HomeMy WebLinkAbout08-12-15 � b
cin
CO -U cn ::0 .
IM ry
BEVERLY J. BAKER,DECEASED "`-
CD
-71
-, -T
DISCLAIMER and RENUNCIATION ` e>
o
-T1
WHEREAS, Beverly J. Baker died on May 8, 2015, a resident of Mechanicsburg, Silver
`t' s Spring Township, Cumberland County, Pennsylvania(the"Decedent"); and
WHEREAS, during the Decedent's lifetime, she invested in an Odyssey Plus Fixed
Annuity, Contract Number ODP-48004801, issued by Mass Mutual Financial Group (the
"Annuity"); and
WHEREAS, the Decedent had designated her spouse, Harry R. Baker, as primary
beneficiary, and her three children, Steven G. Baker, Edwin R. Baker, and Kevin L. Baker as
contingent beneficiaries, of the Annuity; and
WHEREAS, less than nine (9) months have elapsed since the date of death of the Decedent
and the undersigned Disclaimant has not accepted any of the Annuity nor has he exercised any
control as beneficial owner over the Annuity or any interest therein; and
WHEREAS, the Disclaimant acknowledges, but does not direct, that the effect of his
execution of this Disclaimer and Renunciation is that the Annuity that would have otherwise been
distributed to him shall pass to the Decedent's three children.
NOW, THEREFORE, I, HARRY-R. BAKER, the Decedent's surviving spouse and an
adult beneficiary residing at 215 N. Locust Point, Mechanicsburg, Pennsylvania 17050, do
hereby exercise the rights granted to me in the Pennsylvania Probate, Estates and Fiduciaries
Code, 20 Pa. C.S.A. §6201 et seq., and do hereby DISCLAIM AND RENOUNCE all of my
10b
right, title and beneficial interest in and to the Annuity as the primary beneficiary thereof.
IN WITNESS WHEREOF, intending to be legally bound hereby and that this Disclaimer
and Renunciation shall be filed of record with the Cumberland County Register of Wills Office, as .
provided in 20 Pa. C.S.A. §6204(a), I have hereunto set my hand this day of August, 2015.
WITNESS: DISCLAIMANT:
X� .
t
= Harry R. BaVer
COMMONWEALTH OF PENNSYLVANIA )
J/1'1A�la�' ) ss:
COUNTY OF )
On this, the day of August, 2015, before me, a Notary Public in and for the
Commonwealth of Pennsylvania, the undersigned officer, personally appeared Harry R. Baker,
known to me (or satisfactorily proven) to be the person whose name is subscribed to the within
instrument and acknowledged that he executed the same for the purposes therein contained.
Notary Public
My Commission Expires:
CoM*A.0:N,WEAjTH OF PENNSYLVANIA
NOTARIAL SEAL
D-enise.,M Long,Notary Public
Der ,T
Aauphin County
My Cornmisnx;p;ires May 25,2019
MEMBER,PENNSYL,, Nl .�7S PATI
2