HomeMy WebLinkAbout03-04-15 J 15056184D3
J'��' pennsYIvania
���f�� DEPARTMENTOFREVEN�X(03-14)
REV-1500 OFFICIAL USE ONLY
Bureau of Individual Taxes County Code Year File Number
Po Box 28oso� INHERITANCE TAX RETURN
HarrisburQ PA 17128-0601 RESIDENT DECEDENT 21 15 0191
ENTER DECEDENT INFORMATION BELOW
Social Security Number Date of Death MMDDYYYY Date of Birth MMDDYYYY
205 03 7580 11 29 2014 09 16 1920
DecedenYs Last Name Suffix DecedenYs First Name M�
TERSIGNI FRANCES
(If Applicable)Enter Surviving Spouse's Information Below
Spouse's Last Name Su�x Spouse's First Name M�
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
FILL IN APPROPRIATE OVALS BELOW
� 1. Original Return � 2. Supplemental Return � 3. Remainder Return(date of death
prior to 12-13-82)
� 4. Agricultural Exemption(date of � 5. Future Interest Compromise(date of � 6. Federal Estate Tax Return Required
death on or after 7-1-2012) death after 12-12-82)
� 7. Decedent Died Testate � S. Decedent Maintained a Living Trust � 9. Total Number of Safe Deposit Boxes
(Attach copy of will) (Attach copy of trust.)
� 10. Litigation Proceeds Received � 11. Non-Probate Transferee Return � 12. Deferral/Election of Spousal Trusts
(Schedule F and G Assets Only)
� 13. Business Assets � 14. Spouse is Sole Beneficiary
(No trust involved)
CORRESPONDENT-THIS SECTION MUST BE COMPIETED.ALL CORRESPONDENCE AND CONFIDENTIAL TAX INFORMATION SHOULD BE DIRECTED T0:
Name Daytime Telephone Number
CHRISTOPHER E RICE 717 243 3341
First Line of Address
10 EAST HIGH STREET
Second Line of Address
City or Post Office State ZIP Code
CARLISLE PA 17013
CorrespondenYs email address: crice(a�martsonlaw com
REGISTER OF WILLS USE ONLY
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REGISTER OF WILLS USE ONLY `-�—� """
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DATE FILED MMDDYYYY t-
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DATE F4LED STAMP
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I I��I�I II��I�IIII��I�I�III��II�I II��I I�III�I�II��I��IIII I��I 15 0 5 618 4 0 3 � �
� 1505618403
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� 1505618411
REV-1500 EX
Decedent's Social Security Number
DecedenYsName T@�Slglll, Frances 205 03 7580
RECAPITULATION
1. Real Estate(Schedule A)....................................................................................... 1.
2. Stocks and Bonds(Schedule B)............................................................................. 2.
3. Closely Held Corporation, Partnership or Sole-Proprietorship(Schedule C)......... 3.
4. Mortgages and Notes Receivable(Schedule D).................................................... 4.
5. Cash, Bank Deposits and Miscellaneous Personal Property(Schedule E).......... 5. 17, 4 8 2 • 8 7
6. Jointly Owned Property(Schedule F) ❑ Separate Billing Requested............ 6.
7. Inter-Vivos Transfers&Miscellaneous Non-Probate Property
(Schedule G) ❑ Separate Billing Requested............ 7. 12 5,9�4 • 2 8
8. Total Gross Assets(total Lines 1 through 7)........................................................ 8. 14 3,3 8 7 • 15
9. Funeral Expenses and Administrative Costs(Schedule H).................................... 9. 9,9 41 • 6 5
10. Debts of Decedent,Mortgage Liabilities and Liens(Schedule I)............................ 10. 10,0 31 • ?3
11. Total Deductions(total Lines 9 and 10)................................................................ 11. 19,9 7 3 • 3 8
12. Net Value of Estate(Line 8 minus Line 11).......................................................... 12. 12 3, 413 • 7 7
13. Charitable and Governmental Bequests/Sec 9113 Trusts for which
an election to tax has not been made(Schedule J)............................................... 13.
14. Net Value Subject to Tax(Line 12 minus Line 13)............................................... 14. 12 3,413 • 7 7
TAX CALCULATION-SEE INSTRUCTIONS FOR APPLICABLE RATES
15. Amount of Line 14 taxable
at the spousal tax rate,or
transfers under Sec.9116
(a)(1.2)X.00 15. 0 • 0 0
16. Amount of Line 14 taxable
at lineal rate X .045 0 • 0 0 16. 0 • 0❑
17. Amount of Line 14 taxable
at sibling rate X.12 0 . 0 0 17. 0 • 0 0
18. Amount of Line 14 taxable
at coilateral rate X.15 12 3, 413 • 7 7 18. 18,512 - 0 7
19. TAX DUE................................................................................................................ 19. 18,512 • 0 7
20. FILL IN THE OVAL IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT �
Under penalties of perjury,I declare I have examined this return,including accompanying schedules and statements,and to the best of my knowledge and belief,
it is true,correct and complete.Declaration of preparer other than the person responsible for filing the return is based on all information of which preparer has
any knowledge.
SIGNATURE OF PERSON RESPONSIBLE FOR FILING RETURN Nicole M.Thompson O� O DA �O/�
ADDRESS
1064 Rebecca Street, Carlisle, PA 17013
SIG�T /E�F PREP RER�OTH�jR THAN REPRESENTATIVE Christopher E. Rice �� /DATE ��
/ � ��u.i6.� � � / '- �..�
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ADDRESS
10 East High Street, Carlisle, PA
I IIIIII IIIII IIIII IIIII IIIII(IIII III�I IIIII IIIII IIIII IIII IIII Side 2
� 1505618411 1505618411 �
REV-1500 EX Page 3 File Number 21-15-0191
Decedent's Complete Address:
DECEDENT'S NAME
Tersigni, Frances
STREET ADDRESS
Thornwald Home
442 Walnut Bottom Road
CITY STATE ZIP
Carlisle PA 17013
Tax Payments and Credits:
1. Tax Due(Page 2,Line 19) (1) 18,512.07
2. Credits/Payments
A. Prior Payments 16,750.00
B. Discount 881.58
Total Credits(A +B) (2) 17,631.58
3. Interest �3�
4. If Line 2 is greater than Line 1 +Line 3,enter the difference. This is the OVERPAYMENT. (4)
Check box on Page 2,Line 20 to request a refund
5. If Line 1 +Line 3 is greater than Line 2,enter the difference. This is the TAX DUE. (5) $$0.49
Make Check Payable to REGISTER OF WILLS, AGENT
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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:............................................................................... ❑ 0
b. retain the right to designate who shall use the property transferred or its income:.................................. � ❑x
c. retain a reversionary interest;or................................................................. .............................................
, x
d. receive the promise for life of either payments,benefits or care?............................................................ ❑ �
2. If death occurred after Dec. 12, 1982, did decedent transfer property within one year of death without ❑ ❑
receivingadequate consideration?.................................................................................................................... x
3. Did decedent own an"in trust for" or payable upon death bank account or security at his or her death?....... 0 ❑
4. Did decedent own an individual retirement account,annuity,or other non-probate property which ❑ ❑
containsa beneficiary designation?.................................................................................................................. x
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES,YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN.
