HomeMy WebLinkAbout02-0869
IN RE: NANCY CHERYL SCULLY
: IN THE COURT OF COMMON PLEAS
: OF CUMBERLAND COUNTY,
: PENNSYLVANIA
: ORPHANS' COURT DNISION
A disabled adult
: NO. 2. \. 02-P.1DC\
On the Petition of Rita S. Balogh
PETITION TO CREATE AND FUND A SUPPLEMENTAL NEEDS TRUST FOR
THE BENEFIT OF NANCY CHERYL SCULLY, A DISABLED PERSON
TO THE HONORABLE PRESIDENT JUDGE OF SAID COURT:
NOW COMES Petitioner, Rita S. Balogh, by and through her attorney, Marielle F.
Hazen, Esquire and files the within Petition to create and fund a Supplemental Needs Trust for
the benefit of NANCY CHERYL SCULLY, and in support hereof, avers as follows:
1. NANCY CHERYL SCULLY, the disabled adult, currently resides with the
Petitioner at 1423 Bridge Street, New Cumberland, Pennsylvania 17070. She is thirty-eight (38)
years old, her date of birth being September 14, 1964.
2. The Petitioner is Rita S. Balogh of 1423 Bridge Street, New Cumberland,
Pennsylvania, 17070, and she is the natural mother of NANCY CHERYL SCULLY.
3. NANCY CHERYL SCULLY is divorced and has no children.
4. NANCY CHERYL SCULLY suffers from paranoid schizophrenia and is disabled
as defined in Title XVI of the Social Security Act, 42 V.S.C. ~1382C(a)(3). (A statement from
Dr. Vivencio Del Rosario of the Holy Spirit Department of Behavioral Health is attached hereto
as Exhibit "A").
5. Because of NANCY CHERYL SCULLY's severe disabilities and lack of personal
assets, she is presently receiving Supplemental Security Income benefits and Medical Assistance,
which is provided through the Pennsylvania Department of Public Welfare. (A copy of the
Gateway Health card is attached hereto as Exhibit "B").
6. NANCY CHERYL SCULLY's father, Paul Balgoh, died intestate on December
8,2000, in St. Paul, Minnesota. (A copy of the Order ofIntestacy is attached hereto as Exhibit
"e").
7. As heir to Paul Balogh's estate, NANCY CHERYL SCULLY will receive a
portion of said estate in the amount of Nine Thousand Forty-Nine Dollars and 51/00 ($9,049.51).
(A copy of the distribution check is attached hereto as Exhibit "D").
8. In order to maintain Supplemental Security Income and Medical Assistance,
placing NANCY CHERYL SCULLY's inheritance into a Special Needs Disability Trust is
permitted pursuant to a special provision of Title XIX of the Social Security Act, specifically 42
U.S.C. g 1396p(d)(4)(A). (A copy of the Trust is attached hereto as Exhibit "E").
9. The Social Security Act allows for the creation and funding of a Trust, but
requires that the Trust be created and funded under a Court Order.
I O. The Special Needs Disability Trust for the benefit of NANCY CHERYL
SCULLY was drafted in accordance with 42 U.S.C. g 1396p(d)( 4)(A) and 55 Pa.C.S.A.
gI78.7(f)(I). The Trust contains the assets of an individual under the age of65 who is disabled
as defined by the criteria in 42 U.S.C.A.g1382c(a)(3); the Trust was established by the Petitioner,
as the natural parent of NANCY CHERYL SCULLY; and the Trust contains a provision that the
Commonwealth of Pennsylvania will receive the amounts remaining in the trust upon the death
of NANCY CHERYL SCULLY, up to the total amount of benefits paid on behalf of NANCY
CHERYL SCULLY.
11. A copy of the Special Needs Disability Trust has been filed with the Department
of Public Welfare. (A copy of correspondence dated July 18,2002, from Patricia Nace, a claims
investigation agent for the Department of Public Welfare, is attached hereto as Exhibit "F").
12. Petitioner believes it is in the best interests of NANCY CHERYL SCULLY to
have NANCY CHERYL SCULLY'S inheritance from the Estate of Paul Balogh transferred into
the Special Needs Disability Trust created for NANCY CHERYL SCULLY's benefit. This
Trust will preserve her eligibility for Supplemental Security Income and Medical Assistance
benefits, while protecting the inherited funds to provide for her supplemental needs.
