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Home My WebLink About05-20-15 +v � �''� �7 i�'1 Johnson, Duffie, Stewart 8�Weidner By: Mark C. Duffie, Esquire � � � �� I.D. No. 75906 Attorneys for Petifidrr�r �? , C,, 301 Market Street '� � �'' ' �`' � ,.. o ,__, P. O. Box 109 � - . , ,,._, Lemoyne, Pennsylvania 17043-0109 •:� � r �` (717) 761-4540 `�� :;.:: �:> mcd@jdsw.com --; �= rn o v� � ^J "'r] IN RE: MADISON RAE GOULD : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA : ORPHANS' COURT DIVISION : DOCKET NO. `,�,'• !�—�� PETITION FOR THE APPOINTMENT OF GUARDIAN FOR THE ESTATE OF A MINOR PURSUANT TO PENNSYLVANIA ORPHANS' COURT RULE 12.5 AND NOW, comes the Petitioners, Adrianna R. Brumbaugh, Madison Rae Gould, a minor, and Adrian R. Frodge by and through their attorneys, Johnson, Duffie, Stewart & Weidner, and file this Petition for Appointment of Guardian pursuant to Orphans' Court Rule 12.5, and in support of their Petition, aver as follows: 1. Petition is Madison Rae Gould, a minor child, who resides at 706 Henry Street, Mechanicsburg, Cumberland County, Pennsylvania 17055. 2. Petitioner is fifteen (15) years of age. 3. The natural parents of Petitioner are Adrianna R. Brumbaugh and Steven C. Gould. The parties are divorced. 4. Adrianna R. Brumbaugh resides at 706 Henry Street, Mechanicsburg, Pennsylvania 17055. �T' � .�.� ��,��»�,r� 5. Steven C. Gould formerly resided at 2130 Canterbury Drive, Mechanicsburg, Pennsylvania 17055. 6. Steven C. Gould passed away on December 27, 2014. 7. Adrianna R. Brumbaugh, as the remaining natural parent of Petitioner, consents to this Petition and her appointment of the guardian of the estate of the petitioning minor. 8. Steven C. Gould, the natural father, deceased, designated the Petitioner, Madison Rae Gould, as beneficiary under his MetLife Group Life Insurance Policy (Group No. 150693). 9. Following the passing of Steven C. Gould, Adrianna R. Brumbaugh, on behalf of her daughter, Madison Rae Gould, filed a claim for the benefits to be payable to her daughter, the minor Petitioner herein. 10. In response to said claim, Adrianna R. Brumbaugh received correspondence from MetLife directing Adrianna R. Brumbaugh to Petition the Court to be named "legal guardian for the `Property' or `Estate' of the minor." The correspondence further directed that "Payment of the proceeds can be released to the guardian on behalf of the minor upon receipt of certified court- appointed Guardianship Papers bearing a raised or colored seal." A true and correct copy of said correspondence as well as a copy of the claim form enclosed with said correspondence is attached hereto and incorporated herein as Exhibit A. 11. The death benefit payable to the minor Petition is Forty Thousand ($40,000.00) Dollars. 12. The natural mother and proposed guardian, Adrianna R. Brumbaugh, joins in this Petition to indicate her consent to be appointed guardian of the estate of the minor child, Madison Rae Gould. 2 �i rr ir riu.rn7�r = 13. The Maternal Grandfather, Adrian R. Frodge of 4152 Nantucket Drive, Mechanicsburg, PA 17050, of the minor beneficiary joins in this petition pursuant to 20 Pa. C. S. A. 5112(3) and requests to be appointed co-guardian of the minor's estate. 14. The benefit payable to Madison Rae Gould will be utilized for the benefit of Madison Rae Gould to assist in post secondary education. WHEREFORE, Petitioner respectfully requests that this Honorable Court enter an Order approving the appointment of Adrianna R. Brumbaugh as legal guardian and Adrian R. Frodge as co-legal guardian of the estate of Madison Rae Gould, a minor. Respectfully submitted, JOHNSON, DUFFIE, STEWART &WEIDNER �r.�i"a�°�/ By. A� � Mark C. Duffie, Attorney I.D. No. 7 06 301 Market Street P.O. Box 109 Lemoyne, PA 17043-0109 Telephone (717) 761-4540 3 �„ �,„�,,,�,�,w� � VERIFICATION We, Madison Rae Gould, Adrianna R. Brumbaugh and Adrian R. Frodge do verify that the statements made in the foregoing Petition are true and correct to the best of our knowledge, information and belief. We understand that false statements made herein are subject to the penalties of 18 Pa.C.S. §4904 relating to unswom falsification to authorities. . �r"� �; � �� Mad' on ae Gould �tiL ��_...��__ l�- ��. Ad 'anna R. Brumbaugh _.�','� . - Adrian R. Fradge Dated: � �I �� 4 CERTIFICATE OF SERVICE I HEREBY CERTIFY that I served a true and correct copy of the foregoing Petition, by depositing a copy of same in the United States Mail at Lemoyne, Pennsylvania, with first-class � postage prepaid on the �d day of , 2015, addressed to the following: Adrianna R. Brumbaugh 706 Henry Street Mechanicsburg, PA 17055 Adrian R. Frodge 4152 Nantucket Drive Mechanicsburg, PA 17050 JOHNSON, DUFFIE, STEWART &WEIDNER I�, ., (.