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LIVING TRUST ESTATE OF BEVERLY I BAKER, DECEASED
DISCLAIMER and RENUNCIATION ' ,
(FAMILY TRUST) G °; c'
WHEREAS, Beverly J. Baker died on May 8, 2015, a resident of Silvgr Spring Tcua;nsh ,
Cumberland County. Pennsylvania(the"Decedent"); '��,' ;= n
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WHEREAS, during the Decedent's lifetime, she created the Beverly J. Baker LivW 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
WHERAS, the Decedent had designated the Trust as primary beneficiary of the Annuity;
and
WHEREAS, the Husband has disclaimed the Annuity and all of his interest in the
Survivor's Trust, as a result of which the Annuity was allocated to the Family Trust to be held,
administered and distributed according to the provisions of Article Nine of the Trust.
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.
WHEREAS, the Disclaimant acknowledges that the effect of the execution of this
Disclaimer and Renunciation is that the Annuity that would have otherwise been held for his benefit
under the Family Trust shall pass to his and the Decedent's children, Steven G. Baker, Edwin R.
Baker, and Kevin L. Baker.
NOW, THEREFORE, I, HARRY R. BAKER, 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 seMc., 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 Family Trust, as a consequence of which the Annuity
shall now pass to Steven G. Baker, Edwin R. Baker, and Kevin L. Baker.
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:
t
Harry R. Baker
COMMONWEALTH OF PENNSYLVANIA )
ss:
COUNTY OF �t URIJi� )
On this, the (P 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
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