13. Petitioner requests this Honorable Court to consider the entire circumstances of
the life and needs of NANCY CHERYL SCULLY, and what is in her best interests in order to
maximize the quality of her life.
14. Petitioner requests this Honorable Court to schedule a Hearing in this matter if
such Hearing is necessary. If no Hearing on this matter is necessary by this Honorable Court,
Petitioner further requests this Honorable Court to enter an Order, authorizing the following:
a. The creation of a Special Needs Disability Trust for the benefit of NANCY
CHERYL SCULLY, pursuant to 42 D.S.C. 91396p(d)(4)(A) and 55 Pa.C.S.A.
9178.7(1)(1), naming the Petitioner, Rita S. Balogh, as Trustee ofthe
Supplemental Trust for the benefit of NANCY CHERYL SCULLY; and
Date:
b. The authority to fund the Special Needs Disability Trust for the benefit of
NANCY CHERYL SULLY with NANCY CHERYL SCULLY's inheritance
from the Estate of Paul Balogh.
Respectfully submitted,
IAN L. BROWN & ASSOCIATES
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Attorney for Petitioner
Attorney ill No. 68003
845 Sir Thomas Court, Suite 12
Harrisburg, Pennsylvania 17109
(717)541-5550
COMMONWEALTH OF PENNSYLVANIA
SS:
COUNTY OF DAUPHIN
On this, the ~ day of ';i r*m hi A , 2002, before me, the undersigned officer,
personally appeared Rita S. Balogh who, being duly sworn according to law, does depose and
say that the facts set forth in the foregoing Petition are true and correct to the best of her
knowledge, information and belief.
IN WITNESS WHEREOF, I hereunder set my hand and official seal.
~f 2Z~
SWORN to and subscribed before me thisJ? 'lit- day of A.pi1lJ M.r ,2002.
NOTARIAL SEAL
JESSlCAA. HOlLANO. NOTARY PUBLIC
CITY OF HARRISBURG. DAUPHIN COUNTY
MY COMMISSION EXPIRES MARCH 4 2006
VERIFICATION
I verify that the statements made in this Petition are true and correct. I understand that
false statements herein are made subject to the penalties of 18 Pa.C.S. Section 4904, relating to
unsworn falsification to authorities.
~J!. ~~
Rita S. Balogh
INRE: NANCYCHERYLSCULLY
: IN THE COURT OF COMMON PLEAS
: OF CUMBERLAND COUNTY,
: PENNSYLVANIA
: ORPHANS' COURT DIVISION
A disabled adult
: NO.
CERTIFICATE OF SERVICE
I, Marielle F. Hazen, Esquire, certify that on S.{.pf . tLS , 2002, I served a true
and correct copy of the within Petition on the party(ies) named below, by depositing same in the
United States mail, certified mail, postage prepaid as follows:
Karen Louise Balogh
153 Joralemon St.
Brooklyn, NY 11201
Patricia Nace
Claims Investigation Agent
Commonwealth of Pennsylvania
Department of Public Welfare
Bureau of Financial Operations
TPL Section Casualty Unit
P.O. Box 8486
Harrisburg, P A 17105-8486
By:CWdtR2s-
ari lle F. Hazen, EsqUIre
Jan L. Brown & Associates
845 Sir Thomas Court
Suite 12
Harrisburg, P A 171 09
(717) 541-5550
~J HOLY SPIRIT-HOSPITAL
. BehPIoral Health Center
li03 No 21- S1rIIlIt
c.np .... PA 11011-2218
o O~. M.D. -110 037444E
frV.G. del RooarIo. M.D. - MD 0284521
o S.S. dB II Cruz, M.D. -MO 030105E
o M.B. WIlle, 0.0. - OS 0D70lllll
o R.IC MIler, M.D. - MD 058402L
o PhyolciM:
Telephone (717) 763-2219
Fu: (71T) 783-2385
o C.E. CIIcII~ Jr., M.D. - MD 014193E
o F.R. Meue, M.D. - MD 02547SE
DB. Sumballan, M.D. - MD 418305
OM. HemIda. D.O. - OS 008798L
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EXHIBIT "A"
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Health Plan
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NAME, MEMBER
SCULLY, NANCY C
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EXHIBIT "B"
, ,"IIC'''''- FORMAL 4622 MillerlDavis Co. 0 St, Paul, MN 651.642.1988
Minn. Stat, 524,3.403; 524.3.502; 524,3.801
,
STATE OF MINNESOTA . DISTRICT COURT
PROBATE DIVISION
COUNTY OF WASHINGTON Tenth JUDICIAL DISTRICT
Court File No. Pl-01-400093
ESTATE OF NOTICE AND ORDER OF HEARING ON PETITION
Paul Balogh FOR FORMAL ADJUDICATION OF INTESTACY,
DETERMINATION OF HEIRSHIP, APPOINTMENT
OF PERSONAL REPRESENTATIVE AND NOTICE
DECEDENT TO CREDITORS
It is Ordered and Notice is given that onl,,,,7M;,y 1, 7001 at 1:00 flIJrla>6 (p,m,}
a hearing will be held in this Court at Stillwater
, Minnesota, for the adjudication of intestacy and
determination of heirship of the Decedent, and for the appointment of Arlene V, Johnson
whose address is; 51 Scarlet Oak Street East, Oakdale, Minnesota 5,5128