,. . „, . „ ....... . . . ... ..,, . „ .. , ,.... . ., „ .,,ro . t. . , .,,.. „ 5 k�3�- ..., , . .
,,t, _ ,n'e �. �.m , >. ,, . . ..
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 January 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)(ii)]. The statute does not exempt a transfer to a surviving spouse from tax,and the statutory requirements for disclosure of assets and
filing a tax return are still applicable even if the surviving spouse is the only benefciary.
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 step-parent of the child is 0 percent[72 P.S.§9116(a)(1.2)].
• The tax rate imposed on the net value of transfers to or for the use of the decedenYs lineal beneficiaries is 4.5 percent,except as noted in�72 P.S.§9116(a)(1)J.
. The tax rate imposed on the net value of transfers to or for the use of the decedenYs sibiings is 12 percent[72 P.S.§9116(a)(1.3)). A sibling is defined,
under Section 9102,as an individuai who has at least one parent in common with the decedent,whether by blood or adoption.
Rev-1508 EX+(OS-12)
SCHEDULE E
pennsylvania CASH, BANK DEPOSITS, & MISC.
DEPARTMENT OFREVENUE p E RS O NA L P RO P E RTY
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Tersi ni, Frances 21-15-0191
Include the proceeds of litigation and the date the proceeds were received by the estate.
All property jointly-ownedwith the right oi survivorship must be disclosed on schedule F.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 Members 1st Federal Credit Union Checking Account#0000493847-0011 -Date of death 14,331.69
value,see attached
Accrued interest on Item 1 through date of death 0.54
2 Members 1st Federal Credit Union Savings Account#0000493847-0000-Date of death value 5.00
3 PNC Bank Checking Account#81-3044-3113-Date of death value,see attached 191.92
4 Express Scripts Medicare-Refund 32.20
5 Hoffman Roth Funeral Home&Crematory, Inc. -Refund from pre-paid funeral bill 2,511.12
6 United Church of Christ Homes -Refund 203.65
7 United Healthcare Insurance Company-Refund 206.75
TOTAL(Also enter on Line 5, Recapitulation) 17,482.87
(If more space is needed,additional pages of the same size)
Copyright(c)2012 form software only The Lackner Group, Inc. Form PA-1500 Schedule E(Rev.08-12)
Rev-7570 EX+(08•09)
SCHEDULE G
pennsylvania lNTER-VIVOS TRANSFERS AND
DEPARTMENTOFREVENUE MISC. NON-PROBATE PROPERTY
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Tersi ni, Frances 21-15-0191
This schedule must be completed and filed if the answer to any of questions t through 4 on page three of the REV-1500 is yes.
ITEM DESCRIPTION OF PROPERTY DATE OF DEATH °�OF DECD'S EXCLUSION TAXABLE
NUMBER THE DATE OF TRANSFER.SATTACN A CO Y OF THE DEED OR REAL ESTATE. VALUE OF ASSET INTEREST (IF APPLICABLE) VALUE
1 Members 1st Federal Credit Union-Frances Tersigni 100,522.51 100.000% 100,522.51
Third Party Supplemental Needs Trust-CD Account
#xxx-884-0040-Date of death value,see attached
Accrued income on Item 1 through date of death 87.85 100.000% 87.85
2 Members 1st Federal Credit Union -Frances Tersigni 25,287.91 100.000% 25,287.91
Third Party Supplemental Needs Trust-Checking
Account#xxx-884-0011 -Date of death value,see
attached
Accrued income on Item 2 th�ough date of death 1.01 100.000% 1.01
3 Members 1st Federal Credit Union-Frances Tersigni 5.00 100.000% 5.00
Third Party Supplemental Needs Trust-Savings
Account#xxx-884-0000-Date of death value,see
attached
TOTAL(Also enter on Line 7, Recapitulation) 125,904.28
(If more space is needed,additional pages of the same size)
Copyright(c)2009 form software only The Lackner Group, Inc. Form PA-1500 Schedule G(Rev.08-09)
REV•1511 EX+(OS-13)
pennsylvania SCHEDULE H
DEPARTMENTOFREVENUE FUNERAL EXPENSES AND
R SE ENTDECEDENT URN ADMINISTRATIVE COSTS
ESTATE OF FILE NUMBER
Tersigni, Frances 21-15-0191
Decedent's debts must be reported on Schedule I.
ITEM DESCRIPTION AMOUNT
q, FUNERAL EXPENSES:
See continuation schedule(s) attached 3,785.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative(s)
Street Address
City State Zio
Year(s)Commission Paid
2, Attorney's Fees Martson Law Offices 6,156.65
3, Family Exemption: (If decedenYs address is not the same as claimanYs,attach explanation)
Claimant
Street Address
City State Zi�
Relationshin of Claimant to Decedent
4. Probate Fees
5. AccountanYs Fees
6. Tax Return Preparer's Fees
7. Other Administrative Costs
TOTAL(Also enter on line 9, Recapitulation) 9,941.65
Copyright(c)2013 form software only The Lackner Group, Inc. Form PA-1500 Schedule H(Rev.08-13)
SCHEDULE H
FUNERAL EXPENSES AND ADMINISTRATIVE COSTS
continued
ESTATE OF FILE NUMBER
Tersigni, Frances 21-15-0191
ITEM
NUMBER DESCRIPTION AMOUNT
Funeral Ex ep nses
1 Funeral expenses-Grave opening, plaque and installation,flowers, meal,travel expenses, 3,700.00
and officiant fees
2 Stan Shiveli-Reimbursement for travel expenses for cremation 85.00
H-A 3,785.00
Copyright(c)2002 form software only The Lackner Group, Inc. Form PA-1500 Schedule H(Rev.6-98)
Rev-1572 EX+(12-12)
SCHEDULE 1
pennsylvania DEBTS OF DECEDENT,
DEPARTMENTOFREVENUE MORTGAGE LIABILITIES AND LIENS
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Tersi ni, Frances 21-15-0191
Report debts incurred by the decedent prior to death that remained unpaid at the date of death,including unreimbursed medical expenses.