� By: �-----rolark C. Duffie � 5 �..., �,„�„��T��-�,�� d EXHIBIT A _.:+.rn n��ir��ur.rmur.� � � � etl.if e Metropolitan Life Insurance Company Grou�p Life Claims P.O.Box 6100 Scranton,PA 18505 March 20, 2015 Adrianna Gould Brumbaugh FBO Madison Gould 706 Henry Street Mechanicsburg,PA 17055 RE: Insured: Steven Gould Group No.: 150693 Claim No.: 21501003385 Dear Ms. Gould: We are writing in regard to the above-referenced claim for Group Life insurance benefits. Please accept our sincere condolences at this time. The information in our file indicates Madison Gould, a minor, is the beneficiary designated to receive the insurance proceeds. In order to file a claim,please complete the enclosed Claimant's Statement with the minor beneficiary's information. MetLife is not permitted to make direct payment to a minor. There are two options for payment processing: The first option calls for a family member or other individual who is legally responsible for the welfare of Madison Gould to petition the court to be named legal guardian for the"Property" or "Estate"of the minor. Payment of the proceeds can be released to the guardian on behalf of the minor upon receipt of certified court-appointed Guardianship Papers bearing a raised or colored seal. As an alternative, MetLife will deposit the proceeds into a Minor on Deposit Account. The proceeds will earn interest while in this account, and when the minor reaches the age of majority, MetLife will provide further information on accessing the funds in the Account. If a guardian of the minor child's estate or property is named, such as guardian may access the proceeds upon presentment of court-issued guardianship papers. A self-addressed envelope is enclosed for your convenience. Upon receipt of the requested information we will continue our review of this claim. gli 108.rev.0015 . • If you have any questions,please contact our office at 800-638-6420. Sincerely, Group Life Claims Operations Enclosures gli 108.rev.0015 MINOR BENEFICIARIES An insured may name a minor child as the beneficiary to the Group Life proceeds. However, since minor children are adjudged to be incompetent by law, MetLife generally cannot distribute the proceeds to the minor directly. If a person of legal age has petitioned the court, and has been appainted as guardian of the "property" or"estate" of the minor, the proceeds may be released to that person in his/her capacity as guardian. Absent such court authorization, MetLife's standard procedure when presented with a claim by a minor is to deposit the proceeds into a Minor on Deposit Account. The proceeds will earn interest while in this account, and when the minor reaches the age of majority, MetLife will provide further information on accessing the funds in the Account. If a guardian of the minor child's estate or property is named, such guardian may access the proceeds upon presentment of court-issued guardianship papers. The fact that a minor child resides with a parent does not make that parent a legal guardian. The parent is the custodial guardian, but MetLife is unable to release any funds until a guardian of the property or estate of the minor is appointed by the court. This makes certain that the proceeds designated to the minor are used for the benefit of the minor, as the insured intended. g1i108.rev.0015 ,� ��,�-„�,,��,�� d U.S. Life Insurance Claims �e��t�� January 1,2014 Metropolitan Life Insurance Company Your life insurance claim kit On behalf of MetLife, please accept our sincere condolences during this difficult time. Helping you submit your claim Our standard method of paying the proceeds of your claim is to deposit them into a convenient Total Control Account.You'll find more details in the enclosed document, "About the Total Control Account." We're here to help We recognize this may be a challenging time for you. If you have questions, or need help preparing your claim, call us at 1-800-MET-6420 (1-800-638-6420). Our Customer Service Center is open Monday through Thursday, 8:00 a.m. to 8:00 p.m. EST, and Friday 8:00 a.m.to 5:00 p.m. EST. Sincerely, � MetLife U.S. Life Insurance Claims Page 1 of 1 Fs GR-LTR-TCA-A(03115) �i �r er rrn�,rn��ur � U.S. Life Insurance Claims Metl.if� About the Total Control Account� A convenient place to hold the proceeds from your claim while you decide what to do with the money �-�.�--��.