(2)
whose address is:
(3)
whose address is:
as personal representative of the Estate of the Decedent in 0 an UNSUPERVISED 0 a SUPERVISED
administration. Any objections to the Petition must be filed with the Court prior to or raised at the hearing,
If proper and if no objections are filed or raised, the personal representative will be appointed with full
power to administer the Estate, including the power to collect all assets, pay all legal debts, claims, taxes
and expenses, to sell real and personal property, and do all necessary acts for the Estate.
Notice is also given that (subject to Minn. Stat, 524.3-801) all creditors having claims against the Estate
are required to present the claims to the personal representative or to the Court Administrator within four
months after the date of this Notice or the claims will be barred.
(COURT SEAL}
Susan R. Miles 04-03-2001
Attorney For Personal Representative
nos mTllUMJ:NTWAS DRAFTED BY (NAME AND ADORUS): Judge Date
David W, Larson Christina M. Volkers 04-01-7001
DUDLEY AND SMITH, P.A.
2602 Firstar Center
101 East Fifth Street Court Administrator Date
St. Paul, MN 55101
651-291-1717
Trina Nelson
NOTE: If notice to creditors has been previously given, delete the notice to creditors, Deputy
NOTE TO PUBLISHER: Do not publish text that is unchecked and text of Notes,
NOTICE AND ORDER OF HEARING ON PETITION FOR FORMAL ADJUDICATION OF INTESTACY. DETERMINATION OF HEIRSHIP,
APPOINTMENT OF PERSONAL REPRESENT A TIVE AND NOTICE TO CREDITORS
WARNING: UNAUTHORIZED COPYING OF THIS FORM PROHIIIITED.
EXHIBIT "e"
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NANCY CHERYL SCULLY
2002 IRREVOCABLE TRUST AGREEMENT
THIS AGREEMENT is entered into this 20 day of --::::S-Ul--Q , 2002, by
and among Rita S. Balogh, as the natural mother of Nancy Cheryl Scully, a disabled adult
hereinafter referred to as the "Settlor," and Rita S. Balogh, hereinafter referred to as the
"Trustee."
WITNESSETH:
The Settlor hereby assigns, transfers and delivers to the Trustee, irrevocably and
absolutely, all incidents of ownership and all right, title and interest, both present and future,
in and to, the cash, securities and other property, real or personal, set forth in Schedule" A "
attached hereto, and this property, together with any cash, securities and other property
hereafter added by the Settlor, or by anyone else, shall be referred to as the Trust Estate. The
Trustee shall hold and administer the Trust Estate upon the terms and conditions which
follow.
The express purpose of the Nancy Cheryl Scully 2002 Irrevocable Trust Agreement is
to provide for Nancy Cheryl Scully extra and supplemental care in addition to and over and
above the benefits Nancy Cheryl Scully otherwise receives as result of her handicap or
disability from any local, state or federal government, including but not limited to Medical
Assistance and! or Medicaid, or from any other private agency, any of which provides services
or benefits to handicapped or disabled persons. It is the express purpose of the Settlor to use
the Trust Estate only to supplement other benefits available to or received by Nancy Cheryl
Scully. To this end, the Trustee may provide such resources and experience it has acquired as
EXHIBIT "E"
a fiduciary as will contribute to and make Nancy Cheryl Scully's life as pleasant, comfortable
and happy as possible. Nothing herein shall preclude the Trustee from purchasing those
services and items which promote Nancy Cheryl Scully's happiness, welfare and
development, including, but not limited to, vacation and recreation, trips away from places of
residence, expenses for traveling companions if requested or necessary, entertainment
expenses, supplemental medical and dental expenses, social services expenses and
transportation costs. The Trust is to be considered as a discretionary trust, and not as a basic
support trust. The Trust Estate shall not be used to provide basic food, clothing and shelter,
nor be available to the beneficiary for conversion for such items, unless all local, state and
federal benefits for which the beneficiary is eligible as a result of disability or handicap, have
been fully expended for such purposes. It is the Settlor's express purpose to establish the
Trust in accordance with 42 U.s.c. 1396 (d) (4) (A).