ITEM VALUE AT DATE
NUMBER DESCRIPTION OF DEATH
1 Cumberland Goodwill Fire Rescue EMS-EMS transportation services,account payable 81.75
2 Express Scripts Medicare-Prescription plan,outstanding check posted to Members 1st 32.20
Federal Credit Union Checking Account#0000493847-0011 after date of death
3 Millenium Pharmacy System-Medicine bill,outstanding check posted to Members 1 st 136.29
Federal Credit Union Checking Account#0000493847-0011 after date of death
4 Millenium Pharmacy System -Medicine bill,account payable 108.69
5 Nicole Thompson-Reimbursement for Christmas gift purchases,outstanding check posted 500.00
to Members 1st Federal Credit Union Checking Account#0000493847-0011 after date of
death
6 Thornwald Nursing Home-Nursing home care,outstanding check posted to Members 1st 8,966.05
Federal Credit Union Checking Account#0000493847-0011 after date of death
7 United Healthcare Insurance Company-Healthcare plan,automated payment posted to 206.75
Members 1st Federal Credit Union Checking Account#0000493847-0011 after date of death
TOTAL(Also enter on Line 10, Recapitulation) 10,031.73
(If more space is needed,additional pages of the same size)
Copyright(c)2012 form software only The Lackner Group,Inc. Form PA-1500 Schedule I(Rev. 12-12)
REV-1513 EX+(01-10)
pennsylvania SCHEDULE J
DEPARTMENT OFREVENUE
INHERITANCE TAX RETURN BENEFICIARIES
RESIDENT DECEDENT
ESTATE OF FILE NUMBER
Tersi ni, Frances 21-15-0191
NAME AND ADDRESS OF RELATIONSHIP TO SHARE OF ESTATE AMOUNT OF ESTATE
NUMBER PERSON(Sl RECEIVING PROPERTY DECEDENT ��/ords) ($$$)
TAXABLE DISTRIBUTIONS [include outright spousal
I• distributions,and transfers
under Sec.9116 a 1.2
Nicole M.Thompson Grand Niece 123,413.77
1064 Rebecca Street
Carlisle, PA 17013
Total 123,413.77
Enter dollar amounts for distributions shown above on lines 15 throu h 18 on Rev 1500 cover sheet,as a ro riate.
NON-TAXABLE DISTRIBUTIONS:
II. A.SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT TAKEN
B.CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
TOTAL OF PART II-ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET
Copyright(c)2010 form software only The Lackner Group, Inc. Form PA-1500 Schedule J(Rev.01-10)
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�R�lNC�S T�'RSIC�NI
I, FRANCES TERSIGNI,residing at P.O.Box 1055,Alpha,County of Warren,
State of New Jersey,being of sound and disposing mind and memory,do make,publish
and declare this to be my Last Will and Testament,hereby revoking any former Wills by
me made.
FIRST: I direct that all of my just debts and funeral expenses be paid by
my Executor hereinafter named as soon as may be reasonable after my death.
SECOND: I give,devise and bequeath all of my property,whether real,
personal,ar mixed,of any kind whatsoever and wheresoever situate to my ti•iend,JOHN
HliTNICi�,to b,his absolutely and forever,provided,however,that he survives me by
thirty days. In the event my friend,JOHN HUTNICK,predeceases me,fails to survive
me Ly thirty days,or if we should meet death in a common disaster,then it is my will that
the interest to which he would have been entitled vest in NICOLE M. SHIVELL,to be
hers absolutely and forever.
THIRD: I hereby appoint my friend,JOHN HUTNICK,Executor of my
Last Will and Testament with full power to sell and convey any or all of my
property,real and personal,at public or private sale,at such time and upon such terms
and in such manner as he shall think fit.
�
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FRA��'�S ERSIGNI i
I
-Page One of Three-
FOURTH: ln the event my friend,JOHN HLITNICK,should predecease me,
or should we die at the same time or as the result of the same accident or disaster,or
under circumstances that are such that the order of our deaths cannot be ascertained��ith
reasonable certainty,then and in any such event,I hereby appoint NICOLE M. SHNELL
Executrix of my Last Will and Testament,and grant unto her all the powers granted to
JOHN HUTNICK. I further direct that neither Executor/Executrix shall be required to
furnish bond.
FIFTH: I hereby revoke any and all wills by me at any time heretobeforc
made.
IN WITNESS WHEREOF,I have hereunto set my hand and seal to this M�'
LAST WILL AND TESTAMENT,which consists of three(3) pages,to each of which I
bave affixed my signature,this ; 7 day of December,in the year of Our Lord,Two
Thousand and Seven.
SIGNED,SEALED,PUBLISHED AND DECLARED BY THE TESTATRIX as
and for her LAST WILL AND TESTAMENT,in the presence of us,who have hereunto,
at her request,subscribed our names in her presence and in the presence of each other,
as wimesses hereto.
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STATE OF NEW JERSEY .
;:OUNTI'OF WAKRF.N .
l,FRANCES TERSIGNI,whose name is signed to tlie attached or
foregoing instrument,having been duly qualified according to law,do hereby acknowledge
-Page Two of Three-
.
that I signed and executed the instrument as my LAST WILL,that I signed it willingly;and
that I signed it as my free and voluntary act for the purposes therein expressed.
;,
7
F ANCES TERSI NI �
e
Sworn to and subscribe�d
before me this .f�"�
day of ,�2�ff07.
Arthur . usso -
An Attorney at Law of New Jersey
STATE OF NEW JERSEY �
ss.
COUNTY OF WARREN .
WE, � �v: and ��C�:ie�4��Sc� �( tn ,the witnesses
whose nan�es are signed to the attached oi faregoirig instrument,being duly qualifieci
according to law,do depose and say that we were present and saw the Testatrix sign and
execute the instrument as her LAST WILL AND TESTAMENT;that she signed it
willingly and that she execute�it as her free and voluntary act for the purposes therein
expressed;that each of us,in the hearing and sight of the Testah-ix,signed the Will as
witnesses;and that to the best of our knowledge,the Testatrix was,at that time,l8 years
of age,of sound mind and under no constraint or undue influence.
_� '" 4 '� -�--�--J_J
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Sworn to and sui>:e.ribec;
before me this d day
o ;,cemL�r,2 07.
Art ur J.Russo
An Attorney at Law of New Jersey
-Page Three of Three-
, �
� FRAi�iCES TERSIGNI
THIRD PARTY SUPPLENIENTAL iYEEDS TRUST
On this day of November, 2013, I, WILLIAM J. HUTNICK, Administrator of
the ESTATE OF JOHN HUTNICK, residing at 812 East Plaintield Avenue, Pen Argyl,
Pennsylvania 18072, as GRANTOR (hereinatter referred to as "Grantor") by this Agreement
(the "Trust") with NICOLE M. THOMPSON, residing at 1064 Rebecca Street, Carlisle,
Pennsylvania 17013, as TRUSTEE (hereinafter referred to as "Trustee"), have caused or will
cause certain property to be transferred and shall be administered by my Trustee as herein
provided.
This Trust is for the benefit of FRANCES TERSIGNI (born September 16, 1920, age 72,
Social Security Number XXX-XX-7580), a disabled person as defined in 42 U.S.C. §
1382c(a)(3)(A) (hereinafter referred to as "Beneficiary" or "First Name of Beneficiary"), whose
address is c/o Thornwald Home located at 442 Walnut Bottom Road, Carlisle, PA 17013. Said
Beneficiary suffers from dementia.
SECTION 1. IDENTIFICATION
l.l. SPOUSE. FRANCES TERSIGNI is unmarried.
1.2. CHILDREN. FRANCES TERSIGNI has one child, Carolyn Tersigni, with whom she
has been estranged for over 20 years.
1.3. NAME OF TRUST. The name of this Trust is the "FRANCES TERSIGNI Third Party
Supplemental Needs Trust dated November , 2013."
