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orthopedic surgery residency in Ksnsas City College
of Osteopathic Medicine. In 1980 and 1981 I did a
six-month hand fellowship and surgery fellowship at
the University of Missouri in Kanaas City. May,
1981 I entered practice here in York, Pennsylvania.
I have been here ever since.
I became board certified April 1, 1985. I am on
staff the Memorial Hospital, York. I am also on
active staff at York Hospital. I am also on the
consulting staff at HealthSouth Rehab Hospital. I
limit my practice to orthopedic surgery.
Real briefly, for those members of the jury who may
not understand what orthopedic surgery is, please
tell us.
Basically, orthopedic surgery is the care of
musculoskeletc.l probl.ems, back problems neck
problems, extremity problems, take care of
fractures, lacerations, those types of things.
Bones and joints and muscles?
That's it.
You are licensed to practice in Pennsylvania?
Yes.
And do you routinely treat patients with complaints
like Mr. Monismith presented to yOU?
Yes, I do all times of spinal surgery. I also take
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care of pelvic fractures and, in fact, operate on
the very severe pelvic fractures.
I offer Dr. Mittrick as an expert in the field of
orthopedic surgery.
MR. BUCKLE'll No problem,
BY MR, GEDULDIGt
Doctor, at my request, did you evaluate Paul
Monismith, III this past May?
Yes,
Did I provide you with a number of medical records
and so forth?
Yes, you did. You provided me with many, many
medical records.
Did you have an opportunity to review those?
Yes, I did.
Did you take a history from the patient?
Yes, I did.
What is a history, real briefly?
Basically, a history is the story of what happened
to the patient and what they are feeling, what kinds
of problems they are having and what kind of
treatment they basically had in regards to their
chief complaints.
As part of your independent medical evaluation, did
you also conduct a physical exam on Mr. Monismith?
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Yes,
And did you do any tests, X-rays, anything like
that?
We did do a few X-rays, yes,
Now, if Mr. Monismith were your patient, would you
do the same things? Would you take a history from
him, look at previous medical records and other
X-rays, do your own X-rays and do an exam?
Yes.
What's the difference between what I asked you to do
and if Mr. Monismith came to you to be your patient?
The only thing is, Mr, Monismith is not going to be
coming back to me for follow-up care. He's here for
opinions, that's all.
Do you approach him the same as if he became your
patient?
Yes, basically, yes.
Please tell the jury the significant history you
obtained from Mr. Monismith?
I saw him on 5/21/99 as you already mentioned, At
that time, Paul was 47 years old. He was five feet,
ten and half inches tall and approximately 190
pounds, Currently he was employed. He was working
as maintenance man at a glass factory in Carlisle.
He told me he works full time but he does not work
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helpful to show the jury a model of the pelvis to
explain to them where this is?
Certainly. This is a model of the pelvis, I'll try
to hold that steady. This would represent the right
hip, the left hip. In other words, the patient
would be facing you, This area up front here, this
is called the pubic bone. This is the superior
pubic ramus, This is the interior public ramus,
This model actually shows the location of a
fracture of the inferior pubic ramus and superior
pubic ramus fracture would have been right here,
On the X-rays I saw, I did not see evidence of
any other fracture. However, there are other
reports, specifically there was a CT scan report
that said the patient had also had a fracture to
this bone here, which is in the back of the pelvis,
and I don't know if you can see that, His fracture
would have been in the area of the sacrum on the
right side.
MR. MCINTYRE: Can you twist that around a
little, Doctor.
Okay.
MR. GEDULDIG: There we go.
You got it? Okay. This would be the sacrum, which
is in the back of the pelvis, There was also a
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mention of a possible fracture of this bone down
here, which would have been his left ischium. Are
you able to see that?
MR. MCINTYRE, I need you to turn it a little.
Okay, On his left side, okay? So the crack in the
left disc is non-displaced. A crack in the superior
and inferior pubic ramus is relatively non-displaced
and an absolute non-displaced fracture in the
sacrum.
When I looked at the X-rays I could visualize
the healed bone around the superior and inferior
pubic ramus. I could not s~e evidence of a fracture
of the sacrum nor could I see evidence of the
fracture of the ischium, That does not mean that
they weren't there. It means that they were healed
without much bone formation around them,
BY MR. GEDULDIG:
Doctor, one follow-up question to that. You say
that they were non-displaced fractures. What does
that mean, and is that significant in this case?
That means that the bone was struck, but
fortunately. his pelvis was not crushed. When you
get a tremendous force, these bones can actually be
pushed in.
His injuries he had sustained from the front to
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back type of force, Some injuries come in from the
side such as when you get hit, when a driver would
get hit from the side. But his came in from the
frontal brachius, The fact that they were not
displaced means that the injury was not as severe as
it could have been,
Thank you, Finally, Doctor, the areas you are
pointing to on the pelvis, they have nothing to do
with the hips?
The hip joint's out here.
Please continue, I am sorry for interrupting.
After the accident, he was taken to Memorial
Hospital in Cumberland, Maryland. He told me that
the Jaws of Life had to extricate him from the
pickup truck. He was hospitalized for approximately
ten days.
Following that accident he told me he did not
work for about five and a half months. He
eventually returned to his original place of
employment. He was initially released to light
duty, maintenance and eventually went back to his
regular duties.
At the time of the accident, he told me this his
biggest problem was the pelvic factures and that he
had had severe pain. Prior to his accident he told
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me he had worked 40 hQurs per week at this glass
factory plus up to 100 hours a month overtime. He
was also working a great deal of time on the farm,
Following the accident, he was followed by a Dr.
Hamsher. Dr. Hamsher saw him on a fairly regular
basis and as of September 4th of 1995 -- that would
have been about five months after the accident --
he was released to full duty but he was released to
light duty,
He was eventually released by Dr, Hamsher to
full duty as of January 1st of 1996, that would have
been about seven or eight months after the
accid~nt. At that time he was basically
asymptomatic. X-rays taken in Dr. Hamsher's office
revealed that the pelvic fractures had healed.
May I stop you there, Doctor?
Sure.
At this point in January of 1996, Dr. Hamsher had
released him full duty to his job,
Yes.
In your experience with treating patients with this
type of injury, would that be appropriate for Dr.
Hamsher to do that?
I believe so, yes.
And it was appropriate for him to release him to
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light duty earlier, back in December?
Yes,
Try to get him back up on his feet again and moving
around, active?
Yes,
With the type of pelvic fractures that he sustained,
in your experience, are those ones that usually go
on to heal eventually?
Yes.
And the X-rays which were taken by Dr. Hamsher
around when he released Mr, Monismith to return to
work, you saw, I understand?
I did see a set of X-rays.
Would the findings on those X-rays of healing
fractures be consistent with the course you would
expect this man to take?
Yes.
Full recovery?
Yes.
Please continue, Doctor.
On or about February 16th of 1996, which was ab'out a
month and a half after he had gone back to work, he
saw a Bruce Kipp, Dr. Bruce Kipp, at the Belvedere
Medical Corporation. At that he was complaining of
some problems with his left shoulder, which had
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pain and was doing his regular job, He also had
2 full a range of motion of his neck without any
3 complaints,
4 Dr. Kipp, again saw Paul on September 20th,
5 1996, or about five months after Dr. Hamsher had
6 last seen him. At that time X-rays were obtained of
7 the neck and he showed some degenerative changes
8 C3-4 and C6-7. He was prescribed some LOdine, which
9 is an antiinflammatory pill as well as some physical
10 therapy but Paul elected not to follow up on the
11 physical therapy.
12 He did not seek treatment again until December
13 of 1997, That would have been about 15 months after
14 he had last seen Dr. Kipp. He was complaining of
15 some low back pain at that time. Some X-rays were
16 obtained and it was felt that there was some
17 degenerative disc disease at the L5-S1 manif~sted by
18 some slight narrowing of the disc space.
19 Doctor, may I interrupt you again, please?
20 Yes.
21 We heard that Mr, Monismith returned to work in
22 January of 1996 and for the first time, a that
23 point, started complaining about some neck and
24 shoulder pain?
25 Yes, sir.
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Is that related in any way to this accident?
I would not think so, No.
Please continue,
An MRI was obtained on December 18th of 1997 and it
was felt that Paul had a disc herniation at the last
lumbar segment, the L5-S1 segment. It was central
and was causing some slight spinal stenosis,
Doctor, I am sorry for interrupting, Lumbar spine,
where is that?
That's the very low back,
Low back. Thank you.
January 8th of 1998, Paul was seen by Dr, John
Rogers at Orthopedic Surgery of Carlisle. The
story, at that time, was that the patient had simply
bent over to tie his shoe. He felt a sudden onset
of back pain which radiated into his left leg.
Paul was concerned as to whether or not this
disc problem in his back related to the accident of
April 30th of 1995. Dr. Rogers felt it was not.
Paul told me that the disc rupture was handled under
his regular health insurance, which was Health
America.
My I interrupt you, again, doctor?
Sure.
Do you agree with Dr, Rogers that the low back
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Doctor, is that important that, there was very
little else found when he was at the hospital or
after this accident other than minor abrasions,
contusions and these pelvic fractures?
Right. I think that what he is saying is there were
no other major injuries. The patient was not
complaining about anything elBe,
No neck, shoulder complaints? Anything like that?
That's correct.
sorry to interrupt you,
It was also noted that P.aul. was very rarely ill and
rarely missed any work, He has a past history of
multiple fractures of the right arm and wrist from
fighting and other contact activities.
There is also a history of occasional stiffness
of the back and neck with no definite history of
injury. The neck exam at that time showed that it
was supple.
What does that mean, Doctor?
That it was soft, that basically, he could move it.
There was no tenderness. It stated that there was
no tenderness. The exam also showed -- the exam
report also showed that there was no soreness or
limitation of motion. The cervical spine on
physical exam showed normal curves with no obvious
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His chief complaint at this time was pain in his
r''')
2 pelvis especially on the right side, He pointed to
3 the area of the right greater trochanter as to where
4 he had his discomfort,
5 Doctor, could you show the jury what he was pointing
6 to, because that's significant, isn't it, in terms
7 of whether his current complaints are related to
8 this accident?