ARTICLE I
A. During the lifetime of Nancy Cheryl Scully (hereinafter the "Beneficiary"), the
Trustee may pay to the Beneficiary, or expend for her benefit, so much of the net income and,
if necessary, the principal of the Trust Estate to carry out the purposes set forth in the above
recitals, as the Trustee, in its sole and absolute discretion, considers advisable, in view of other
funds or benefits available from governmental or other sources, both public and private, of
which it has knowledge.
By means of illustration, and in no manner attempting to limit the Trustee's
discretion, the Trustee may make distribution of the net income and, if necessary, principal of
2
the Trust Estate, to or for the benefit of the Beneficiary, for such purposes as, but not limited
to:
1. Supplemental medical, surgical, dental or health care procedures,
treatments or rehabilitative services.
2. Vacation and travel.
3. Traveling companions on vacations.
4. Recreation.
5. Transportation.
6. Cosmetic services such as haircuts, massages, etc.
7. Clothing.
8. Travel to home.
It is the Settlor's intention that distributions of income and! or principal from the
Trust Estate shall be used only to supplement, not supplant, any benefits to which the
Beneficiary may be entitled under any governmental program, and if the existence of this
Trust should at any time be used by any governmental agency as an excuse for denying the
Beneficiary such benefits, then the Trustee is authorized, in its sole and absolute discretion, to
terminate the Trust Estate by distributing the then remaining principal and any income
accrued or on hand to Rita S. Balogh's daughter, Karen Louise Balogh, of New York City,
New York, Per Stirpes. The Trustee may accumulate and reinvest any income that is not
paid out pursuant to this Section A.
B. At such time as the Beneficiary is adjudicated by a court of competent
jurisdiction to no longer be an incapacitated person, the Trustee shall pay to the Beneficiary,
outright and free of trust, the remaining balance of the Trust Estate and any accumulated,
3
undistributed income thereon. However, if the Beneficiary has received, or is receiving
Medicaid or Medical Assistance benefits at such time as she is adjudicated to no longer be an
incapacitated person, the Trustee shall, before making any distributions to the Beneficiary,
request a written statement from the Commonwealth of Pennsylvania Department of
Public Welfare, or its successor(s), reporting the actual value of benefits paid for the benefit
of or on behalf of the Beneficiary (hereinafter the "Benefit Amount"). Upon receipt of such
statement of benefits the Trustee shall pay and distribute to the Commonwealth of
Pennsylvania Department of Public Welfare, or its successor(s) an amount equal to the
Benefit Amount from the remaining balance of the Trust Estate and any accumulated,
undistributed income thereon.
C. Upon the death of the Beneficiary, prior to any adjudication referred to in
Section B, above, the Trustee shall pay and distribute the remaining balance of the Trust
Estate and any accumulated, undistributed net income thereon, outright and free of trust to
Nancy Cheryl Scully's sibling(s), Per Stirpes. However, if the Beneficiary has received, or is
receiving Medicaid or Medical Assistance benefits at the time of her death, the Trustee shall,
before making any distributions to the Beneficiary, request a written statement from the
Commonwealth of Pennsylvania Department of Public Welfare, or its successor(s),
reporting the Benefit Amount. Upon receipt of the Benefit Amount statement the Trustee
shall pay and distribute to the Commonwealth of Pennsylvania Department of Public
Welfare, or its successor(s), an amount equal to the Benefit Amount from the remaining
balance of the Trust Estate and any accumulated, undistributed net income thereon.
4
ARTICLE II
A. No beneficiary shall have the power to sell, assign, encumber or in any manner
to anticipate his or her interest in the Trust Estate, or in the income produced thereby.