1.4. TRUST FUNDING
1.4.1. Initial Trust Funding. This Trust shall be funded with such assets &om the ESTATE
OF JOHN HUTNICK, deceased, or as I, or any other person, transfers to my Trustee, or which are
bequeathed hereto by me, or any other person.
1.5. INTENTION. I believe it to be in the best interest of FRANCES TERSIGNI to establish a trust
with discretionary and spendthrift provisions to enhance the quality of her life both now and in the
future by providing for her special needs. I intend that this Trust will provide benetits to supplement
those which may otherwise be available to her from various sources, including , insurance benefits and
governmentally-sponsored programs. It is my intention that she receive all government entitlements
to which she would otherwise be entitled but for the existence of this Trust and distributions
hereunder. I 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 the Trust is to permit the use of trust
assets to supplement and not supplant or diminish any benefits or assistance of any federal, state or
other governmental entity for which she may be eligible or which she may be receiving. All provisions
of this Trust shall be interpreted to qualify this Trust as a Supplemental Needs Trust.
• , Any provisions of this Trust which may prevent this Trust from being interpreted as a Supplemental
Needs Trust that achieves these objectives shall be null and void. All provisions of this Trust
• - agreement are intended to be construed and interpreted such that the Trust agreement meets the
requirements of the Social Security Administration's Program Operating Manual ("POMS").
l.6 ESTABLISHMENT. The within Trust is established by the Superior Court of New Jersey
for the County of Warren.
SECTION 2. DISTRIBUTION OF INCOME AND PRINCIPAL
2.1. DISTRIBUTIONS DURING BENEFICIARY'S LIFETIME
2.1.1. Discretionary Distribution Standard. During the lifetime of FRANCES TERSIGNI,
the Trustee may distribute from the principal or income, or both, of this Trust, such amounts which the
Trustee, in Trustee's sole, absolute and unfettered discretion, may from time to time deem reasonable
or advisable for her Special Needs. Any income of the Trust not so distributed shall be added
annually to principal.
2.1.2. No Right to Direct Distribution. FRANCES TERSIGNI shall have no right to direct a
distribution from this Trust to make any provision for her food and shelter or to direct a distribution
from this Trust for any other purpose.
2.1.3. No Trust Revocation or Grantor Retained Rights. No party shall have the right to
revoke this Trust. In addition, the Grantor shall have no right to direct, control or re-acquire trust
assets or equivalent assets of the trust, subsequent to the relinquishment of any such assets to the
Trustee. The Grantor shall likewise not retain and shall have no subsequent responsibility relating to
the Trust, trust assets, the Trustee or the Beneficiary.
2.2. DISTRIBUTION GUIDELINES
2.2.1. Special Needs. As used in this instrument, "special needs" refers to the requisites for
maintaining FRANCES TERSIGNI's good health, safety and welfaze when, in the discretion of Trustee,
such requisites are not being provided by any governmental agency, office or department, non-profit
organizations, or are not otherwise being provided by any other public or private source. While
Trustee is authorized to consider these other sources, and where appropriate and to the extent possible
endeavor to ma�cimize the collection of such benefits and to facilitate distribution of such benefits for
the benefit of FRANCES TERSIGNI. Trustee may also, in the exercise of Trustee's discretion,
disregard these other sources when making distributions to or for the benefit of FRANCES
TERSIGNI.
2.2.2. Preference. This Trust is for the sole benefit of FRANCES TERSIGNI.
2.3. EXAMPLES OF TRUST DISTRIBUTIONS. Distributions by Trustee for the benetit of
FRANCES TERSIGNI, which are not required but may be appropriate and are consistent with the
terms of this Trust and pursuant to POMS, include but are not limited to the following:
• , a. Any and all reasonable expenses incident to the implementation of a "life care plan" for
FRANCES TERSIGNI, 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, denial, 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
Medicaid;
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 FRANCES TERSIGNI, her family,
educators and care givers to maximize the benefits to her, except for that care that would
be provided by Medicaid;
d. Medical, physical, and mental health care needs of FRANCES TERSIGNI, including but
not limited to physicians' office visits, prescription 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 Medicaid;
e. Reasonable compensation and appropriate expenses for FRANCES TERSIGNI's care givers,
whether professional, paraprofessional, rehabilitative, vocational, attendant, respite or
custodial (including, in the Trustee's sole discretion, any members of her family who render
requested, necessary and appropriate services to her, 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 FRANCES TERSIGNI, and who is familiaz with related
governmental or private entitlement or assistance programs,except for that care that would be
provided by Medicaid;
f. Attendant care and adaptive aids and equipment for FRANCES TERSIGNI'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 Medicaid;
g. Private insurance coverage for FRANCES TERSIGNI, 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 her;
� . h. Travel costs for FRANCES TERSIGNI and for such travel companions as are necessary
or appropriate, associated �vith access to medical, physical and/or mental health care
� services of all types;
i. 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 FRANCES TERSIGNI;
j. Travel and transportation costs for FRANCES TERSIGNI, and for such travel companions
as may be necessary or appropriate, to and from any school or residential accommodation
removed from the residence of FRANCES TERSIGNI's immediate family members or
legal guardian of the person, as well as the reasonable out-of-pocket travel and lodging
expenses for her immediate family members and legal guardian of the person, if any
incurred with their periodic visits to her at her place of residence;
k. Purchase of a residence for FRANCES TERSIGNI, 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 FRANCES TERSIGNI 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 FRANCES TERSIGNI'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 FRANCES TERSIGNI or for her benefit,
including but not limited to vans or automobiles specially equipped and adapted for
her particular disability and the cost of insuring, maintaining, repairing and
periodically replacing such transportation;
n. Appropriate home-based and community-based recreational opportunities and social
initiatives, and the expenses and travel costs of FRANCES TERSIGNI and such travel
companions as may be necessary and appropriate associated with access to such
opportunities and social initiatives;
o. Appropriate furniture and furnishings required for the care of FRANCES TERSIGNI,
customized and adapted to her use,and periodic replacements of such items;
p. Expenses associated with periodic vacations and sabbaticals For the benefit of FRANCES
TERSIGNI, together with the expenses associated with such tra.vel companions as may be
necessary or appropriate;
� , q. Such technological equipment as may enhance FRANCES �I'ERSIGNI's quality of life or
education or training, including but not limited to television, audio and video recording
. � equipment, computers, au�nented communication systems, related sol��are and hardware,
including the cost of training FRANCES TERSIGNI,her family, legal guardian of the person,
educators and care givers in the proper use of such equipment to marimize the benetit to her;
r. Professional services rendered for the benefit of FRANCES TERSIGNI, including but
not limited to, the legal fees and costs associated with the preparation, execution, funding,
administration and termination of this 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 FRANCES TERSIGNI; and
s. Improvements to a vehicle to protect the safety of FRANCES TERSIGNI, the driver and
any passenger of that vehicle.