9 The area of his complnint was out here. This would
10 have been over the very lateral aspect of the upper
11 portion of his thighs. His fractures were here, and
12 he was complaining of pain over here,
13 Thank you.
14 He was also complaining of pain in his neck. He had
15 told me that the pain was like a toothache. He also
16 complained of right shoulder discomfort. He also
17 told me his left foot was numb and that he had no
18 reflex in his left leg. The numbness sometimes goes
19 to the knee. He also complained that he gets
20 headaches from his neck and he gets depressed a
21 lot.
22
I did have an x-ray from April of 1998. The
23 X-ray was actually a copy of an original x-ray, It
24 was poor quality but it did show that he had
25 superior and inferior pubic ramus fracture on the
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touched his chest. He extended to 35 degrees and he
laterally rotated laterally to about 60 degrees on
each side. He also laterally flexed to about 45
degrees. In other words, he had a full range of
motion of his neck.
He had little or no tenderness in his neck. The
foraminal compression test, which is a test where I
actually push down on the head, was negative. I
examined his upper extremities. He had a full range
of motion of his shoulders. I could not appreciate
any crepitance or grinding, although when I had him
put his arm behind the shoulder, he said he felt a
pop in the right shoulder.
His biceps, triceps and brachial radialis
reflexes were all normal. He had a full range of
motion of his elbows. He had no tenderness about
either elbow. There was no atrophy in either upper
extremity. He had a full range of motion of his
wrist and fingers, as well as his thumbs. He had
normal pulses.
Carpal tunnel was negative. He had excellent
grip strength. I did notice that his hands were
heavily callused, indicative of heavy use.
Doctor, did you just describe a physical examination
of the neck and shoulders and arms?
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propensity to ever develop arthritis as a result of
these fractures.
The right hip you called it a bursitis. Is that
just an inflammation of the soft tissue outside the
hip?
That is an inflammation of the soft tissues over the
very prominent portion of the hip similar to like
bursitis in the shoulder. That's a very common
problem, something I see every day. That's
something, I think, developed much later. I don't
think he had any bursitis at the time of the
accident.
Does that bursitis have anything -- bursitis of the
hip have anything to do with the healed pelvic
fractures that he had?
I would doubt it.
With regard to his complaints in the neck and
shoulder and arm, do they have anything to do with
this accident?
I don't believe so. He had some arthritic changes
that were clearly documented at the time of the
accident. He, from the records, it was painfully
obvious that he had absolutely no neck complaints
either at the time of the accident or for months
later after the accident.
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His first complaint of any neck pain was after
he had returned to work. So, and he had had
complaints of neck pain which related in his
history, even prior to the accident. So I'm not
sure that those complaints really had anything to do
with the accident. I don't think they did.
You have already said earlier that you agree with
Dr. Rogers who did his low back surgery, that that
has nothing to do with the accident?
That'E; correct.
Now, with the complaints he came and referred to
you, would you put any physical limitations on him
at all in any of his activities?
I have stated this in my report, as well. He did
have a low back surgery, and any time I do a low
back surgery on somebody, depending on the size of
that individual, I put a weight restriction on them
as far as how much they can lift safely.
In his case, because of the fact that he
ruptured a disc and had back surgery, I would say
that he could safely lift up to 35, maybe 40 pounds
and that would be the restriction I would place on
him.
That restriction would be for something that has
nothing to do with our accident, though; correct?
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That is absolutely correct, yes.
Any restrictions for the healed pelvic fractures?
None. Those fractures are healed solidly. They are
not a problem.
MR. GEDULDIGI You may cross examine.
MR. BUCKLEYl Thank you.
BXAKINATION
BY MR. BUCKLEYl
Doctor, I was reading in your literature for your
office that you have a specialty. What specialty is
that?
I am an orthopedic surgeon. I have some
subspecialty training, as I mentioned. in hand
surgery.
Do you do the majority of your work in hand surgery
or general surgery?
I do about 25 to 30 percent hand surgery, but I can
assure you that I handle will extremely complex
pelvic fractures. I do all types of spinal surgery,
as I already mentioned.
And this particular accident involving Mr.
Monismith, you said that his injuries, I believe you
testified that his injuries were to his pelvis?
Correct.
What j.njuries did he have to his head?
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To his head, I don't believe he had any.
Are you aware that he struck the windshield with his
head?
No.
Would that change any of your opinions?
I read the emergency room report and I really didn't
see anything that was related to his head. They did
a thorough neck exam and said there was no neck
complaints, no neck problems.
Are you aware that the vehicle in which he was
riding struck a tree at approximately 55 miles an
hour or more?
I am aware that the vehicle went off the road and
hit a tree. I don't know what rate of speed it was
traveling at when it hit the tree.
If I told you it was admitted by the defendant that
it was at least 55 miles an hour, and that he was
seat belted, Mr. Monismith was seat belted and that
the tree struck the truck in front of him, in the
passenger seat, what would have happened to his
body, from your experience?
Well, if he waD seat belted in, the impact of the
car would have folded into him. That's, I think,
what happened to him. He had a compression injury
from front to back and that's what broke his
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And your testimony is that baaed on that, that a
2 person would not have any residual effect from that
3 force as against their neck?
4 My testimony is that I read the emergency room
5 report and at that time, there were no complaints of
6 any neck problems. They did a thorough exam, as I
7 outlined. The exam of the neck was normal.
8 Have you had patients come to see you who have been
9 in automobile accidents and don't show any pain or
10 problems immediately after the accident but then
11 it's manifested at a later time?
12 I think that's hogwash. I think if a person is
13 injured they are going to have complaints right
14 away.
15 And in what condition was Mr. Monismith for the ten
16
days he was in the hospital? How was he kept?
17 How was he kept? I would assume that he was
18 basically kept in bed and as he felt better, they
19 got him up and started walking him.
20 Do you know, was he in a cast or anything?
21
Doctor, you also testified that there was -- I read
I would not believe there was a cast, no.
22
23 the report from the hospital as well. The hospital
24 states that he had some injuries to his upper
25 thigh.
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former counsel. They were on the list of all the
records that were given to you.
MR. GBDULOIGl Okay.
MR. MCINTYRB I Back on video at 9:0S a.m.
(The following pr.oceedings were held on the
video record beginnlng at 919S a.m.)
BY MR. BUCKLEY I
Doctor, then later he had asked if you had reviewed
records of Dr. Daniels or Dr. Davis, the doctors for
PPG Industries and you stated you had not. Is that
correct?
I I'eally don't bel ieve I reviewed any records by
that name; certainly doesn't sound familiar.
And if I told you that the Dr. Davis or Dr. Daniels,
who is PPG's doctors, had seen Mr. Monismith on a
regular basis following the accident, as well as
following his return to work, and that it was noted
on there of his continued hip pain, would that have
changed your opinion?
As far as what?
Standing for long periods of time, just noticed hip
pa in --
I mean, did I render an opinion?
Well, you had stated that he had -- Your opinion was
that he had bursitis, I believe.
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2 And that the bursitis was not, had nothing to do
Right.
3 with the accident.
4 Right.
5 And my question to you is would it change your
6 opinion if he was noting that he had hip pain
7 following the accident and his return to work?
8 Possibly. I didn't notice any of that in Mr.
9 Hamsher's early reports and I, like I said bursitis
10 in the hip is something I treat every day in this
11 office. It could be just something that is related
12 to an increase in activity.
13 But certainly, if it was well documented that he
14 had been complaining of pain in that area ever since
15 the accident, then certainly it could be related to
16 it. r don't have a problem with that. But like I
17 said, from the records I reviewed, I really didn't
18 see anything to that effect.
19 Now, isn't it true that a cause of bursitis could be
24
20 trauma?
21 Yes.
22 And as you have stated, the cause of it could be, I
23 think you said, an excessive use?
Yes. Repetitive type of -- repetitive use injury.
.,.)
25 If a person, after an accident had to be on crutches
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1 letters I reviewed -- then, you know, I'd say yes,
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it is related to the accident. But we are talking
about a situation, as I had mentioned earlier to
4 you, that it's usually very self-limited thing.
5 It's usually, a month two month and usually it's
6 taken care of by a cortex steroid injection which is
7 not usually much of a problem.
S Now, if Mr. Monismith in his history, did he tell
9 you that he had had this hip pain, when you took a
10 personal history?
11 Yes.
12 And when did he say that that began to develop?
13 I am not sure exactly when.
14 If he said that it had began to develop right after
15 the accident and he got back on his feet and had
16 continued up until today, where he stands on his
17 legs for more than six hours or eight hours of work,
18 would you still say that that's not related to the
19 accident?
20 I would think it could be.
21 You think it could be?
22 Yes.
23 Now, Mr. Monismith, I believe he told you that he
24 worked approximately, he worked full time 40 hours a
25 week plus he had his own farm that he worked on?
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Yes.
2
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But he also worked an extensive amount of overtime
prior to the accident?
4 Right. He told me that he was working up to a
5 hundred hours overtime which would equate to about
6 25 hours a week. So it was a lot of hours he was
7 working.
8 And if we had records that show that --
9 I absolutely believe him.
10 At the present time, I believe he told you that he
11 only works a few hours?
12
13
Right. He told me he was not working forced
overtime.
14
And why was he not? Did he tell you?
He sai.d he couldn't take it anymore.
Couldn't take what?
15
16
17
Working the overtime.
22
What aspect of the overtime couldn't he take?
it the pain in his hip, did he say?
He said he having discomfort. That's right.
In his hip?
I believe that's what he said.
Was
18
19
20
21
23 But in your report you said that you believed he was
24 working at the same level he had worked at prior to
25 the accident?
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He was working overtime. lie didn't tell me how mlloh
he was working overtime. lie was still runnin~l hill
beef industry, so he was still working a lot.
Still working on -- now, do you know how large of a
farm that he had operated prior to the accident?
I am not sure. But he told me that he wall
maintaining a beef farm and had 200 acres of land.
So I don't know, you know, if, around he t'e, when
somebody says they have 200 acres that don't doesn't
necessarily mean that they are just farming 200
acres. They could be farming a lot more.
If I told you that prior to the accident, Mr.
Monismith farmed 500 acres, okay, and that
subsequent to the accident that he reduced it to 200
acres and also did beef farming, would you say that
he reduced his level of work?
Sounds like it. Sounds like he was doing an
incredible amount of work before the accident, too.
He was sleep deprived and having other problema from
that, as well.
The sleep depression or excuse me, the sleep
deprivation --
DeprivatJ.on.