B. If any beneficiary, other than the Nancy Cheryl Scully, who is entitled to
receive a share of the principal of the Trust Estate shall be a minor, the Trustee is hereby
authorized and empowered to continue to hold and manage such share for the benefit of the
minor during his or her minority as the minor's Guardian and may use all of the income from
the minor's share, together with such amounts of principal as the Trustee deems advisable for
his or her health, education, maintenance and support. This shall be construed as a power
only and shall not operate to suspend the absolute ownership thereof by the minor nor to
prevent the absolute vesting thereof in the minor.
C. In the disbursement of funds directed to be paid to or for the use and benefit of
any beneficiary, other than Nancy Cheryl Scully, the Trustee may make payment of the
same to the parent, guardian, or such other person who may have custody of the person of
that minor at the time such payments are made, to be used fort he health, education,
maintenance and support of the minor, but without liability on the part of the Trustee to see
to the application of said payments by the payee. The receipt of any such person shall be a
full acquittance of the Trustee as to any amounts so paid; or the Trustee may make payment
of the same directly to or for the benefit of the minor beneficiary.
D. For purposes of interpretation of this Agreement the word "minor" whenever
used herein shall mean any person under the age of twenty-one (21) years, notwithstanding
any law to the contrary.
5
ARTICLE III
In addition to the powers conferred by law, the Trustee shall have the following
discretionary powers which may be exercised without approval of any court:
A. To retain any and all property, real or personal, received from any source,
without any duty of diversification.
B. To sell any and all real estate held as a trust asset, at public or private sale, for
such prices and upon such terms as the Trustee shall believe advisable and to make, execute
and deliver any deed or deeds therefore, conveying title thereto in fee simple absolute or for
any lesser estate to any purchaser or purchasers, freed and discharged of any and all trusts
hereunder.
C. To sell, grant options to purchase, exchange, and alter assets of any trust
created hereunder or any part thereof, at any price and upon such terms which the Trustee
shall deem proper.
D. To invest and reinvest in all forms of property, including common and
preferred stocks, common trust funds operated by the Trustee, and any regulated investment
company or mutual fund including, those in which the Trustee has an economic interest.
E. To invest the principal and! or income of any trust created hereunder in any
assets or security including, but not limited to stocks, bonds, debentures, notes or other
similar obligations issued, owned or underwritten by any corporate trustee or its affiliate
which may be acting hereunder.
F. To invest such principal and! or income in any bond or other debt security
secured, supported or otherwise enhanced by a letter of credit of any corporate trustee or its
affiliate which may be acting hereunder.
6
G. To execute security transactions through the Trustee's or any affiliated
discount brokerage service.
H. To purchase real property whether improved or not and to lease property on
any terms and conditions and for any term of years, even though extending beyond the
period of any trust created hereunder.
1. To insure, improve, repair, alter, abandon and partition real estate; erect or
raze improvements; grant easements; subdivide and dedicate to public use.
J. To cause any of the investments which may be delivered to or acquired by the
Trustee to be issued, held, or registered in the name of the Trustee, in street name negotiable
form, in the name of a nominee, or in any form in which title will pass by delivery. Any
corporation or its transfer agent may presume conclusively that said nominee is the actual
owner of the securities submitted for transfer.
K. To vote in person or by proxy any securities held in the Trust Estate and, in
such connection, to delegate powers, discretionary or otherwise, for any purpose to one or
more nominees or proxies with or without power of substitution and to make assignments to
and deposits with committees, trustees, agents, depositories and other representatives; to
retain any investments received in exchange in any reorganization or recapitalization; to
subscribe for stocks and bonds; to grant, obtain or exercise options; and generally to exercise
all rights of security holders.
L. To settle, compromise, contest or abandon claims or demands in favor of or
against any trust created hereunder.
M. To borrow money, assume indebtedness, extend mortgages, and encumber by
mortgage or pledge.
7
N. To distribute the principal of any trust created hereunder in kind or in cash, or
partly in kind and partly in cash.
o. To allocate receipts and disbursements to principal or income, or partly to each
as the Trustee deems proper.
P. To retain a consultant knowledgeable in the subject of Medical Assistance
and! or Medicaid benefits or other public or private benefits available to the Beneficiary
because of her handicap or disability, and to advise the Trustee concerning discretionary
distributions of income or principal so that such distributions will be made in a manner
consistent with the purpose of the Trust.
Q. To deal in every way and without limitation with the representatives of any
trust or estate which the Beneficiary has any existing or future interest, even though the
Trustee is acting as the representative of such other trust or estate, without liability for loss
resulting from said transaction.