��-- _, - � How the account works The Total Controi Account(TCA) is a draft account that works like a checking account: • When your account is open, MetLife' will send you a package which includes additional details about the TCA. We pay the full amount owed to you by placing your proceeds into the TCA and providing you a book of drafts. You can use the drafts like you would use checks. • You can use a single draft to access the entire proceeds or severaf drafts for smaller amounts(as litrle as $250). There are no limits on the number of drafts you can write. Processing time is similar to check processing. • You earn interest on the money in your account from the date your account is open. • We'll send you an account statement each month when there is activity in your account. If you have no activity,we'll send you a statement once every three months. • You can name a beneficiary for your account.We'll include a beneficiary form in the package we send you when we open your account. Interest rates and guarantees The interest rate on your account is set weekly, and will always be the greater of the guaranteed rate stated in your TCA package(currently 0.5%), or the rate established by a�east one of the following indices:the prior week's Money Fund Report Averages�'/Govemment 7-Day Simple Yield, or the Bank Rate Monitor'" National Money Market Index. We calculate interest daily and compound it, so you earn interest on your interest. The interest is added to your account monthly.The interest earnings generally are taxable so you should speak with your tax advisor. No monthly maintenance fees There are no monthly maintenance or service fees on your TCA, no charges for making withdrawals or writing drafts, and no cost for ordering additional drafts.You may be charged for special services or an overdrawn TCA, and the current fees(subject to change)for those are: draft copy$2; stop payment$10;wire transfer$10; overdrawn TCA$15; overnight delivery service$25. ' "MetLife"means Metropolitan Life Insurance Company or the MetLife affiliate that issued the underlying policy Page 1 of 2 GR-TCA-A(03115) Fs ��-� u�ir��nr��nnnr � Other important information • Your Total Control Account is backed by the financial strength of MetLife. The assets backing the funds are held in MetLife's general account and are subject to MetLife's creditors. In addition,while the funds in your account are not insured by the FDIC, they are guaranteed by your state insurance guarantee association. The coverage limits vary by state. Please contact the National Organization of Life and Health Insurance Guaranty Associations(www.NOLHGA.com or 703-481-5206)to learn more. FOR FURTHER INFORMATION, PLEASE CONTACT YOUR STATE DEPARTMENT OF INSURANCE. • If you do not want a TCA,you may request a check for total benefits by writing "check" beneath your signature on the attached claim form. • If there is no activity on your account for a period of time(typically three years, but this may vary by state), state regulations may require that we contact you at the address we have on file. If we aren't able to reach you, we may be required to close your account and transfer the funds to the state. • We may limit or suspend your access to the funds in your account if we suspect fraud or if there was an error in opening your account. • We use the services of The Bank of New York Mellon, 701 Market Street, Philadelphia, PA 19106, for Total Control Account recordkeeping and draft clearing. • A TCA generally is not available if your claim is less than $5,000, you reside in a foreign country, or if the claimant is a corporation or similar entity. • We may receive investment earnings from operating the Total Control Account. The performance results of any investments we make do not affect the interest rate we pay you. • To learn more about TCA, please call us at 800-638-7283 (TDD callers: 800-229-3037) or write us at Metropolitan Life Insurance Company,Total Control Account, PO Box 6100, Scranton, PA 18505-6100, Attention: TCA. Total Control Account�is a registered service mark of Metropolitan Lrfe Insurance Company. Page 2 of 2 Fs GR-TCA-A(03/15) fr� irir�iu�-rmnr � U.S. Life Insurance Claims ��'�� Claim Fraud Warnings - �ClfG' vcs. � '+s^�'_�.'�i:�^..3�:9g."'S'� .�:.m.c-r.o�SS3i:5d^"��.TJ _'_�'"��4a+ .. .. . . . . . T wr- Before signing this claim form, please read the warning for the state where you reside and for the state where the insurance policy under which you are claiming a benefit was issued. Alabama,Arkansas, District of Columbia, Louisiana, Massachusetts, Minnesota, New Mexico,Ohio, Rhode Island and West Virginia:Any person who knowingly presents a false or fraudulent claim for payment of a Ioss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Alaska: A person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim contairnng false, incomplete or misleading information may be prosecuted under state law. Arizona: For your protection, Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties. California: For your protection, California law requires the following to appear on this form:Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. Colorado: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may inctude imprisonment, fines, denial of insurance and civil damages.Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleadmg facts or information to a policyholder or claimant for the purpose of defrauding or attemptmg to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. Delaware, Idaho, Indiana and Oklahoma:WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. Florida: A person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilry of a felony of the third degree. Kentucky:Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act,which is a crime. Maine,Tennessee,Virginia and Washington: It is a crime to knowingly pravide false, incomplete or misleading information to an insurance company for the purposes of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits. Maryland: Any person who knowingfy or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance�s guilty of a crime and may be subject to fines and confinement in prison. New Hampshire: Any person who,with a purpose to injure, defraud or deceive any insurance company,files a statement of claim containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud as provided in R.S.A. 63820. New Jersey:Any person who knowingly files a statement of claim containing any false or misleading information is sub�ect to criminal and civil penalties. Oregon and Vermont:Any person who knowingly presents a false statement of claim for insurance may be guilty of a criminal offense and subject to penalties under state law. Puerto Rico:Any person who knowingly and with the intention to defraud includes false information in an application for insurance or files, assists or abets in the filing of a fraudulent claim to obtain payment of a loss or other benefit, or files more than one claim for the same loss or damage, commits a felony and if found guilty shall be punished for each violation with a fine of no less than five thousand dollars($5,000), not to exceed ten thousand dollars ($10,000); or imprisoned for a fixed term of three(3)years, or both. If aggravating circumstances exist,the fixed jail term may be increased to a maximum of five (5)years; and if mitigating circumstances are present,the�ail term may reduced to a minimum of two (2)years. Texas: Any person who knowingly presents a false or fraudulent ctaim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. Pennsylvania and all other states:Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal or civil penalties. Page 1 of 1 Fs GR-CLAIM-FRAUD(03115) �,-^� irir��riir7m�r� ° U.S. Life Insurance Claims �� Life insurance claim form Use this form to submit your claim for a life insurance policy payment. Things to know before you begin • Each beneficiary submitting a claim must complete and submit a separate claim form. However, we only need one death certificate. • Please answer each question fully and accurately. If you return this form with missing or incorrect information, it will delay your claim. • You may have to send us other documents with this claim. See the A Please correct and initial list in Section 6:How to submit this form. any errors on the form. �.a�- «�¢�.,��-:� � ��:ti SECTION 1: About you Tell us in what capacity you're making a claim (check one): ❑ Individual beneficiary ❑ Representative of a trust, estate or other organization Your relationship to the person who died (check one): ❑ Spouse/Partner ❑ Parent ❑ Child ❑ Trust/Estate/Charity ❑ Other(please explain) Your name(frst, middle, last)-Please print your name the way you want it to appear on your payment. First Middle Last Maiden or other names('fapplicable) Mailing address(Street number and name, apartment or suite) City State ZIP code Date of birth (mm/dd/yyyy) Sex (M/F) Social Security number Country of Citizenship Trust/Estate/Other Organization name Date of Trust(mmldd/yyyy) Tax Identification Number(Trust, Estate, or other Organization) Please tell us how you prefer to be communicated with (check one and provide information) ❑ Phone number ❑ Cell phone number ❑ Email address Have you signed a document with a funeral home that authorizes us to make a payment directly to them? This document is usually referred to as a funeral home assignment. ❑ No ❑Yes—If yes, please send us a copy of the document with this claim form. Page 1 of 5 CS-GL-FORM-A(03115) Metropolitan Life Insurance Company Fs .,,�.i irir��ru��rn��. p - ,.�.�.�,��- —.�_a...��,,,�.-�;s__� �--.��:. . .�: .. ,.. SECTION 2: About the deceased Name (first, middle, last) First Middle Last Maiden or other names(fapplicable) Residence address(Street number and name, apartment or suite) City State ZIP code Date of birth (mm/dd/yyyy)I Date of death (mm/dcUyyyy) Social Security number I Marital status(check one) ❑ Single ❑ Married ❑ Divorced ❑ Separated ❑ Widow/widower ��,�� -�, --- .