Came about subsequent to the accident, though. Is
that correct?
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I am not sure exactly when that was. But I think it
2 was.
3 And were the reports that he was having problems
4 with finances and thinking about financial matters,
5 which were causing some of his sleep problems. Is
6 that the report?
7 I didn't see that.
8 Now, also, in the report for the, we had talked
9 about and in your report it said and the sleep
10 clinic there was something in there that said he was
11 working 80 hours a week. Okay?
12 I believe that is --
13 This was in your report. If I told you that that
14 was a typo, that it meant to say forme.ly had worked
15 80 hours a week, would that be something that you
16 would believe? By that, I mean, have you ever made
17 errors in your records or reports?
18 Absolutely.
19 As a matter of fact, in your report, I am looking at
20 page 7, I believe, on page 1, excuse me -- you note
21 that Paul's 47, he's five ten and a half and he
22 weighs 190 pounds. Then again in another part of
23 your report
24 It says 140 pounds. I admit that's a typo.
25 So that was a typo. You have your model there.
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I don't think his body was thrown. I think
something hit him here.
3 Hit him there. You are saying that ba~ed on your
4 belief that the disc damage that he had two years
5 later had nothing to do with that, even though it
6 was right above where the fracture was?
7 He had had no back complaints, you know, bent over,
8 ruptured disc. I don't think it has anything to do
9 with the accident.
10 Doctor, earlier, when you testified you were asked
11 questions if you treated Mr. Monismith as though he
12 were just a regular client, or excuse me, a regular
13 patient.
14 As far as interviewing him, x'eviewing the X-rays and
15 doing the exam, yes, there's no difference.
16 And what you, if you would have taken a full report
17 or history of him, you would have asked him every
18 doctor he had seen about this accident or about the
19 problems?
20 You have to understand, he had three and a half
21 inches of records here. I try to get as much
22 information as I can from people.
23 But if he was going to be a client or a patient and
24 you were going to try to figure out what this
25 problem was, you would get every record possible;
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correct?
2 Would I try to get every record possible?
3 Yes.
4 I would try to get records that I thought I needed.
5 To get every record possible is, would be
6 prohibitive.
7 And then once you have received all those records
8 and reviewed them, then you would make a prognosis
9 or a diagnosis for him; correct?
10 Yes.
11 Now, how long did you spend with Mr. Monismith?
12 Approximately one hour.
15
Approximately an hour. Do you know his family
history? Anything?
Other than what I outlined here, no. But I thought
13
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14
16 it wa~ a fairly accurate history.
17 Do you know how many children he has or --
18 No.
19 What's right hip synovitis?
20 A synovitis of the hip would be actually an
21 inflammation of the tissues that actually surround
22 the hip joint, the actual ball and socket joint as
23 opposed to a bursitis which is out on the tip of the
24 thigh bone. It's not at joint problem.
25 Okay. Dr. Rogers, I believe you said in your report
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that he had stated that the hip problem may be right
2 hip synovitis secondary to length, basirally. Is
3 that correct?
4 That's what he stated, yes.
5 And that was back when?
6 I don't know the date to say that accurately.
7 And the problems that Mr. Monismith iB having, this
8 continued pain in his hip, could it be right hip
9 synovitis?
10 No.
11
No? So Dr. Rogers was not correct?
12 I have a feeling that, and I am not sure if it was
13 Dr. Rogers, some of the reports that look like Dr.
14 Rogers, one of the reports that look looks like Mr.
lS Rogers, the physician assistant, alluded to the hip
16 pain, but diagnosis of synovitis in an adult is
17 almost unheard of. We see some synovitis in
18 youngsters, but rarely do we see synovitis in an
19 adult. It's almost always a bursitis if there's
20 pain in that area.
21 Synovitia would be inflammation deep in the hip
22 joint. Like I said, it's just something that almost
23 never happens in an adult. You get arthritis and
24 with the arthritis you can have some inflammation of
2S the joint, but not a true synovitis in the correct
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meaning of the word. So what I have a feeling he
alluded to is really a bursitis.
Would someone who had a limp or improper gait for a
period of time, would that cause a bursitis?
It could.
MR. BUCKLEY I Those are all the questions.
Thank you very much.
Thank you.
MR. GEDULDIGI Just a couple follow-up, Doctor.
BXANINATXOK
BY MR. GEDULDIGI
People with back injuries like Mr. Monismith
sustained by reaching over and tying his shoes,
would that cause a limp? A low back injury like
that?
If you have a ruptured disc and you have some
subsequent nerve entrapment, nerve -- failure of
nerve function, with resultant muscle weakness, you
most definitely would have, we have a name for, what
they call a sciatic limp.
Exactly what he had here, isn't it?
When I saw him in the office he was not limping any
longer. He certainly had complaints of numbness.
He still had absent reflex, but he was walking
normally. He did not have any obvious weaknesses.
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After the injury but before the surgery would it be
2 reasonable to expect that he would be limping from
3 that original injury in the back?
4 Are we talking about the car accident or after he
5 ruptured his disc?
6 After he ruptured his disc?
7 I think after he ruptured his disc it would be
8 reasonable to think that he would have been limping
9 for a while, sure.
10 And he still is complaining of ongoing problems with
11 his low back, problems with his leg, absent reflex,
12 numbness and so forth?
13 He has numbness and he has absent reflex. I don't
14 think the reflex is actually a problem, but numbness
15 is I think, probably more of an annoyance than
16 anything.
17 Bursitis is something that many, many, many people
18 have?
19 It's something that every day in this office I see.
20 It's very common.
21 Is that a disabling thing?
22 Not usually. It can be uncomfortable. Most of the
23 people, they go to rollover on their hip, it hurts
24 them, you know, when theY're trying to sleep or
25 getting up from a sitting position after a few
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minutes.
53
Finally, on cross examination you indicated that the
hursitis could be related to the accident I think
you were asked the question based on the premise
that he had continued complaints from the accident
till now. Is that what you understood the premise
for?
That he was complaining of this right hip pain ever
since the accident and that he had seen people that
had documented that.
Would occasional flares of right hip discomfort
which are hrief and resolve with rest, would that be
continued complaints of right hip discomfort?
Sounds like intermittent would be a better word.
Is your opinion still that the bursitis could be
related to the accident if the documented complaints
are intermittent or occasional? And I'll be happy
to show you the records. I don't know why you
weren't given these records when Attorney Buckley
was referring to them. I am happy if you'll look
through these because I want you to have as much as
you can.
If you look through those records, we really
want to know, is there anything in there which would
change your opinion regarding whether this hip
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still had a limp. It says, 011 9/15/95, he was
2 tolerating four hours a day, one half of that time
3 was at the computer. He still had pain after
4 walking, does not say anything about the right hip
5 pain.
6 On 9/22/95 it still says that he has an antalgic
7 gait with a slight limp. On 10/21/95, it Bays he is
8 currently tolerating all current activities. It
9
saya that
I am trying -- Some of this is a little
10 difficult to read. It says, standing, walking for
11 eight hours.
12 It says here, he managed a Montana hunting
13 trip. I have been out hUllting in Montana and that's
14 usually pretty tough terrain. On 1/30/96, it says
15 occasional flares of right hip discomfort which are
16 brief and resolve with rest. It says he's working
17 overtime without difficulty. It says he's
18 ambulating without difficulty. The next reference
19 is 10/ -- and I may have missed something but I have
20 read through them.
21 Next reference as to any right hip pain is
22 10/25/96. It says right hip ache comes and goes, no
23 limp. And that's all I see.
24 The 64 thousand dollar question is, does any of this
25 change your opinion regarding whether the bursitis
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you saw in him is related to the accident?
I think that the bursitis, most likely, has nothing
to do -- If this guy was out hunting in Montana five
months after r.his injury and he gets a occasional
flare-up of some hip pain, he was working full time
and overtime without difficulty, you know, I have a
real hard time believing that's related to the
accident; sorry.
Doctor, you said on those records, when you read
that he worked overtime without difficulty --
Without difficulty, yes. That's what the line on
there says, without difficulty. That's what it says
in the notes you provided to me.
It doesn't say with difficulty?
It's an "S" with a line over it. That's without,
sans.
Now, there was also, following that date on the
lSth, 3/1S
What date?
3/1S/96.
Ninety-six?
Is there a continued mention of neck pain?
It says left-sided cervical impingement, doing full
duties on Feldene. It says guarded range of motion
in neck. Pain with extension and left-hand rotation
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19991111:11 3:4 1~.9 2h:3 161 agree III 17:2~ J2:7 2'1: 17 brief III 13: II 51:lh
58:11 11:11 17 IH 31:7 attendance III 1~:17 briefly 141 4:11
htlll 13:11 abnonnallll JII2 ahead III In attended III 41H ~:12 h: IH 22: 17
2111 1:11 above 141 37:11 21:16 4:211 bring II I 47 I
20111 8:4 47:21 47:2J 4Hh alcohol III H7 attorney III J.I~ broke III 34:B
2001'1 1:5 41:7 abralionll'l 211.25 alignment III 14: I J 53: 19 14:IJ broken III 41:1
41:~ 45: 10 41:14 II:J 2114 J~4 30 II JOII attomeYI III ~H I.J Bruce III /4:13
200211111:lh 351 allergic III H7 automobile III JOIO 14:IJ
201111 41 abHCnt III .\1'24 alluded III ~O' I ~ Jh:9 Buckley IlOI 1:11
20th III Ih:4 51: II .11: 1.1 \12 Avenue III I II 1:5 J:ll 3:1\
22111 1:11 H absolute 1'1 II.I almostlll ~o 17 31 4:H 6:5 I~ I: Ih
23rdlll 1524 24:11 lll:I'I ~1I11 aware PI .H.I 1.211 JJh 33:1
24thlll abaolutely 1'1 9:1 alwaYHll1 ~o: 19 141t1 .HIJ JH'I 31:11 jH:IH
11:21 Il'h 17.l IH I ambulating III II IH JHI4 3~:7 ll:h
25111 JJI7 44.6 JII'15 .1I:lJ .1.1 I away III J6:14 lJ:19 54:IJ lU5
14:1 44:~ 46 IH Ameriealll 1711 ball III 4'1.22 l7:ll
27111 14:7 541 accident Itll I)'h amount III 441 baHCd 141 J6: I building II I 4: III
2ndlll 33 /2:11 1217 IllJ 45.IH 4111 4H..J ~.J4 bunitiN Iltl 21:13
3111 14 II:I~ 1.J4 1.17 anklcllIl 171~ baaillllllh J'I: 16 31:3 JI:I JI'II
3/15111 l61H 1.1:IJ 171 171H annoy ana: III ~2, I ~ beardllll.111I 3113 31'13 3~:21
IH:2 21121 21.J antalgie III 1'Ilh became III q 4111 411'1 411:1~.