R. To employ such agents, attorneys, accountants, investment counsel and
professional advisors as may be required in managing, protecting and investing the assets of
the Trust Estate and to pay their reasonable compensation.
s. To receive and administer hereunder any property that may be added by
anyone by deed, Will or otherwise, to the Trust Estate.
ARTICLE IV
A. The Trustee may resign at any time by giving prior written notice to the
Settlor, otherwise to the Beneficiary's mother, Rita S. Balogh. In the event of Rita S.
Balogh's incapacitation, or if Rita S. Balogh is unable or refuses to act as Trustee, then Jan 1.
8
Brown, of Ian L. Brown & Associates, Attorneys at Law, of 845 Sir Thomas Court, Suite
12, Harrisburg, P A 17109, is appointed as Successor Trustee with all the rights and duties of
the original appointed Trustee.
B. The Settlor, in her capacity as the natural mother of Nancy Cheryl Scully, a
disabled adult, may at any time, by written instrument, approve the accounts of the Trustee
with the same effect as if the accountS had been approved by a court having jurisdiction of the
subject matter and of all necessary parties.
C. If any Trustee designated to act or at any time acting hereunder is merged with
or transfers substantially all of its assets to another corporation, or is in any other manner
reorganized or reincorporated, the resulting or transferee corporation shall become Trustee in
place of its corporate predecessor.
D. Any successor Trustee shall have all of the title, powers, and discretion granted
to the original Trustee, without court order or act of transfer. No successor Trustee shall be
liable for any act or failure to act of a predecessor Trustee. With the approval of the persons
indicated in Section C of this Article, a successor Trustee may accept the account furnished, if
any, and the property delivered by or for a predecessor Trustee without liability for so doing,
and such acceptance shall be a full and complete discharge to the predecessor Trustee.
E. Any Trustee which may be acting hereunder shall be entitled to deduct each
year as compensation reasonable fees, which fees shall be in accordance with the then
prevailing rate of compensation charged by the Trustee for like services at the time such
services are rendered. In addition to the Trustee's normal compensation, the Trustee shall be
entitled to deduct such fees as shall reasonably compensate the Trustee for such additional
services which the Trustee may be required to perform.
9
F. No bond shall be required in any jurisdiction of any Trustee or of any
successor Trustee or, if a bond is required by law, no surety on such bond shall be required.
ARTICLE V
This Trust shall be and is intended to be irrevocable, and the Settlor hereby renounces
any and every right, power or authority which she otherwise might or could have to revoke,
alter or amend this Trust Agreement or any of the provisions hereof.
ARTICLE VI
This Trust Agreement has been delivered to and accepted by the Trustee in the
Commonwealth of Pennsylvania, and all questions pertaining to the validity and
interpretation of this Trust Agreement and to the management and distribution of the Trust
Estate hereunder shall be determined in accordance with the laws of the Commonwealth of
Pennsylvania.
IN WITNESS WHEREOF, the Settlor has hereunto set her hand and seal and the
Trustee has caused this Agreement to be executed by its duly authorized officers and its
corporate seal to be hereunto affIxed, as of the day and year fIrst above-written.
(YI';a,'dagi1'~
Witness
11l1';~r1c~~ ~AJtJi",)
WItness
2!JIf-- /~ b a~
Rita S. Balogh, Settlor
(SEAL)
~ti; ~r;3~
Rita S. Balogh, Trustee
(SEAL)
fflJA~rkc:4ll ~
Witness vi
(SEAL)
Brown, Successor Trustee
10
COMMONWEALTH OF PENNSYLVANIA )
) ss:
COUNTY OF DAUPHIN )
On this, the do'ti.. day of S LA.J\.Q , 2002, before me, a Notary Public,
personally appeared Rita S. Balogh, known to me (or satisfactorily proven) to be the person
whose name is subscribed to the within instrument as Settlor and Trustee, and acknowledged
that she executed the same for the purposes therein contained.
IN WITNESS WHEREOF, I have hereunto set my hand and official seal.
