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LIVING TRUST ESTATE OF BEVERLY J.BAKER,DECEASED = c'
DISCLAIMER and RENUNCIATION
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(SURVIVORS TRUST)
WHEREAS,Beverly J. Baker died on May 8, 2015, a resident of Silver Spring Township,
Cumberland County, Pennsylvania(the "Decedent");
WHEREAS, during the Decedent's lifetime, she created the Beverly J. Baker Living Trust
dated May 3, 1996, and any amendments thereto (the"Trust"); and
WHEREAS, the Successor Death Trustee of the Trust is the Decedent's husband, Harry R.
Baker(the"Husband"); and
WHEREAS, during the Decedent's lifetime, she invested in an Odyssey Plus Fixed
Annuity, Contract No. OSL-24710023 issued by Mass Mutual Financial Group (the "Annuity");
and
WHEREAS, pursuant to Section 7.01 of the Trust, the remaining trust property of the
Decedent is to be allocated to the Marital Share, to be held, administered and distributed according
to the provisions of the Survivor's Trust as set forth in Article Eight of the Trust, for the sole benefit
of Husband.
WHEREAS, Section 7.03 of the Trust provides that "If my husband disclaims the interest
he has in any portion of the Non-Marital Share, my Trustee shall dispose of the disclaimed interest
under the provisions of this agreement(the Trust) as though he had predeceased me"; 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
held for his benefit under the Survivor's Trust shall pass to the Family Trust and distributed as
provided in Article Nine of the Trust.
NOW, THEREFORE, I, HARRY R. BAKER, the Decedent's surviving spouse and an
adult beneficiary residing at 215 N. Locust Point Road, 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 seg., and do hereby DISCLAIM AND RENOUNCE all of my
right, title and beneficial interest in and to the Annuity, and all of my interest in the Survivor's
Trust.
IN WITNESS WHEREOF, intending to be legally bound hereby and that this Disclaimer
and Renunciation shall be filed of record with the Trustee of the Trust, as provided in 20 Pa. C.S.A.
§6204(a), I have hereunto set my hand this day of August, 2015.
SIGNATURE APPEARS ON NEXT PAGE
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WITNESS: DISCLAIMANT:
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Harry R. Bak
COMMONWEALTH OF PENNSYLVANIA )
ss:
COUNTY OF (�I�t.�vi�'��' )
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.
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otary Public
My Commission Expires:
COMMONWL H OF PENNSYLVANIA
NdTARIAL SEAL
Denbo M,Long.Notary Public
DOry.TWp.,Dauphin County
My Gommiailon Expires May`25.2019
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