3/15/96111 ~6:211 IJI 2~:l) JOII
5\6 7: I~ 412 41:4 41:111
30111 JJ 17 JIIII Jill 31.1'1 anterior III 2411 41.14 4111 49.13
31 :22 31 :24 Jill bed III .16.IH
300411132 JI4 316 .12.'1 anteriorly III 141H lll:l~ .\11 ll:4
. .
FII.IUS &. MCUlCAS RHPORTING SERVICIi
Index Page I
MICIIAIlI. I'. MI'I'I'RICK, DO
CondcnllClt '"
buttock - dro
d
chTcfll1 h 21 - ....~.
~217 IJJ '3:11 IJ ~ III \ ~h n .q} UaVIK'" l'l21j '2"
14: I IUI ~~:2~ HI conlrtlllll .'H J.' \1,lo1 _1'111 \'I 14 diKcccttlmy III
~h2 chlldn:n III I ~ II
41} 17 ctlnluKI"n 1'1 2! 1.1 '41,' dlKcharllC III .1<]
bUllock 'II 2" h chinlll 2H 21 .\71 daYK1I1 12 III 'fll/l dlKctlmftlrt 1111
bUllonll1 3712 chronic 1'1 conlUKlunK '" dcallll 1.\1 151
1'/22 }IJ:' 111.\ IH 24 1~lr"
CJ-41111hH 417 214 II 14 1\4 l>cccmbcr"1 1.11 211 22 214 HIo
C4-SI1I24 17 1425 City III <I q 15 H .17 II II, 12 1'/01 44 211 "'11 .'111
CSIII 2UII CIVIJ.1I1 I' convalCKcC III 4lk dccp II I '1111 II I.
C6-71111hH 2UI U COlIJlCrativc III 2' IH , defcndant", I '7 dlllCallC III Ihl7
242. clalmlnlllll I'j'~ COpYlI1 llll I III III 1 II IlJf,
calciricatlon III clcarly 1'1 lH cordill 27 II .1 14 .1411. dlKplaccd 1'1 In
24: IH Jill Corporatlunllll'llol dcflnitclIl 21 II' 1111.1 2IIlh 111 Ih
calluacd II I 2~ 23 cUcntfll 4H II correcll "I oIll dcflnitcly III ~ I II) dlKtalll1 .111 11
canllllllH:17 4H2,1 219 2H 11 II III defunnlty III 1II1o1 dlKtn:KK III 2h I
captlonl" 3:h cUnlcl1I 4h III 1225 1,11 .1.124 14 III diviKionK III 4714
carlll 2H .1U3 ColICIlClI1 UII 17.1 .1'111 01121 dcgcncrativc 1I11 " 7 docturl1" 322
j.:~ 4211> 120\ .:1 4'J I ,",II I} .\11.\ Ih 17 19'(1 14 17 U 1>7 HIli
.:1, I 17 comfortablcll12111 ,111:11 ~l/ 2~ 177 201 H.I.1 '11,\ Itl21
carelli 17 17 IH III dCIlI'CC III IIIH 127 13:lh
h:1 7:1.1 4lh cumlnlllll 7.11 421
c'lrrelated III n21 111 7 4212 100 Ih I~ 17H
carefully III 2lK comminuted III NI2 cortex III 43 " dCIlI'CCK III 17.21 211:1 21:1
CarUKlc 111 7:24 commlulunllllHl1 2~ I 21 I~ lJI 2H:lh
17:1) IHH counllCllIl 111 2'12 2'14 2'124 311" Jl'l
cummon "1 13 .1'11 5tU.z dcmonKtrated 11 I
Carpll'll 2'1:21 IH4 31.H .2211 31>.22 lH:22 3'1.H
County III 13 211: II 421 4H III 4H:IH
callC 1'1 lh 11111 Commonwcalth III IH.2 IH 01 dcnlcKlI1 HI> ~ll} IU 16:'1
32:19 3H:21 'H:I IH:4
CUt"1 3h211 31>21 complalncd "1 COUplCIII 1114 dcpendinlllll 121h 17:22
IH2.' 41h ~19 IU dcpoKition III doCtofllll1 3724
caullhtl'l 2h:21 23:lh HI'I 27,1} 1:9
H3 lH 20 -'1),1) .'9:15
cauacd'll 27211 2H H 2k 14 .14 .1111 nl7
37:lh 2H211 counclIl loll I 17'21 ~725 :'H:' ~4: III
37:17 complalninllllll Court III IJ dCpn:KKCd III H2O document I' , 42:H
cauKlnK III 17:7 ,1:IH dcpreKKion "I documented III 3 III
4h:, 1424 1.2 IH I'IH
1<:11 11,14 11,23 crack 111111 11(, I': 14 I'IIH 19:19 411'13 4224 nlll
Cenlcr 11 I 49 21:7 HI2 2114 craKh III 31 24 4'.21 nlh
4: III 1921 411:14 .2111 .JK craKbcd III dcrrlvltion III 4522 dOCKn'tl11 H:I>
II Iii
centrll", 17:h complaint 1'1 9:5 crepitancc III 2911 4, .23 2113 3~:1.1 42:21
certlln 111 2h:IH HI 2.19 321 dcprlvcd III 45 1'1 45:9 .h:14 ,7: III
26:1<) .7: 14 complaintK 1111 5:21 creKtll1 21> H 271> dollar II I ,,:24
certlinly 1" croKKIII135 lH:22 dCKcribe III 29:24 doncIII <)1'1
111:3 623 '1:2 1."i:(1 dCKcribed III 22:IH
3<): IJ 411:13 411:1, ":211 11>.\ 1'/11 ,J:2 202 doubt III
42:1<) <1:23 I'I:IH 21H cruKhcd III II :22 dcvclop 1'1 .11:1 31 :Ih
22: 1'1 DoulllaK III
certlinty III 307 23:7 31 17 1113 crutchcK III 40 2~ 4.112 4.114 1 :"
42:12 .12:3 32:~ 3211 41 :2 dcvcloped III .11111 3: I
certification III .H21 34:'1 Jh::" J() 13 CTI'I III 14 211.7 4221 downllll 1):1)
certlficd III 4H:7 ~1l1 ~J} W:H 24'6 dcvicCK III .1~ I X III 1,21 2,:21
U nl3 nil> '1'3 diabeteK III 21>:1.1 2h22 2h:2,
certify III ,H5 comp Icte III Cumberland PI I J 9:4 2H2 2HI> 2H:24
.HH ,H:12 5H H 12: 11 diallnoKcd PI H:22 29:H 42:17 47:111
certifying III .H:23 complcted III .111..1 current PI 2.1.7 1'1:24 Dr "'1 hJ 13:4
cervicII POI ":IH complcx III nix ,~ H diallnoKiK I" H2, 13:, 13:10 13:14
1<):3 1'1:4 1<):7 compreKKion 1112'} 7 curvcll12hl7 21> IH .1U 49:9 511'1h 13: IH 1112 14:10
21:24 24:" 24: Ih 34:24 2(): IH 21> 1'1 2ll:19 diffcrence PI 7: III 14:2.1 ID ":'1
2425 26: 11 'h:23 computer III :".".1 CUrvcK III 2125 4H:" ,,: Ih 15:22 ":24
Chlmplilln-Urbana concerncd PI I)':" 21>' 17 dirricult III ~:": III 11>:4 IIU Ih:14
4.1'1 17:17 CUKKCd III J7 15 dirriculty PI 17: 12 17:1'1 17:2.\
III :":": 17 IH: 10 IH:II IH 17
chlnce III 371'1 concludcd III 5724 I) III I IH 21 5~:IH ~(J:fl ~h: III IH:23 1'1'14 1'1:211
chln~c I I I )4. concrete III 41 III 31:' 5h'll 5() 12 ~I>: 14 19:24 .1I'K 37:211
3H:1. 411:, ,l2~ condition III )(1 I ~ damallc PI 4X4 directlll ~H:22 37:24 JI};9 3'1:<)
.<:25 417 DanielK III 17.211 direction III 5H III 1'1:14 3'114 4'1:2,
chlnKcd III .1'1:1'1 conduct III I> 2~ 3724 WI) 1'114 directly III 4222 ~IIII ~1I13 ,0: 13
~410
,4:21 conHiKtent II I 14 II qlll diKlblinllfll ~2:21
chln~cK III Ill.? conKulting III ."10 date PI III 1.1 diKC11I1 II h II> 17 drink III Xh
24:1 2U 25.4 contlc,tlll 41h 24 'I ~o II II>.IH 175 17.IH DrivclIl, 3:2
2,:111 .11111 21 14 .\6:17 :"(1'11) drivcnlll
continuc '.1 17.211 IH" IH II Y:9
checkcd III 2H2 1211 dated 1112111 X IH 15 IH 12 IX I) 2422 drivcrlll 122
14211 17.1 IX 7
cOOltll1 H.23 2~ I continucd III daullhtcr' Kill 9'1'1 27.11, 272.1 .12211 driving III 9:7
Chiclgo III 4211 l'IIH Dauphin III IH 2 471h 4H 4 4H X 'III
4.1lh 511H :"1." 511h 52.1
5H4 :"2:h dropped III 1):1}
FII.IUS &: MCI.UCAS RI!PORTIN(J SI!RVICI!
