Use.of facilities and services for
Funeral.ceremony $_tx�_ D. Cash Advances
3. Use of facilities and services for 1. Opening Grave S q5c)
Memorial service S 2, Cemetery Equipment S zx C6
4. Use of equipment and services for r)
3. Newspaper Notices-Local S 150
Graveside service $=•\_ 4. Newspaper Notices-Out=of-town$
5. Other use of facilities 5. Airfare S
$ 6. Clergy Honorarium S id0
7.Automotive Equipment & Music , $
1. Vehicle to transfer remains to 8. Certified Copies of DC's�� $ 3c
� 9. Flowers $i6,(o__
Funeral Home $1msl__. 14. Vault Service Charge $
2. Hearse(Funeral Coach) S :,Cl 11 $
3. Limousine S 12 S
4. Family Car S 13 $
5. Flower Car or Floral disposition $__LEL 1.4. $
6. Lead/Clergy Car Total-of'Cash Advances.. . . . . .. ... .S IS3(c
7. Out of town transportation S
Total of Professional Services,Facilities
And Automotive Equipment. .. . . . ... S 5475- Total of All Selections S ? 191 e S_4;k Ae9
B. Charges For Merchandise�Selected
Ciskei Selected_y -4jL E— 17A11'en_ Description of Services& Special Instructions
W3 _$ el.__ t�ki�.M1 1 iFi� V. AA.
C $ b7 1toc� 4 l;, I 1JA t 1+ Mr t1ANC 6
Outer Burial Container Selected
C""reA. GrA.S-
S39r
Register Book(s) S
-Memory Folders S
Prayer Cards S
Cremation Um $
Clouting $ Reason For Embalming
Other Merchandise S _ !='er -DU 61;' WCA',' i
Total Merchandise Selected . . . . . S Z9-ro
This is not a Purchase Contract
Prearrangement worksheet.doc EXHIBIT B
COMMONWEALTH OF PENNSYLVANIA
GOVERNOR'S OFFICE OF GENERAL COUNSEL
December 31,2013
Via email(iessica @kevstoneelderlaw.com) Via email(ceshields3 @comcast.netl
and Regular Mail and Regular Mail
Jessica Fisher Greene,Esq. Charles E. Shields,III,Esq.
Keystone Elder Law 6 Clouser Road
555 Gettysburg Pike,Suite C-10 Mechanicsburg,PA 17055
Mechanicsburg,PA 17055
Re: The Irrevocable Special Needs Trust for the Benefit of Tammy
Leigh Dougherty of Mechanicsburg,Cumberland County,
Pennsylvania
Dear Ms. Greene:
I reviewed the Special Needs Trust that you prepared on behalf of the above-named
disabled beneficiary. The Commonwealth of Pennsylvania's Department of Public Welfare has
no objection to this Special Needs Trust("SNT").
The disabled beneficiary's assets used to fund the SNT will not be considered an i
available resource in determining her eligibility for Medical Assistance. If the beneficiary has
other assets that are not part of the SNT,the County Assistance Office("CAO")may determine
that she is not eligible for Medical Assistance. In order to assist the Department in making its
determination of Medical Assistance eligibility,please provide to the CAO (with a copy to me)
the documentation regarding the funding of this SNT,if not already provided, and any
subsequent additions to the SNT.
Thank you for your continued cooperation with the Department. If you have any
questions,please feel free to contact me.
V/er truly yours
r
Addle A. Abelson
Assistant Counsel
cc: Special Needs Trust Depository (via e-mail) E
jt
t
OFFICE OF CHIEF COUNSEL I DEPARTMENT OF PUBLIC WELFARE
30.p FL.WEST, HEALTH&WELFARE BLDG, 1 625 FORSTER STREET i HARRISBURG,PA 17120 --
Ph: 717-783-2800 1 Fx: 717-772-0717 1 www.dow.state.oa.us
EXHIBIT C
� �
i