MOTARIAlSEAl
JESSICA A. HOll.AIID, MOTAR'! PUBLIC
CITY Of HARRISBURG, OAUPHIM COUIfIY
MY COMMISSIOM EXPIRES MARCH 4 2006
STATE OF ]€(\OS\.1 \ VCLnll\ ) )
) S5:
COUNTY OF ""IxA-.\.l P ~Lf\ )
On this, the ~ day of 0LL \\..0 , 2002, before me, a Notary Public,
personally appearedJan L. Brown, known to me (or satisfactorily proven) to be the person
whose name is subscribed to the within instrument as Successor Trustee, and acknowledged
that she executed the same for the purposes therein contained.
IN WITNESS WHEREOF, I have hereunto set my hand and official seal.
NOTARIAL SEAL
JESSICA A. HOLLAND, NOTARY PUBLIC
CITY OF HARRISBURG, DAUPHIN COUNTY
MY COMMISSION EXPIRES MARCH 4 2006
11
SCHEDULE A
The following asset(s)/account(s) have/has been transferred into the Nancy Cheryl
Scully 2002 Irrevocable Trust Agreement:
1.
2.
12
*'
IdUL 2 3 REt"lJ
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WelFARE
BUREAU OF FINANCIAl OPERATIONS
TPl SECTION CASUAL TV UNIT
PO BOX 8466
HARRISBURG, PA 17105-8486
JAN L BROWN & ASSOCIATES
JAN L BROWN ESQ
OLDE ENGLISH GAP
845 SIR THOMAS CT STE 9
HARRISBURG PA 17109
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July 18, 2002
Re: NANCY SCULLY
CIS #: 710009565
Incident Date: 6/20/2002
Dear Attorney Brown:
Our office has set a file for the special needs trust regarding the
above-referenced individual, a recipient of cash and/or medical assistance.
After receipt of the initial statement of claim, you will receive an updated
statement of claim annually.
Thank you for your cooperation in this matter. If you have any
questions, please contact me.
Sincerely,
-r~.-g~
patricia Nace
Claims Investigation Agent
717-772-6616
717-705-8150 FAX
EXHIBIT "F"
~
SEP 2 5 200Z
IN RE; NANCY CHERYL SCULLY
: IN W~F COMMON PLEAS
: OF UNIT,
: PENNSYLVANIA
: ORPHANS' COURT DIVISION
A disabled adult
: NO. 21- O..1-?L,q
On the Petition of Rita S. Balogh
, 2002, it is hereby ORDERED,
ADJUDGED and DECREED that the Petitioner, Rita S. Balogh, as the natural mother of NANCY
CHERYL SCULLY, will have the authority to:
I. Create a Supplemental Trust for the benefit of NANCY CHERYL SCULLY,
pursuant to 42 U.S.c. S1396p(d)(4)(A) and 55 Pa.C.S.A. SI78.7(f)(1), naming the Petitioner,
Rita S. Balogh, as Trustee of the Supplemental Trust for the benefit of NANCY CHERYL
SCULLY; and
2. The authority to fund the Special Needs Disability Trust for the benefit of
NANCY CHERYL SCULLY with NANCY CHERYL SCULLY's inheritance from the Estate of
Paul Balogh.
BY THE COURT:
.. J.
111.__ '.~ (~~
JAN 1. BROWN & ASSOCIATES
ATTORNEYS AND COUNSELORS AT LAW
OLOE ENGLISH GAP
845 SIR THOMAS COURT
SUITE 12
HARRISBURG, PA 17109
EMAIL jlbassoc@ptd.net
JAN L. BROWN"
MARIELLE F. HAZEN"
"CERtiFIED elDER LAW ATTORNEY BY
THE NATIONAL ELDER LAW FOUNDATION
TELEPHONE (717) 541-5550
FACSIMILE (717) 541-9223
"AOMfTTED IN FA ANOOlSTRfCT OF COLUMBfA
October 24, 2002
Register of Wills
Cumberland County Courthouse
One Courthouse Square
Carlisle, P A 17013
Re: Nancy Cheryl Scully
No. 21-02-869
Dear Donna:
Per my telephone conversation with the Register of Wills on October 23, 2002, this letter
serves as notice that a correction needs to be made to the caption on the Final Order signed by
Hon. George E. Hoffer on October 2, 2002 in the above-referenced matter. The caption should
list Cumberland County rather than Dauphin County. I am enclosing a copy for reference.
I apologize for any confusion or inconvenience this may have caused. If you have any
questions, please feel free to contact my office. Thank you for your attention to this matter.
Sincerely,
~
MFH/jah
Enclosures
cc: Rita S. Balogh
( \\ essica A. Holland
U Legal Assistant