I ndcx Pugc 2
Ill. I'. Ml'nRICK, DO CondcnllClI I)rs - ca ni
DrllIl l4 Il cllaminc III .1J~ 1'114 41 I" rOIlOWSlI1 Ii' .Nl .~ I 'I 'III
drulllll s~ cumincd 101 JH rarminll141 2) 2~ 1'001111 il 17 l'IlI ~.. I) .~.. 12 ~417
DUClll l4.6 227 2l2.l 2" 24 4~.III 4.' II ...\ I ~ roraminallll 2'}'l '712
dulYl'1 324 l" s 2'1~ IH 2) rarmKlI1 " , rorCC 141 II H 121 GcnC1I1 ,\ ~o
dwnmicIlI1 H24 cllccllcnt III 2'121 rllher 141 114 ,11:11 1Il.\ IIcncrallll .11.11-
durlnlllll 411.\ CllCCKKivc III 41121 '1.7 9 II I} I ~ rorced III K 2 IIcncrally III 41 I
dulicl \II 1222 cllchlCd III I" II ralilluClI1 1'122 44 12 lIivcn 141lll" 1'12
S~:24 IH:IS Fcbruary III IJI'} forelrms III .,~ ," ~lll} ~~,t}
duty 1'1 1221 I,IH CllCUIIC141 M,I) 1421 forelloinll141 ~H ,1\ lllaKK 101 7 24 IJ I
II'~ 1111 IJ.I'I 4121 46211 4H 12 feclinlllll (llil IH III ~H l2 'H 21 1')2.\ inl 17.2~
14: I III S IH:I'I cllcrcisc III I ~ 22 ~II II .111 forehcad III 1H 41 I"
IH:21 Clln:C1111 1411, fecI 1'1 721 10 ]~(j IIIIKIICKIII 2S III
I! III 21 S .2 I~I'I l'I7 21 1'1 rormalion III II 16 IlOCKIII illH 42H
carly 1'1 411.'1 S7:15 cllrzricnce 141 4 16 41 12 41'17 4220 rormer II I I'll .\~22
1:21 IU ,\421 HI~ lloncl41 1422 ISI~
cully III 42:211 clln:ricnced III I H 2< I'cldcnc III .~t12" rormerly III 411 14 IS.2.l .17.111
errect 1'1 J~:2 forth.'1 6 II ~2: 12
40: IH 2 21 rclI II I I) II ~Hh (jOOdlllO 44
ei,ht 141 II: 12 41: I 5 ell~ricncinlllll fcllowship III .11,.\ rortunately III 1112 llranuloml8l1l H24
1211 ~:J
4 :17 5S:11 fell 1141 forwlrd III 2H,i~ llrell II I IlJ
either 101 2U ell pert III III H 2~ 1<4 JS I ~ ]~:,B llreater III 2ll
2'1:~ 2H:2 2~:17 cllpireH III ~K I ~ I ~6 I ~ II) ""6 found III 2HH
175 17:1' 171') H2.1
2~:17 11:24 ellplainlll 1112 IH: II II}: I ~ 1'117 11121 21:2 llrindinlll'l 2'1:11
elbow III 2~:17 cllplanalion III I~ II 26 II 29: 12 )'dH four III ~~:2 llrip II I 2~22
elbowKlI1 2~:1~ ellpoKun: III IH 16 few.ol 74 III four-ycar III 42S lluardedlll 5~:24
elected III I~:III clltended III 2'11 4U 4411 ~2:2~ fraclure 1141 1):]0 lIuy II I ~hl
emergcncy III 22.4 41 :1 571H ~211 10:111 10:11 llymlll 2~l4
\4:6 1~:4 clltension III ~(US field III 61 111:11 10: 15 10: 17 habits III 2111
employed III 7:2\ clltensive III 172\ Jlifthlll I 12 II III II :H 11'12 IIAFERIII 1211
5H:IJ 44:2 4,H II :14 20:'1 20 1.1 hllfl1l
employer II I fillhtinlllll 21111, 2024 21:25 722 121H
5UO elltensorlll 271H 21 :14 24:7 24111 24: II 1422 ill') 46:21
cmploymentlll1220 elltraarticular III figun: III 4H24 111:14 1016 JIII7 4H20 .lI,~-2
end III IH: I 111:21 !'i1iUK III .121 47:1 4H6 hllluels II I 27:IH
entered III ~:5 elllremelYlI1 JlIH Finally III 1i.7 fraclured III '117 lIamsher 1111 II:l
entrapment III 51 17 elllremiticslll 15:tl ~12 ~7:1) l7: 1.\ 115 13:10 I J:IH
equaIIl12h:~ 27:11 2'1'1 finances 1'1 4h 4 fraclures 1111 ~ IH 1121 14:10 15:'1
clllremity III 1'17 financial III 61 6:2 9:2:'i I ~16 1522 15:24
equa"'lIl H5 411.4
2~:IH finding III 111'1 1.1: 15 1,16 16:5
errorl III 4~17 elllricate III 2~,1 1415 21.4 21' 1.1 lIamsher'Kll1 1114
12.14
elpceially III 2J:2 elllruded III findings III 14: 14 2211 2.1: II 24:2 40:9
IH 12
ESQUIRE III I IH fingcrs II I 21): It) 24.4 .101.1 .Ill: 17 hand 101 III 51
1:211 eyclll 26:21 finish I 'I .1" 17 JlI22 31 :2 ,11: I ~ 22:16 JllI nil
EugenclIl 1:14 1'161 1:'1 2:.1 firsll1l 1622 21115 .1]2 JJ.1 .1J 1'1 1.117
SH:I lH:IH 1'1 .1:2\ U \21 47: III 4711 fragment 111 I H: I J handlclIl nlH
evaluate III 5H7 4715 47:21 frequcntly III 2122 handled III
6:7 Fabcn:'KIII 2HJ 17'211
evalualion 111 ~:24 five PI 7.21 12 IH 42:14 hands III 2'122
evenluallr 141 facingpl 11I~ IJ:7 I fl'~ 25' Jt) fronll'I'I:11 10:6 .15~
12: 1'1 facl161 6:1 124 4~:21 ~IIJ II :2~ .14:1'1 .1425
12:21 I: III 14H handwrilten 111 5424
cvldence III 2H 12 I'} 41 II fivc-day III 41: " fronlallll 124 h~rftr"l
10:12 4fi:I'I 5J:17
II: 12 11:1.1 1517 faclory III flare-up III ~6:5 full 11'1 4~ 725
24: III 24: II 2~: 10 724 flareH III .IJ II I.1H 13:11 1.1'1'1 hard III 24H
Il2 1'1:2.1 2224 56:7
2H I ~~' I ~ 141H I~" 1112
411S flClllI1 1'11.1 2724 2H" lIarrisburg 1'1 5H:ll
ellacl 11 I \5:17 fllClun:SIlI 1224 2H:21 2'14 2'1.'1 l'Il,I head 101 2~: II 2~:H
Cllac11Y111 HIJ fail un: 11 I 5117 flelled III 26 12 NIH 4.124 4H 16 n2~ 14:1 .10
46:1 51:21 fairly PI 2'1:J 5~~ 511'2.1 147
ellam 1"1 11:25 1.1'5 foldcd 111 14.2.1 rullYlI1 5H.11I headaches III
IH:4 4'1.1', 2111~
7:H 1'1:1 211:2,1 fallen 111 follow 111 If, III funclion 111 51 I H 2.1211
21: 17 21 :22 21:22 t)15
21:25 22:2 25' 16 familia, 11 I 1'11.1 follow-up 1'1 71.1 "XIII ~7h headresllll \5:\H
2Id J4:H 16~ family 111 II IH IH 17 ,111" lIaillll 1'Ilh ~ I ,1 1~:21
4'1: 1.1 51 :1) ~7:(, ~7:9 heal 1'1
J67 4H: 15 ,\~.7 14H
ellaminalion 1101 farlll 9:4 .121H ~i" 1.1 Gcduldif 1111 healed" 'I '1:211
Jl: 17 W,211 4H 14 followcd "I 1.14 \20 ,
2:2 4: I 22:'1 24 ,.1.1 ,1:1.1 1111 II: 15 1.1:1
farm 1'1 III \H 1'1 following 191 12\7 4.2 24 I 24:6 24:1. . .