2.4 PUBLIC ASSISTANCE PROGRAMS
2.4.1. Public Resources. Trustee may, in the exercise of Trustee's best judgment and
fiduciary duty, assist in any application on behalf of FRANCES TERSIGNI for all available public
benefits. Trustee shall take into consideration the applicable resource and income limitations of any
public assistance program for which she 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.
2.4.2. Maintain Public Assistance Eligibility. If Trustee is required to release principal or
income of the Trust to or on behalf of FRANCES TERSIGNI to pay for benetits 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 FRANCES TERSIGNI, including obtaining instructions
from a court of competent jurisdiction ruling that the Trust corpus is not available for her 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.
2.5. REGULAR CONTACT WITH BENEFICIARY. Trustee or agent(s) are requested to
personally visit or contact or arrange for a Care Manager to visit or contact FRANCES TERSIGM to
evaluate her physical condition; educational, residential and vocational and training opportunities;
recreational, leisure and social needs; appropriateness of existing program services; legal rights including
access to public benefit programs; and to inspect her living conditions, to inquire of care providers and,
to the extent possible,to inquire of FRANCES TERSIGNI regarding her treatment by care providers; to
let her know that she has a friend and advocate in addition to family members, to see that she has
spending money for the items she may want (within the constraints of this Trust): to know that she
is receiving any available educational and recreational programs, and to ensure that governmental
assistance, private contractual benefits and Trust funds are in fact being expended by or for her
benefit.
2.6. DISTRIBUTIONS AFTER DEATH OF BENEFICIARY
2.6.L Taxes and Espenses. "rhe Trustee may pay all federal and state ta�ces due because of the
death of FRANCES TERSIGNI and any administrative eYpenses and costs attendant to terminating or
settling this Trust, including any costs or fees associated with the preparation of tinal accountings or
making any distributions provided for herein. Such taxes, administrative expenses and costs
attendant to terminating or settling this Trust shall be paid first out of the Trust's income and then out
of principal.
2.6.2. Last Illness, Funeral and Debts. Trustee may then pay all expenses of any last
illness, funeral and burial costs, and enforceable debts.
2.6.3. Residuary Distributions. Upon the death of FRANCES TERSIGNI, Trustee shall
distribute the remaining principal and accrued income, if any, to NICOLE M. THOMPSON, or if she
fails to survive her, to her issue. These remaindermen are herein refened to as my Remainder
Beneficiary(ies). Under no circumstances shall FRANCES TERSIGNI or her estate receive a share of
the trust estate or undistributed income.
2.7. POOLED TRUST. My Trustee may enroll FRANCES TERSIGNI, with the consent of
the guardian, if there is one, in a pooled trust for the severely disabled, established pursuant to
applicable state statute. My Trustee may obtain from the pooled trust follow-along services,
guardianship services, and such other services that my Trustee determines, in my Trustee's sole and
absolute discretion, to be necessary, subject to the limitations of the subsection titled "Death Tax
Clause" below. My Trustee may also increase the pooled trust services she is to receive subject to the
limitations of the subsection titled "Intent Regarding Distributions" of this Section.
2.8. AGE REQUIREMENT. If any Remainder Beneficiary less than thirty (30) years of age is
entitled to receive a distribution under this Trust, my Trustee shall retain such distribution to be
administered as follows:
2.8.1. Income. My Trustee may, in my Trustee's sole and absolute discretion, pay any part
or all of the net income to or for the benefit of my Remainder Beneficiary or may add any part of
such income to the principal of the Trust; and
2.8.2. Principal. My Trustee shall pay to or apply for the benefit of my Remainder Beneticiary
as much of the principal of my Remainder Beneficiary's share as my Trustee may deem proper for my
Remainder Beneficiary's health, maintenance, support, and education. My Trustee may use principal to
assist my Remainder Beneficiary in buying a home or starting a business; and
2.8.3. Withdrawal Rights. Any Remainder Beneficiary shall have the right to withdraw
principal from his or her trust upon attaining the age of thirty(30) years.
� , 2.8.�. Predecease. [f my Remainder Qeneticiary dies before the entire principal of such trust
has been withdrawn, the entire principal shall be distributed by my Trustee to my Remainder
. - Beneticiary's then-living descendants by representation; or, in default of such descenciants, to my living
descendants by representation (the share thus aceruing to any descendant of mine for whom, at that
time, my Trustee holds a separate trust hereunder shall be added to such trust and thereafter held as
though originally forming a part hereot); or, in default of such descendants, then to such persons who
would be entitled to inherit from me under the Intestate Laws of the New Jersey NJS 3B: 5-3 to NJS
3B5-14.
SECTION 3. FIDUCIARY PROVISIONS
3.1. TRUSTEE PROVISIONS
3.1.1. Original Trustee. NICOLE M. THOMPSON shall serve as original Trustee
hereunder with all of the obligations, powers and authority contained in this Trust Agreement.
3.1.2. Death, Disability or Resignation of Original Trustee. If NICOLE M. THOMPSON
fails or ceases to serve for any reason, I appoint JODY A. SHIVELL as Successor Trustee.
3.1.3. Resignation of Trustee
3.1.3.1. Right of Trustee to Resign. Any Trustee shall have the right to
resign at any time during the life of Beneficiary by giving notice in writing to Beneficiary,
his or her custodian, his or her guardian, his or her conservator or other legal
representative, if any, and to the Bureau of Administrative Action and Recoveries and at any
time after Beneticiary's death by giving notice in writing to the then income beneficiaries of
the trust and to the Bureau of Administrative Action and Recoveries.
3.1.3.2. Incapacity of Trustee. A Trustee who becomes incapacitated shall be
removed from office and replaced by a Successor Trustee. The incapacity of any
individual serving as Trustee shall be conclusively presumed by any acting Co-Trustee(s) or
named Successor Trustee, in that order, appointed Upon either: (a) Receipt by such person of
a written medical opinion certifying the incapacity of the individual serving as Trustee to
manage his or her financial affairs from two physicians licensed to practice in this state or other
state of the United States, one of whom shall, if possible be the Trustee's personal physician
certifying the individual was by reason of accident, physical or mental illness, progressive
or intermittent physical or mental deterioration, or other similar cause, incapacitated to act
rationally and prudently in his or her own financial affairs, or (b) Upon a judicial
determination of the incapacity of the individual serving as Trustee. Subsequent proof of
competency or capacity shall be established by the same procedures. However, the
reappointment of an individual serving as Trustee shall be effective upon approval by a court
with jurisdiction over this Trust of the previously incapacitated Trustee's petition to act again
as a Trustee of this Trust.
31.3.4. Power of Successor Trustee. Any Successor Trustee shall have the rights,
powers, privileges, discretions, and duties conferred upon or vested in my Trustee by the provisions
of this Agreement. The Trust beneficiary and guardian, if any, shall be given prior notice if there is a
change in the Trustee.
3.1.3.5. Nomination of Successor Trustee. [f a vacancy occurs in the office of
Trustee, then the Trustee or Co-Trustees, at that time, may appoint a Successor Trustee or Co-Trustee
that is not subordinate to any beneticiary or beneticiaries. Such appointment shall be made in a
written instrument that shall be delivered to my beneficiary or beneticiaries. In the default of such
appointment, NICOLE M. THOMPSON shall have the right, power, and authority to designate a
Successor Trustee.