�� SECTION 3: About the insured ❑ Same person as the deceased Name (first, middle, last) First Middle Last Employer name Page 2 of 5 CS-GL-FORM-A(03l15) Fs """'1 II If'�II�I11TNf ° �..:�� -� h�-�.a.-:.-.��4yr.-z-.r�.a. i SECTION 4: How you will receive your payment Our standard payment method is the Totai Control Account.A check will be issued to you if required by state law, regulation or direction. If a Delivering The Promise�Specialist helped you, and you want the Specialist to deliver your check or Total Control Account, please complete the following: Name of you�Delivering The Promise SpeCialist(first, last) First I Last Address (Street number and name, apartment or suite) C�� State ZIP code Page 3 of 5 CS-GL-FORM-A(03115) Fs � n ii°�nii iir�m ° p--¢€6=��. .�. _ _,�� __ _ �.:-�-._;_` , � ��:�-�� - SECTION 5: Certification and signature By signing this claim form, you certify that: • All the information you have given is true and complete to the best of your knowledge. • Any contributions owed by the insured will be deducted from the insurance proceeds paid to me. • If we overpay you,we have the right to recover the amount we overpaid. This can happen if we find we've paid you more than you're entitled to under this life insurance claim, or if we paid you when we should have paid someone else. You agree to repay us the amount we overpaid.You also understand that if you do not repay us,we may take steps, including legal action, to recover the overpayment. • You have read the Claim Fraud Warnings included with this form. New York residents:Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation Under the penalties of perjury I certify: 1.That the number shown as my Social Security Number or Tax Identification Number in"Section 1:About you" above is my correct taxpayer identification number, and 2.That I am not subject to backup withholding because: (a) I am exempt from backup withholding, or(b) I have not been notified by the Internal Revenue Service(IRS)that I am subject to backup withholding as a result of a failure to report all interest or dividends, or(c)the IRS has notified me that I am no longer subject to backup withholding, and 3. I am a U.S. citizen, resident alien, or other U.S. person", and 4. I am not subject to FATCA reporting because I am a U.S. person"and the account is located within the United States. (Please note: You must cross out Item 2 above if the IRS has notifiedyou that you are currently subject to backup withholding because you failed to report all interest or dividend income on your tax return.) *Ifyou are not a U.S. Citizen, a U.S. resident alien or other U.S.person for tcrz purposes,please cross out items 3 and 4 above, and complete and submit form W-8BEN(individuals)or W-8BEN-E(entities). The Internal Revenue Service does not require your consent to any provision of this document other than the certifications required to avoid backup withholding.You must complete this certification to avoid 28% withholding with respect to taxable amounts. �� Signature of person making the claim Date signed (mm/dd/yyyy) � � � .� -— � � �•-�---- .�-� --��.,�� -- - Page 4 of 5 Fs CS-GL-FORM-A(03115) ,""�'I II II Il IP�llfl� ' �, ---�_ - � - SECTION 6: How to submit this form 6A.Check off the items you're sending with this claim form � A death certificate.We require a copy of the death certificate. The funeral director taking care of the funeral arrangements can usually provide a copy of the death certificate. We only require one death certificate—if you're aware of another claimant who's sending one, you don't have to send it. � If you signed a document with a funeral home that authorizes us to make a payment directly to them, a copy of that document. ❑ If you are a representative of an estate, a copy of the appointment papers issued by the courts. � If you are a trustee, a statement that the trust is still in effect and you are authorized to act under the trust. If you are not the original trustee, a copy of the page naming you as the successor trustee. � If you have Power of Attomey, a copy of the appointment papers naming you as the attorney-in-fact for the beneficiary. 66.Submission instructions , Unless you have been advised of different instructions by the administrator/employer, return this claim form and the documents you've checked off above in the envelope included with this package, or mail them to: Mail: Fax: MetLife Group Life Claims 1-570-588-8645 P.O. Box 6100 , Scranton, PA 18505-6100 We're here to help If you have questions, or need help preparing your claim, call us at 1-800-MET-6420 (1-800-638-6420), then press 2. Our Customer Service Center is open Monday through Thursday, 8:00 a.m.to 8:00 p.m. EST, and Friday 8:00 a.m. to 5:00 p.m. EST. Page 5 of 5 CS-GL-FORM-A(03115) Fs .**� irii nr rnr� 5