27:10 2H: I~ 2'124 6:l1 H 12
JO:.1 \3:7 ll:IO 41.25 4~~ 4~7 1.14 .1H.5 .N:5 HIH 1112.1 II 17 2.7,1 .111:21 .1114
5J:2 rarmed III 4~.1.1 I'I'I~ .1'117 4117 JlI .1H2 .lH7 .1.1:2 .1ll
farmer III H5 ,\4.6 16 17 lH11I ,IHI7 .1HI'I healinlllll 14:14
MICIIA
FILIUS &. MCLUCAS REPORTING SERVICE
'"
h Ii
Indcx Pugc 3
MICIIAI!1. II. MI'I'I'RICK, DO
CondenllClI'M
health - mentioned
111:21 4'1 12 4'1 1.1 intermllll:ntpl i.' Ii aceralionH III ' I h IInokinll141 i)4
health III 11i1 hourHI'" h .1 ,114 '.1 11 lamincctomy III i~ 1.1 J'i .It'll\}
1121 1.11 1.11 II~ ~ 1 internHhiplI1 421 1/1 Inoh'Il'1I14
UcalthSouth 111 \Ill 41 14 41 I.' 41 17 inll:rrupll" 'I l' land III ..~ '7 lordoHiH III i~ I J
heudllll~21 4111 41 17 4.\ 14 IhllJ 171.1 11111 largcll14'4 ln I'
4U Hn 4411 1414
heavily III l'U.l 4411 4~: II "tl I ~ laHI", 1"11 't, h IOWIIlI 1t11.1\ 11.1
heavy III lY 2.J '51 ~.Ili II interruplinglll I I II II' I. 17' 41 , 1711 l'Il.\ 211 20
11 H ill2l! 27',\ .12 K
heel 1" 1~.1 11 1.1 hundred III 4.. :\ inlcrvicwcd II I i' il Illteral", ]IJ '4 Ill' Ill.l \I 14
heellllll~5 huntingl" :\."'12 II III 14 14 2.' 1:\ '111
inlcrvicwinlllll n 11
height III l~ 1 I' 1.1 :\h ,\ lowcrlll 272
4H 14 latcrally 14! }.l 1:\
heightllll l~:H hurtllll '21.1 introduce III III I'll 291 ltJl II II
heldlll lH:5 JlJ:~ hygicnc II I 192" involvc III 1024 I.AWIIII, lumbar III IH
54:~ idcnlifYII! .11'1 11H 2~ I,
involvcd III 'I,ll; layinglll lH n
help III 11.21 11I1" 1.1 .11 lunglll H 1.1
helpful III .1:1~ (l:M '114 involvinlllll ill 14 IcaHllII HI .\4 17 mainlaininlllll 457
1111 nll Icftll'lJ III' II I
hematoma III 371 I iliac III 2(1H 11~ lodinclIl H H II I II~ 10' maintenlnce PI7.24
hemilamincclomy III iIlill llll iHchium 1'1 " II 17 '" I'J I 1111 211.4
III
IH:Y lIIinoil!11 4 IH 11'14 ill 17 iH I'II~ Nil nil major II I 21 ~
hereby III IH:5 ImagcH III .u 14 III i.1 17 23IH 24H majority III .1.1/\
hereinbefore 1115H:5 immediately 111.11, III January 1'1 1.111 271. iM 1 .111 17 mllnpl '/24 14:1~
hcrniation III 175 impactlll H2i 1.1IH 11:11 Ih 22 Icft-hand III :\lI.2:\ 4i I
UCYIII 5420 imperativclll 12'7 171i left-lidcd III :\(12.\ manlllcd III <<:Ii
himselfl" .1:19 impinllcmentlll JawH1I1 Ii: 14 JCIlIII /7'11, 222i manifcltedlll 1~17
9:li 56:i.1 57: I jobl" 1.1.1'1 I~: I i.1:IH iHi 2HI .1~11
hipl411 important III jobllll IH.I'I 42IH .l'l 1211 Marchlll /\9
111:5 "':1 ill
John III ICIlHIII 4.117 Maryland III li:l.1
li:11I II: Ii IH:il hnpreNHion III nil 171i
/915 iH:3 2H.III joint III Icnllthlll ~ll 2 matter III 4~:19
improper III 11.1 Il)'t, ill II
iH:19 111 .11:5 4'1:ll 4'122 41):24 Iclten III 4.11 IH: 1.1
11:7 31 :14 3Y:IH incheN 1'1 7ii 1022 :\0-2:\ Icvc11611HI^ ill II mllterH III 4~4
39:21 411:~ 411: III 25:19 4H.il joint'HlI1 i.,7 44:i4 4.1 I~
Ii: III ma'll" \4 5:li
41:22 4i:10 419 incilion III i7:1 jointHfll 4711 ~: 9i.1 1.1:1~
44: 19 44:il 49: 19 increaHC III ~: 19
411: 12 10i4 lllil IicenllCd III :\:21 II 1'1 I~ 19 191H
49:211 4'1:22 10:1
511:2 50:H lO'H incrediblcllI 45:IX JOllCphl'l I IH IiclIl 2H2 2H7 nlH .13.5 501
511:15 50:21 52:23 indcpendcnllll I, i4 .1:11 Lifc II I 1214 :\:\19
53:H 53: II Hll indicated III ,.Ii Jrlll 1:7 Jk liftl" .1i:IH .1221 Mclnlyre II II /.11
H25 55:4 55:15 indication III .1M 1 JulYIII lillhtl'l .11 1:1 .1:IH
55:21 55:22 5~:5 IH2.1 liiO 1.1'1 10:20 114 .1H4
57:5 57:1'1 indicati vc III 2'12.1 JurgcnNon III 19:20 141 IH:I'I IH21 3'14 54:5 54H
hipbonclIl 2H:21 individual III .12:17 IY.i4 IikclYlI1 I~2 57:2.1
hips PI li:9 2H:5 InduNtricH III .17:il jury 111 4:5 4: 1.1 limit III 5:11 McLucas III 3:21
iK: 17 39:11) HI~ 4:15 ~ 12 7: I H limitation III il24 meanllol II :14
history 1111 industry III 4~.1 WI UI limitations III 321i 11l<l ill I 21 :1'1
~: I~
~:IH ~:19 7:1> infcrior III 'lil jutlll HI'l limp 1'1 21>.1 " :3 .11):il) 3'lil 41 :i5
7:IK IH:4 J'I:~ 11):11) 11.7 1111 Kansas III 51 ~1'14 ~121) :'i:'i:1 4iil 45:111 4~:1~
ill:17 21):1'1 il:12 il):9 ni~ i45 5A ~5:7 55i.1 ~7: II meloing III 51:1
21.15 21:1~ 32:4 31):14 KcllY1l1 lH'14 ~7: I~ meanH 1'1 /1:11
43:K 43:10 4H:17 innammalion"1 kCplll1 .1~.I^ 11> 17 limping PI ~ 1.22 lIil li.5 2~:17
4'1: 14 49: I~ 31A .111> 4'l:il 3~:IH 12i ~2X IH.22
hit 111 12:2 12:3 51):il ~II-l4 kind III 1>.21 i~22 Iincl" I^" :'ill: I ~ meant!11 i412
34:14 34: 15 35: 15 ioformation III 4H:22 kindslll^211 Lion III .1.1 4~:14
4H:2 4H:.1 iojcction III 4.11> medical 1101
K'fp /61 142.1 14.:n listl'l .1> 1.1 .19:1 ^ II)
hogwaNhll1 3~ 12 in~ured PI ~1.1 ~.24 77
2<1il) 1.4 1^4 II> 14 liHledll1 .1M2 I
Holbert /'1 1:14 i .i.1 .1^13 IH.24 HH H il 1424
J:21) 3:21) 5H:! injuricslIII I III knee III literature III .\J l) .11J7 .17.1'1 4i:12
5H: IH 2.11') location III 4h medicationN III Y:4
li:1 21~ 22:\ kneecap III
holdpl iliA 2~: II 311:11) 30:19 .1322 i7 II 111'1 11.1
home 1'1 'I: III 42:H 33:i.1 3.1.i~ 3/>.24 knCCN PI 27il l.odinclll I ~ H Mcdicioe III 421
hospital 1"1 51.Ii 37' Ii lonllcrlll I ~2:'i 5 i
4:i3
5:H 5:'1 I' III injury 1101 125 known III 4:9 ~1l3 memberH II I 5:li
12:13 IH:H iOH 1322 21: 17 34i4 H'X lonlluMll1 27.1 H Mcmorial141 ~H
ill: IH 21 :2 .11>:1~ 37:7 40.i~ " 14 kytONiH III il>: 14 look!,,, 77 2f'l.22 Ii 12 iO.7 2111H
.1~:23 .1~:2.1 5il ~i.1 ~(1:4 1.3111 i7A .IX: It, 101.1 '1114 mention 141 II:! ,
hospitali7.cd III 'l: 17 insurance III 1721 1.~'SI141 I^ 17 1.120 51i.1 IIli ~~:2i '7:l
Ii: 15 interested III IH 1.1 IH IH III 471 H lnokcd 141 11111 mentioncd 141 7:20
hour '41 34:12 3417 interior III 10 H laceration III J~':'i 24H ilil JUi .1:11.1 .1.12<1 4.1:.1
fiLIUS &. MCLUCAS REPORTING SERVICE
Index Puge 4
MICIIAlU. F. M......RICK. DO
Condenselt'"
Michael - PI.EAS
IMiehlCll'l 1'1 2MI ~I 1M 411 M original 1'1 12 1'1 ].(1 .\7 .111
2:J 1'1 .121 mu~ele~ III .;; 19 noticed III .N}'I 112.1 ~}. \ 'N II lltl (,7 721
4:7 ~M:7 mu~eulosk~let.1111 noting II I 40 h orthopedic 1"1 4 1.\ '112 '1.1.1 I ~ \)
mid III J~ h ~ Ih Novcmberpl 417 ~ I ~ II I ~ 1>1 1f14 Ih III
(1)7 17~ 1712 1717
midline III 114 ~ 11 ~ I ~ (""
mu~tlll HIli ~Hlh 17 11 11 12 lUll IHM 1M I~~ .