3.1.4. Compensation of Trustee. My Trustee shall be entitled to receive reasonable
compensation for services rendered and to reimbursement for all reasonable expenses as provided
by law. N.J.S.A. 3B:18-2 et seq.
3.1.5. Powers of Trustee. In addition to the powers herein provided and those given by law
NJS 3B:14-23, my Trustee, without any order of the Court and in my Trustee's sole and absolute
discretion, may:
3.1.5.1. Professional Care Manager. My Trustee is encouraged to consider retaining
the services of a Professional Care Manager to assist in providing the required care for FRANCES
TERSIGNI. The purpose of the Care Manager would be to coordinate other agencies or professionals
or home health aides or personal care providers or homemakers or any other services which the Care
Manager and my Trustee feel are in the best interests of FRANCES TERSIGNI. The primary purpose
of this Trust is to provide funds to be spent on behalf of FRANCES TERSIGNI. It is my intention to
benefit FRANCES TERSIGNI to the fullest extent possible, rather than the Remainder
Beneficiary(ies). My Trustee shall pay all costs in connection with the Care Manager.
3.1.5.2. Family Caregiver. My Trustee may pay one or more family members of
FRANCES TERSIGNI a fee to enable such person or persons to provide her with the care over and
above that which a family member would normally provide a non-disabled child of her age, if such
care is necessary because of her disability, if the Trustee determines that it would be more economical
to do so rather than to purchase such care from a professional caregiver, and if the cost of such care
does not exceed fair market value.
3.1.5.3. Government Benefits Advisor. My Trustee shall have the power to retain legal
and professional assistance in administering this Trust and fulfilling its purposes. In particular, in
making a determination whether to distribute income or principal to or for FRANCES TERSIGNI
under the provisions of this Trust, my Trustee may engage a professional advisor knowledgeable on
the subject of the availability of funds or benefits from governmental or other sources on account of her
mental or physical disability or handicap, to advise Trustee concerning the availability of such funds
or benefits. Trustee shall be entitled to rely upon the advice and information obtained from such
advisor and shall not he liable for any act or omission on the part of my Trustee attributable thereto.
3.1.5.4. Mutual Funds. Invest in mutual funds, including but not limited to money
market mutual funds. The Trust shall comply with all State laws, including the Prudent Investor Act
N.J.S.A. 3B:20-11.1 et seq. The Trustee cannot take any actions not authorized without regard to
State laws.
' . 3.1.�.�. Residence. My Trustee may acquire, hold and maintain any residence
(whether held as real property, condominium or cooperative apartment) for investment or for the use
� and benetit of FRANCES TERSIGNI, as my Trustee, in the exercise of sole and absolute discretion,
shall determine. If my "1'rustee, in the exercise of sole and absolute discretion, shall determine that it
would be in the best interests of FRANCES TERSIGNI to maintain a residence for the use of
FRANCES TERSIGNI, but that the residence owned by my Trustee should not be used for such
purpose, my Trustee shall be authorized to sell said residence and to apply all or any part of the
net proceeds of sale to the purchase of such other residence or residences or to make such other
arrangements as my Trustee, in the exercise of sole and absolute discretion, shall deem suitable
for the purposes. Any proceeds of sale not needed for reinvestment in a residence as provided
above are to be added to the principal of the trust and thereafter be administered and disposed of as a
part thereo£ My Trustee may use the proceeds to pay all carrying charges of such residence, including
but not limited to any taxes, assessments and maintenance thereon, and all expenses of the repair and
operation thereof, including the employment of domestic servants and other expenses incident to the
maintenance of a household for the benefit of FRANCES TERSIGNI, to expend such amounts as my
Trustee, in the exercise of sole and absolute discretion, shall determine, including, but not limited to,
providing for the personal care and comfort of FRANCES TERSIGNI in any manner whatsoever. My
Trustee may also pay for modifications to the home in which FRANCES TERSIGNI is living
to the extent reasonably necessary to accommodate the needs of her disability.
3.1.5.6. Vehicle. My Trustee may, in Trustee's sole, absolute and unfettered
discretion, purchase or lease and pay for the maintenance of a motor vehicle that is designed or modified
to accommodate the needs of FRANCES TERSIGNI's disability, provided the vehicle will be used
primarily on her behalf. The Trustee may permit title and registration to be in the name of the person
with responsibility for FRANCES TERSIGNI's care. The Trustee may also pay all or part of the
automobile insurance associated with the vehicle. if the Trustee decides to title and register the vehicle
in the name of the caregiver, the Trustee sha11 obtain security or other written assurances from that
person, that the vehicle will not he assigned or otherwise used as collateral for the benefit of another
and that when the vehicle is sold, the proceeds from the sale will he provided to the Trustee. The
Trustee shall have no responsibility to ensure that the vehicle registered in the name of the caregiver is
properly and safely maintained.
3.1.5.7. Limitations. Notwithstanding any of the powers conferred upon my Trustee,
no individual, acting as Trustee hereunder, shall exercise or join in the exercise of discretionary
powers over income, principal, or termination of any trust (1) for his or her own benefit or (2) to
discharge his or her legal obligation to support FRANCES TERSIGNI.
3.1.5.8. Trust Additions. Add to the principal of any trust created hereunder any
property received &om any person by Deed, Will, or in any other manner, provided such property is
acceptable to my Trustee.
3.1.5.9. Post-Termination. Exercise all power, authority, and discretion given by this
Trust, after termination of any trust created herein,until the same is fully distributed.
3.1.5.10. Administration Expenses. The reasonable costs and expenses of
administering the Trust including the retention of legal and professional assistance shall be paid
first out of the Trust's income and then out of principal.
3.1.6. Bond Waived. Neither my original Trustee nor any Successor Tnistee shall be required
to give bond or furnish sureties in any jurisdiction.
SECTION �. TAX AND ADiVIIN[STRATIVE PROV[SIONS
�. 1. DEATH TAX CLAUSE. All estate, inheritance, and other death taYes, 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 my gross estate, whether or not such property passes under this Trust, shall be
paid out of the principal of my residuary trust estate.
4.2. RETIREMENT ACCOUNT DISTRIBUTION. To the extent that this trust is the
beneficiary of a Retirement Account my Trustee shall draw the benefits from the Retirement
Account in amounts sufficient to meet the minimum distribution requirements of IRC Section
401 (a)(9) and the regulations thereunder (the "Required Minimum Distribution").
Notwithstanding any provision of the trust to the contrary, the Required Minimum
Distribution shall be applied for the benefit of the person or persons then entitled to receive
or have the benefit of the income from this trust, or if there is more than one income
beneficiary my Trustee shall make such distribution to such income beneficiaries in the
proportion in which they are beneficiaries or if no proportion is designated in equal shares
to such beneficiaries. "Retirement Account" means a plan qualified under IRC Section 401
or an individual retirement arrangement under IRC Section 408, or a Roth IRA under IRC
Section 408A, or a tax-sheltered annuity under IRC Section 403 or any other benefit subject
to the distribution rules of IRC Section 401 (a)(9), or the corresponding provisions orally
subsequent federal tax law. It is my intention that this trust qualify as a "conduit trust" under IRC
Section 401(a)(9) so that the trust benefciaries shall be considered designated beneficiaries for
purposes of the minimum distribution rules, and that distributions may therefore be taken over the trust
beneficiary's life expectancy (or the life expectancy of the oldest trust beneficiary). The Retirement
Accounts shall not be subject to the claims of any creditor of my estate and they shall not be
applied to the payment of my debts, taxes or other claims or charges against my estate unless and
until all other assets available for such purposes have been exhausted, and even then only to the
minimum extent that would be required under applicable law in the absence of any specific provision
on this subject in this Trust. All distributions shall be made in accordance with Section 2.
4.3. SPENDTHRIFT PROVISION. All principal and income shall, until actual distribution, be free of
debts, contracts, alienations and anticipations of FRANCES TERSIGNI and IZemainder
Beneficiaries, and the same shall not be liable to any levy, attachment, execution; or sequestration
while in the possession of my Trustee.
4.4. DISABILITY PROVISION. Unless otherwise provided for herein, any income or principal
payable to any Remainder Beneficiary who, in the opinion of my Trustee, is mentally or physically
disabled, shall be held in a separate trust by my Trustee during such disability unless the trust share is
sooner terminated as otherwise provided herein. Income may be accumulated, and income and principal
may be expended for the health, maintenance, support and education of such Remainder Beneficiary as
my Trustee, in Trustee's sole and absolute discretion,may determine.
� . Trustee may apply the same directly without the intervention of a guardian or pay the same to any person
. having the care or control of such Remainder Beneficiary or with whom such EZemainder
Beneticiary resides without duty on the part of Trustee to supervise or inquire into the application of
such funds. The balance of such income and principal shall be paid to Remainder Beneficiary when
the disability ceases or to upon the death of Remainder Beneticiary, then to Remainder Beneticiary's
ciescendants by representation.
4.5. RULE AGAINST PERPETUITIES. If any trust hereunder is situated in a jurisdiction which has
a Rule Against Perpetuities, then notwithstanding anything herein to the contrary, no Trust
hereunder shall extend beyond twenty-one (21) years after the death of the last survivor of
[myself/us] and my descendants living at the date of my death. At the expiration of that period, my
Trustee shall distribute the remaining portion of any trust property in my Trustee's hands to the
beneficiaries entitled to the income at that time.
4.6. IRREVOCABILITY. This Trust is irrevocable and I shall have no right (1) to alter, revoke or
terminate this Trust or any of the terms of this Agreement in all or in part; (2) to designate the person
who shall possess or enjoy the Trust property, and the income therefrom; or (3) to exercise any
incidents of ownership in any property transferred to the Trust.
4.7 INCOME TAXES. All parties understand and agree that as an irrevocable trust, the Grantor
shall bear no responsibility to pay any taxes associated with the assets of the Trust, including income
taxes.
4.7. AMENDMENT BY TRUSTEE
4.7.1 Public Benefits Eligibility. My Trustee may amend the Trust from time to time to
ensure continuing eligibility of FRANCES TERSIGNI for the public benefit programs to which she
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 arty 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 FRANCES TERSIGNI shall move to another
jurisdiction, Trustee may amend the trust to comply with the laws of such jurisdiction in order to
maintain her eligibility.
4.7.2. Favorable Tax Treatment. My Trustee may also amend this Trust in writing from
time to time to expressly state any such additional power or authority, and also to limit or grant
powers, as are deemed reasonably necessary to obtain or preserve favorable tax treatment.
4.8. SITUS
4.8.1. Original Situs. Questions pertaining to the validity, construction and administration of
this Trust shall be determined in accordance with the law of the New Jersey.
4.8.2. Changing the Trust Situs. After my death, the situs of any trust established herein may
be changed by my Trustee, in my Trustee's sole and absolute discretion.
� . 4.9. DEFINITIONS
� � �9.1. Distributions by Representation. Unless otherwise specitically provided, all
distributions are to be made to a person's descendants, by representation. The property is divided
into as many equal shares as there are: (1) surviving descendants in the generation nearest to the
designated ancestor which contains one or more surviving descendants; and (2) deceased descendants
in the same generation who left surviving descendants, if any. Each surviving descendant in the
nearest generation is allocated one share. The remaining shares, if any, are combined and then divided
in the same manner among the surviving descendants of the deceased descendants, as if the surviving
descendants who were allocated a share and their surviving descendants had predeceased the
designated ancestor,
4.9.2. Descendants. The descendants of a person mean all of that person's lineal
descendants of all generations. The relationship of parent and child at each generation shall be
determined by the definition of parent and child contained under New Jersey law as of the date of
my death. A descendant in gestation who is later born alive shall be considered a descendant in
being throughout the period of gestation.
4.9.3. Disability. Any Remainder Beneficiary under this Trust is disabled or under a disability
when he or she is under the age of eighteen (18) years and not emancipated; or, if determined to be
disabled by the Social Security Administration or a court of competent jurisdiction.
4.9.4. Education. As used in this Trust, "education" shall include:
4.9.4.1. College. Any course of study or instruction at an accredited college or
university granting undergraduate or graduate degrees.
4.9.4.2. Vocational. Any course of study or instruction at any institution for
specialized, vocational, or professional training.
4.9.4.3. General. Any curriculum offered by any institution that is recognized for
purposes of receiving Financial assistance from any state or federal agency or program.
4.9.4.4. Course of Study. Any course of study or instruction which may be useful in
preparing any beneficiary for any vocation consistent with such beneficiary's abilities and interests.
4.9.4.5. Types of Distributions. Distributions for education may include tuition fees,
books, supplies, living expenses, travel and spending money to the extent such education expenses
are reasonable.
4.9.5. Trustee. Any reference to my "Trustee" shall include the singular or the plural and
the masculine, the feminine, or the neuter and is intended to refer to such person or persons serving
as my Trustee, including my original Trustee or any successor Trustee whether such Trustee shall be
an individual or a corporation.
=�.9.6. Remainder Beneticiaries. "Remainder Beneticiaries" of the Trust are: (a) If the "Cnlst
is then terminating, the persons entitled to distribution of the principal thereof, without regard to any
� requirement that the principal be held in further trust; and (b) If the tnist is not then terminating, the
persons who would be entitled to distribution of the principal thereof if the trust were to terminate at that
time by its terms (and not as a result of any exercise of discretion on the part of the trustees), assuming
that no power of appointment with respect to such trust had been exercised and without regard to any
requirement that the principal be held further trust."
4.9.7. Other Definitions. Except as otherwise provided in this Trust, terms shall be as detined
in the New Jersey Statues 3B:1-1 to 3B1-2 as amended after the date of this Trust and after my
death.
IN WITNESS WHEREOF, the provisions of this Agreement of Trust shall bind WILLIAM J.