midllCetion III 42:h NIII 21 now 11'1 111 .1 1M (}~leopathie 111 421 1'1211 1'1.21 2111
Mikell! JMI4 namelll.11 \,1) H '1 ~ 2K II> >121 ~2 21 :11 221M
mildl'l lUll J211 4.~ 4.1 UII .\7 1'1 .17 24 otherwillC III l'aul'~PI '1.11
miles III 34: II l'IIJ ~I:I'I >111.1'1 4.1k >112.\ "9 >lh:21
34:17
minimal III narrowing 1'1 I~ 1M >I~ >I 4', K oil} II outcome III ~M 11 pelvic "" hi
2h2~ ~H ~4 III .11;4 It; outlincd "I
JII:15 I~ 1M IMI7 1421 lh7 ~1 '12~ 1224
~fl 17 .'71.\ 4'11.\ 13 I ~ 14h I~'M
minimally 1'1 21113 nature 1'1 4 11 numblll
157 IH21 41 4 1) 17 outsidc I \1 lK III 214 243 2hH
20:1~ 30:lh number 111 4 k 1024 .114 n~ lOll .1114
minor III ncccnarilY"1 41]~
20 2~ (,10 42 ~ overtime I "I HI J32 3ll'l 412
213 45'10
mlnule~ III neck 1411 ~ I h Iq numbncss 1'1 HIK M2 Mol 132 pelvis 1101 '/17
HI 2720 ~123 ~2 12 41:1" 442 44.~ 10:1 10:3 I(U~
54:2 ~4l I ~:~ I'll I ~ 1.1 ~21.1 ~2 14 H:1.l 4417 44.1 M 102~ 1122 12M
mi~llCd 1'1 2112 I~: 17 I ~22 1112 Oak III 4~ I 4~ 2 ~~: 17 22: I 3 232 2M 15
I~'I Ih2) IH.24 12
55: 1'1 1'111 1'I1l 21:M object III .17.17 ~llll ~h III Jl23 35:1 ~H
Mi~~ouri III 54 211~ 2117 222 3M2 3M 22 own"l 7M H2~ ~7.'1 57:12 571J
Mlllrick 1'1 1.'1 22:7 2314 H211 objection I" M 14 p.mlll ~47 Penn~ylvanialll
2:J J:'1 J:2J 2\:1 2501 2~ I J M I ~ JH.17 .1H24 page PI 4"20 4~20 1:4 I :IJ J.J
4:7 ~l 5410 25:22 2~IM 17: I Jh ~:~ \21
5M:7 2M:2~ 2'1:~ 29;(, obtained 111 4,21 pain 1"1 12:2~ II: 12 5H:1 5H4
model 171 2'12~ JI.17 J123 7:1'1 I ~:I(l Ill:h 15:13 1\ 14 11:11 peorle III 2H21
1111 Ih Ih IN 241 I~:I I~ 15 1~:24
10:J 10:'1 20: II 32:1 J2.J 34k obvious 111 17:lh IM20 IM:2\ 42: ~ 42:17 4H22
J5:20 4h:2~ 47: I J 34M 34') JI: III 2U~ ~1'12 52:17 \223
J5:12 35.23 .1~:3 31.2J ~ I ,2~ 20:20 22:22 2J: I H'I
Monismith I "I I :J 3~:h 1"7 ~1l:22 occasional I'! 21121 2312 2J:14 nil
I :J 1:7 l7 21'13 2~:1 3 121 perlll III
17 J:H J:14 5~2~ ~7.2 17 J 21:11 IJII 1).17 J2.J J~'1 .J'IIM percent I " JJI7
3:1~ J:17 524 nced"l 114 ~41 55:15 5h:4 J'I:22 40.~ 4014 perfect III
24:13
~:M ~:25 75 nceded III 49:4 offill 91"} Y:ltl 4122 4211 42:2J JIIIM
7:11 7:12 7:1'1 negative 1'1 2M3 .\.I: I 3 JMl JM:4 4l'l 44:1'1 511H perfectly PI
'1:14 14:11 1~4 JU 14.2 54:;1i 50:1~ 11120 IJ:M /112
2M:5 2'1:K 2'1.21 22:'1
1~:21 JJ:21 J4:IM nervel'I27:I~ 2722 offer 111 I>.J ~5:1 55:5 11:21 perfonncd III
J~:J J~:15 37h office 111 I~:~ ~h:22 56:25 20:7
\1:17 ~1'17 \1 IK 4h
J7:'1 3'1:15 41 :s 1114 1~:12 Jl.l11 57:2 57:J 57j perhaps I " K:J
4J:8 4J2J 45: IJ neverl'118 10 1M 211 40:11 ~1:22 52: 19 57:111 57:11 \712 period III 41 :1
4S: II 4'1:11 \0:7 42:8 421\ III:2J 57:1'1
jofficeslll 411 ~1:4
11:12 neat III ~51H ~121 painfully III 1122 periodslll 3'1:21
Montanalll Ninety-sialll Oklahoma 1'1 421
55:12 ~~.21 424 pairlll 2524 person III 1~:2
I\:IJ I~:J non-displaced 1'1
month 1'1 oldlll 721 palpated I" 2~'24 1~12 40:25
IJ:2 II :~ 11:7 IIH older III 1~.211 Pamela 111 IJ personal III Hili
14:22 4J:5 43:~ 11:1'1 JII: I ~
months I "I None III J3J once 1'1 27:21 49:7 17 11~ personally III <):18
12:IH part 111 fd4 4"22 physical I "I
I J:7 IJ:12 I~: I Onel"1 II'IM 1~21 ~25
norl'l 8h II: I) 47~
I~: 10 1~:5 I~: 11 27.M 27:14 47 I Itl:9 Ih II 1'1:1
IK:22 22:20 31:24 nonnall"l 21 :25 47.21 4'i12 1t!:14 particular III 13:21 I'I:J 2018 21121
4 I: I! ~~:4 22:2 22.'1 22.10 Ij:2 parties II I 5M: 12 21 :2~ 22:2 25:1~
2~ 14 2"211 27 II 2'1:24 12: 12
morning I" 4.1 2712 271'i 2724 one-year III 422 parts III 1.25 phrieallYl'1
4:4 2'1:1~ 2'1211 )h:'/ oncslIl 14:7 pa~llCnger PI '1'12 1'1:'1
most/'I 25:22 51:19 J711 ongoing III 3420 .1.: 12
~2: In physician 1'1 10:1\
12:22 5h:2 nonnnllYlI1 ~12~ onset III 171\ past"l h:M 21:12
54:2l1
motionlllJ I ~5 Notary 111 I 15 operate III (d pale liar III 27'12 pickup III
Ih:2 1'1:11 21 :24 'J;7
IMA ~K 1'1 operated III pathology III 2K:J
27:21 2M4 2'1~ 4~5 121~ J12t!
2'1: 10 2'1:1~ 2'1: 1M nOIe 1'1 1\ 12 I M.17 operative II I ll1 20 patient 1"1 I>:I~ piecc1l118:12
4/):2l1 H.14 /):2t! 7:j 7: 1/
5~:24 Operator III II ~ pill III I~:'I
noled 1101 1 ~'7 71~ It!l 111:1\
motorlll 9:" 15: I J Ij:lfl 19::ti o~inion III 39: IlJ 117 1~:14 I ~ 1'1 pinched II I 27:17
moustache II I 2\21 1'1:7 1'112 2111 . 'I:2J J'I24 4l1h 152~ 17:14 1'1:5 place 1'1 1:12 12:1'1
move 1" 21:20 27:M 2\ 10 lM24 .1'117 \1;1\ H2.\ 14.21 I'IM 1'1: I~ 1'1: I ~ J2:22 5h5
moving II I 14:1 noles 1'1 51, 1.\ 17h 11:25 1'1.17 2l1M 20:1'1 places III 421
MRI"I 17:4 1'1:4 57: 1M 57:19 IM.II opinions 111 7.14 21'~ 2211 4M IJ Plaintiff III 1:1'1 ,
3t!~ .14:~ 4M2.1
multiple /'1 2/: I J nothing 1'1 12K opportunity 111 h 14 patients III plaintiffsI'I 14
22: I) 22: 14 154 .12:'1 .122~ 4l1:2 ~2.1 11h
JI:7 37: It! 4M:5 5h:2 54: III ~41M 1.1:21 Jtl:X plantIlI17:2~
muscle III notice III 2'1:22 opposed II I 49.23 Paul 1"1 1.1 17
27:'1 PLHASIII 1.1
FILIUS &; MCl.UCAS REPORTING SIlRVICE
I ndcx Page 5
MICIIAIII 11MI" R
'"
. . II' ICK, I)() CondenllClt DIe...nt - IICC
pleulntlll 2~ IK prohibitive III ,19 II n:ISllnK III \ 1 III n:petltive 111 .11I ~" 1'11'1 17 r" IK III
plus III III 41 II' prominent II I 117 n:ccived III 4'1 , "O}ot IK II I. Ih 1'1 14
H'2~ prone III 41 1'1 n:eommended'll I n:port I "I k In 12 ~ "92'\ '1111
"0 1\ ~o H '111.'
pointllllllK I hil propensity III III II) .. .1/ .Ih III 14
2~: Ih n:cord 1111 11." Jot 'J Ii 14 roll III ~l H
protect III .1' 1'1 . I \ '4', \', ~ '(,]1
pointed III 212 11\1 .11'\ (I Nfl roomlll \4 h _'I,,,,
47~ provide III (1 III 4K i~ 4\11 49 .. ""II 4', Ii ,It I h nlOmS1l1 i24
polntinlllll providcd 1111 " Ii ~.. 2 :'4," '47 "h 9 "tIll 4/l II~ rotlted III
12 K .HI }.1 4k 1/\ ,ll) 2." 2'12
K 1'/ .1K K .1K I) '.. K
tJ:~ lK Iii .1K Ii ). 1.1 n:ported III .'k I} rotltinlllll 422
poorlll 1~24 ill.i n:cords 1111 (,10 rotltion III
.1UiI .\Hl:' .11\ 2~ n:pllrter "1 II' 277
2.124 ~41~ .'h 11 (11.1 7'1 llJt, ,''''2:'
.\1:'1 .n)!! nn \ IK '.4 ."10\ PI
pop III i~:1 l Pro1.le III 1'11.1 .IK III .\K 1'/ .191 '. 1.1 round"shouldcred III
portion III i.1 II pubic 1111 'Iii JI)I) .Nll 411 II Repllrtinll II I 12/ il,7 ih i.1
JI:7 Iii 7 Iii K III Iii 44. .1f,I" ...21 n:ports 1'/ III 14 routinely III 'l.l
position III I ~ I~ 11111 II 7 II Ii 494 4tJ'/ qlh "Ill} 4'1,1 .." 17 rulcdll12i K
2Ul 2h:12 iK 14 2i11i1 i.1 i~ 24:" ."iJ P} ,"i_ll.l .'.1 Ii ~iI I) ,"014 runninlllll 4'2
~ii~ JiI: 14 '414 .....1') ..... 2\
possiblc III public 1'1 ~4 24 :'h t} n:pn:sent PI 12 ruptun: III 172i1
~2 I I'
111.1 rurtUn:dllol 11\4
11'1 4.:i~ 4'12 Iii.. ~K 4 :'H II) recovcry III 14 Ih n:production II I
4'1:~ pullcdlll 4i..' n:currencc III IkH I II 27 Ih i723
.'K 22 32 ill 4K K ~I :Ih
possibly III I ~:tl pUlllCSlI1 i7i4 Rcdlll .1i request III h7 ~i~ lih ~i7
4i1:K \71 2920 reduced III 4' 14 residcncYll1 Sill