HUTNICK, as Administrator of the ESTATE OF JOHN HLJTNICK, deceased, as Grantor and
NICOLE M. THOMPSON, as Trustee, assuming the role of Trustee hereunder, and the beneficiaries
of this Trust as well as their successors and assigns.
���yz�
WILLIAM J. TNICK,
as Administrator of the ESTATE OF
J4HN HUTNICK,deceased,"GRANTOR"
ACCEPTED:
�(,i',t�-t'a
NICOLE M. THOMPSON, "TRUSTEE"
� ° STATE OF NEW JERSEY .
COUNTY OF WARREN : SS.
I CERTIFY that on this��iay lU1u , 24�-�, WILLIAM J. HUTMCK, as
Aciministrator of the ESTA"I'E OF JOHN I- TNIC � , deceased, personally came before me and
acknowledged under oath, to my satisfaction, that this person:
(a) is named in and personally signed the attached document; and
(b) signed, sealed and delivered this document as his act and deed.
� �
otary Public
„�.,..
,�°��.h�:4 KATHERINE SIGAF00
;���, NOTARY PUBLIC OF NEW JERSEY
��� My Commission Expires 91712015
' � ,
'� CONtN10NWE n�LTH OE PENN YLVAN[� :
COUNTY OE t,.LL��A,�.�� : SS.
iZ�Pr�
I CERTIFY that on this � day of i�f�w�e�� 2013, NICOLE M. THOMPSON
personally came before me and acknowledged under oath,to my satisfaction, that this person:
(a) is named in and personally signed the attached document; and
(b) signed, sealed and delivered this document as her a and deed.
Notary Public
I�LYN a��a�l1�LY
NOTAHIAL 3EAL
DARCIE A.NEIL,Notary Public
Boro of Carlisle,Cumberlar�d CouMy
My Commisston Expires November 24,2017
Page 1 of 1
�
MEMBERS ist
•FEDERAL CREDTT UMON
Account Statement
FRANCES TERSIGNI For Account: 0000493847
NICOLE M THOMPSON
1064 REBECCA ST
CARLISLE, PA 17013
Reporting Period: 11/O1/2014 to 11/30/2014
0000 REGULAR SAVINGS
Balance �
l
$ 5 .00 #�
0011 CHECKING
Post Date Transaction Description Amount New Balance
11/05/14 Withdrawal:UnitedHealthcare $206.75- $ 12,407.23
TYPE: PREMIUM ID: 1836282001
CO: UnitedHealthcare
11/11/14 Deposit Check $ 1,020.00 $ 13,427.23
Check Received 1,020.00
11/20/14 Deposit Check $ 1,020.00 $ 14,447.23
Check Received 1,020.00 �
11/26/14 Draft:001058 $ 115.54- $ 14,331.69
11/30/14 Dividends: 0.050% $ .55 $ 14,332.24 #�
SC�IL'n U l.� � �'�►'�' #� � �'
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Standard Checking Statement ��PNCBANK
PNC Bank
Primary account number. 81-3044-3113
Page 1 of 1
For the pe�iod 10/17/2014 to 01/16J2015 Number of enclosures: o
FRANCES TERSIGNI � For 24-hour banking,and Vansaction or
1064 REBECCA ST interest rate information,sign-on to
CARLISLE PA 17013-1638 " � PNC Bank Online Banking at pnc.com
For customer service call 1-888-PNC-BANK
Monday-Friday:7 AM-10 PM ET
Saturday&Sunday:8 AM-5 PM ET
Para servicio en espanol,1-866-HOLA-PNC
Movtngl Please contact us at 1-888-PNC-BANK
� Write to: Customer Service
PO Box 609
Pittsburgh,PA 15230-9738
� Visit us at pnacom
`.`� TDD tertninai:1-500-531-1648
For hearing impaired clients only
Frances Tersigni
Standard Cheddng Acoourrt Summary
AccouM numbx. 81-3044-3113
pverdraR proteqlo� has not been esiablished for this account.
Please contact us if you would like to set up this service.
OverdraR Coverape -Your account is currently OP�-��
You or your jaM owner may revoke your opt-in or opt out choice at a�y time.
To leam more about PNC Overdraft Sdutions visit us online at pnc.coMovardraftsdutions.
Call 1-877-58&3605,visit a�y branch,or Sign on to PNC Online Banl�ng,and se�ed the"Overdre8
Sotutions'link under the Accowit Services secuon to manage bwh your Overdraft Coveroge and Overdraft
Protection seUings.
Balance Summary
Beginnf� Deposits and Checks and otheT �d��9
balarwe other additlons deductirais balance
191.92 .00 .00 191.92
Average moMhly Charges
balance and fees
191.92 .00
�c��uL� � �-�� � �
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Member FDIC Q Equal Housing Lender
� ' . . � � '• � � � � •
S� MemUers lst Fcderat Credit i_rnion 11/01/2014 11/30/2014 1 of 2 XXXXXXX884
5000 Louise Dri��e
P.(�.130�d0
Mechanicsburg PA UO��-OOdO
` � ('800)237-72R8
MEMBERS�is< <717)697-5312(Hc<+ring Im�airedl St
FEDERALCRBnIT UNION ������4'.tt]CITIt1(',iS ISY.01'� �����
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THIRD PARTY SUPPLEMENTAL NEEDS TRUST FRA The perfect gift.
1064 REBECCA STREET �
CARLISLE PA ��0�3 www memberslst.org
15450
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You�current Member Loyalty Rewards level is Titanium.
CHECKING 25,288.95
SAVINGS 5.00
CERTIFICATES 100,613.39
LOANS 0.00
11
BEGINNING BALANCE: 525,287.91
Eff. Post
Date Date Description Deposits Withdrawals Balance
11/30 11l30 Deposit Dividend 0.050% 1.04 25,288.95
Annual Percentage Yield Earned 0.050%from 11/01/14 through
11/30/14
ENDING BALANCE: �25,288.95
Total Deposits 1.04 Average Daily Balance 25,287.91
� � � �
BEGINNING BAtANCE: ;5.00
Eff. Post
Date Date Description Deposits Withdrawals Balance
No Activity During This Statement Period
ENDING BALANCE: 55.00
• � 11 � 1
BEGINNING BALANCE: $100,522.51
Eff. Post
Date Date Description Deposits Withdrawals Balance
11/30 11/30 Deposit Dividend 1.100% 90.88 100,613.39
Annual Percentage Yield Eamed 1.110%from 11/01/14 through
11/30/14 /
ENDING BALANCE: $100,613.39
Total Deposits 90.88 Maturity Date 12/10/15
Trustee NICOLE M THOMPSON
s���u�� l .�S �
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� ME�ERS is� 11/01l2014 11/30/2014 2 of 2 XXXXXXX884
•FEDERALCREDIT UNION
. � �
TOTAL DIVIDENDS PAID
0000 REGULAR SAVINGS 0.00
0011 CHECKING 7.02
y,�,�. 0040 19 MONTH CERT 613.39
Total Year to Date Dividends Paid(Includes Closed Shares) 620.41
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