post III JII:iil 3i1iil push III i'lK ~: I 1.1 1.7
4~:lh n:sidUIIIII .111.2 3:6 .17 ~'>:Il
posterior III 2422 pushed III refcrence III
II 24 :':' Ik resolvc III ~ 1 Ii Sllll 274 4717
pounds III 7:ll PUtl'l 21): 12 .12 12 1'21 :':': If! slcrll'll illi4
i~:iil 32il 4h i2 J2: 17 refcrred III .1211 nil 2411 3111h
4h:24 n:stlll ~3 Ii :":' Ih
PPGIII qualifics III 411, refcrringlll ~.1211 restriction 111 .1117 471 ~
JU~ J'I 10 qU11itY1I1 i324 rencx III il IX slcroiliac III 20.1 ~
~4: Ih .12 ii l124
PPG'sll1 qucstionablc III 27:1.1 i71) 27.1' n:strictions III .1.1i Kacrumllll IO:IK
3~:1~ KB ~I 14 ~2: II ~21.' 11124 II ~ 11.1.1
practice III ~:~ qucstions 111 ~i'14 n:sult 14' P}:\) iO I ~ 24. ih:il
JO:~ 2711 311.li JI.I
3:11 ~:il 4. II ~ 16 rencxcs III 1711 47J 474 4711
premillClII ~J:4 rldillis III 29: I ~ resultant 11 I ~ I Ih 47.il
2'114
3J:6 reglrd I" .1117 return 141 1411 slfcly III 3i:1
prescribed 1'1 I ~:22 rldilted III 17 Ih regarding III IKil J'I.17 411'7 3i:21
radicullrlll I ~ill 5125 returned 1'1
Ih:. I~ 14 ~UI 5525 lil'/ slfcty III l~17
prellCntlll 44:10 rlillC III J 22 rellards 111 (1.22 15.9 1 ~ 14 Ihll Klnslll ~hlh
prellCnted III rlisinll II I iK~ Jii 4121
~:i4 RCllistercd 111 1 14 sarcoid 111 K:22
preltYlI1 5514 rlmuK III I '121 ~hJ 51'\' 19 revcllcd 141 I J I ~ ~I ~:J
previous 14/ 10:. IOK 11110 n:gular III I'll 10 11\ 27.1/
7:7 lOll 11.7 11.11 12'2~ n:vicw 171 6 14 SIW 1101 UII III Ii
I~:I i~:IO i7:15 iO'11I 2Jl~ 14~ IJ:~ 15.15 I~ I I):II} 20(1 11117 1.15 14 Ii 14.i.\
previously III illil 311: 14 17il 'w,If'l .Hi 12 371'/ .'.111 ~41h I ~.i4 Ih'4 I~I"
24:7 4K.li revicwcd III ~1.22 5hl
problcm I "I ran 111 l7:11 Rchablll ' III .WK SIYKII'IIHIK 4~~
h:5 J'lli 411 17 411
.:7 li:24 17:11\ rlngc 1101 I'" rclsted 1101 171 4h24 Hi~ 55.1
49')\
IK:I JI'I JJ:4 16i 1'11.\ i7.i4 171K 19:11) i.l"l 55:t'l 55:7 ~51)
40:lh 41 :4 4i.~ iK:4 294 21).1) Ji3 )47 41111 revicwing 111 4hl4 ~~III 5~li ~514
4i:1I 4i:i5 437 29:15 2'lIK ~1l:24 4111~ 41 :1) 42.12 riding III .14: II 55: Ih ~~: 17 ~~ii
47:2J 4K:i~ 4'1i4 rarely III 1111 4i.22 41i 4J Ih rightl,ol121 4{\ ~h: Ii ~h:li \~2l
511: 1 52: 14 il: 12 50: lk n.l ~.11 ~ 541 'Iii 10'4 11111 ~h.i4 ~7.1.I
problcms IlOI ~:16 rite III J414 ~4.1i 5hl 5{,7 10 1'1 I'U5 ill. III sCln 141 1014 ill7
~:Ih ~:17 ~: 17 relching 111 '1/.1 5H: 12 211.14 il ~ il 1.1 illK 24h
h:il .K Kil read III K II 12.17 relates III ~7.14 iil ~ i.12 2).1 school 111 9:K
14:i~ I~K ii:K J46 Jh'4 .1h.ii relation 111 1),2 2.llh 241 24.~ sciltic III ~120
34:~ J6h Jh:IO ~~:1l1 55:20 5(\9 relationship III 27: 1.1 iK. iX:12 scoliosis 111
4~:1~ 4h3 4h~ Ihl iK I~ il)l) .Ill K i(>:IO
4H:I'I ~O:7 Ii III relding III .If' relltivcly PI 117 .1111.1 .11.1 .1h 1.1 lICit III '11.1 '1:14
~i:11 K: 17 319 ih.ill 4111 4114 427 l411\ )4IK lUll
proceedings II' 3.:~ rell141 ~.Ii fl:ll'\ relcaKc 111 1.\ i~ 4114 444 4412 .1422 .1717 4V
J~:~ ~4:h 47: Il 56:7 relcallCd PI 11211 44111 47h 477 sccond III M'l)
rellly 1'1 . il IlK 1.11\ I) III 4'IK 47.11 471(1 47.1
proccss II I IK II
ill:i4 i4. .Ii ~ 11.1'1 1411 IK.l11 47.ii 4K ~ 41)' 19 llCcondlry III I~ Ih
profcssion III 413 l4:h 3'111 .11I17 n:IYIII ~II: I 51),K .'lh ~1I2
Profcssionalllll:14 ~I :i Hl.1 '.11 ~.111 .\.1:1.1 .~54
5K:J ~K 1'1 relsonlblc III remember III )722 5515 ~~ il 5.li22 llCC 1111 Hlh 10: I,
K 12 removcdlll road III 11117 11.1 Illi
prognosis III 4'1K J06 4ill ~21 '" 14 lilt! .14.1.1 1113 14.13 15:9
prollrlmlll 15i.1 ~2K rendcr 111 .N2.1 Rogers 1111 17 1.\ 24111 24 II .11.'1
Fll.IlJS" MCl.lJCAS REPORTING SERVICI!
Index Page (,
MI('IIAI!I r MI'I"I'RIC'K J}O
d
1M
, . . (.on cnllCll IICCk - tvncs
,
147 ."1 K .;0 IK ~~7 STEVEN,II IlII 1'1 lilllll 4'1 II
4217 4l2~ "11'7 ~lighllYPI }tdl ~1il'fneKK III }I I'" lalhlll 'I I, .' ~ I.... liKKuell1 I'"
47: 12 47 14 ~1I17
~IlIK l21'1 l.\ 1I 2h Il KIi" 11111 .11 Ik 4''11 la" 111 ., 12 )~ P} li~Kue~ III lIh
IICCk III Ih 12 KlowlYlI1 llll ..~\ ...... 'I N lape 111 It} ,\'/ll 4'1 II
~ma"lIll4 IK ].t 1'1 _"'210 .11 1\ :\,"1 lajTId 111 B ,1111 lodaYll1 4.11,....-,
lIC,menllll 17h 2421 ."~ , "."io
I h 471 l ~mukelll KloP1I1 II '" Ie Iinglll 4111 Tuday'~ III .1,1
IIClf-limlled II I k h luelll 2" 1
4.14 ~O<: kcllll 4921 KIOJ:III" 1'1 II'" lenl" 'Ill Ill/,
Scflembcr I 'I l~,I'I 1h I' 4'121 I(X:~PI 2h4 271'1
III ~oftlll Klraghll1l }{19
l 11 h Ih 4 II )II II 4 IcndcmcK~ I '" I'J! lolcralinglll lq
.II^ lK~ ,I' '"
1'/21 KolidlYlI1 Kln:nlllh PI llll 21 22 l21 ~.\ K
Scrvicelll III .1.\,1 17 Ik 2211 l71 271 100111 4122 4\,IK
Komeonc III ~I 1 2922 27\ lK K 2K I' look III
IICtpl 1411 ~Kh ~omelimelll Klriklnlllll .1I,IK lKlll lK 22 ]IUl 24'1 4.1 'I
IICven II I 111l In 11 Klruck 161 2\J-lll 100lhllChc III 2.11~
IICventh II I somelimes III nlK IIlI
I llK somewhal", .10 14 II .14 1'1 \erms II1l1 I, lor 141 ~4.l11 2h K
IICverallll .171h K 2l .1l.lll .1111 \errain III II 14 221 l7\
2hl1 Klufflll.1KI.. louched III 2'/:1
IICVCn:1I1 IJ:2 lest 141 277 2K,.1
12:~ 12:2~ sonlll '1:14 subject III IK 1.1 2'1:7 2'17 lough 11 I l~: 14
shoe III 17:ll son:nCKS 111 21 21 Kubjcr.tivc III 1'111 \eKtificd '" l24 trainingl" 4:1~
22:12
shoesl'IIU 2221 Kub1lCqUC1l1111 oil 14 .1.12.1 .1":22 4KIll 3.113
51:1.1 sorry 141 '" II 17K 4524 ll17 Iestify 111 Kill Iranscribed'll ~K:1tI
21.111 ~trk
shorthand lit jK:11 KOrtK III 42' 1\ KubllCqucnlly III IK'K Iranscriptlll 5K:11
shorts III 25:24 ~K9 tCHlimony III K II 5K21
shouldcrllll 14:25 sound II I "Jll Kubspecialty 111.111.1 3/'" .1"4 ~K" Iransicntlll 41:5
15:11 15:14 Ih:24 SounctK III 4' 1'1 Kuch", 122 ..1l11 ~H;9 Transition III 41 :5
21:K 23:1" 2":7 41.17 HI4 suddcn III IcslKlI1 7:2 Iraumalll
1'111 4020
2'/:12 2'/:1.1 .1IK S~lCCllllhlK IK 11 Kuffen:d lit Thank 1111 K211 Iravclinglll 3411
31 :IK 4:22 .11111 127 1'1:11 IK7
Hhouldcrs 1'1 2'110 Kpasmslll 27'1 Huffering II I 1'117 2.11.1 2~: 15 3.11' treat 1'1 ~:23 40:10
2'/:25 specially PI .1.110 Hummary 111 .112 ~1:'1 ILK 1721 lrealed III 4K:11
ShOWI" 1tI: I 211K .1110 su~rior "1 '1:21 1722 lrealinglll Il21
23:1 23:24 31 11 Hpeclflc III IK 20 117 10:111 "" themllClvcs III ll2 treatment 111 h:22
3h:'/ 3K:7 44K Kpeclflca"y III 11114 1111 2<1'/ 2.121 lherapy III Ih III 1",2
nlK specify lit 24:l .1014 Ih,lI 1'1:.1 tree 161 '1:lh .14:1
l711
showed 1101 Ih7 speed III .1414 su~rviKion 111 IKIO therefore 111 .10,25 .14:14 J4: 15 .14:I~
20:11 2117 2122 l23 3K:22 .1511
21:23 2125 244 Kpendllt 4'111 Kuplnc III 2K 14 thereof III lK 14 lremendous III 11:23
24: Ih 2K:10 30:21 Kpinal'l' ,'25 SUpplC1I1 21 IK thigh",22:15 triceps III 2'1.14
shows III '/:20 17:7 3.11'1 3h25
1tI:'/ sfinc PI17K 19J Hupplics III 27", 373 37:5 4'124 IriplIl 15:13
side 1111 '/22 111:1'1 124 24,15 l4:lh surface III 41K Ihighslll 22:12 lrochanter 111 23:3
11:5 12:2 12:3 24:21 2h.'/ surgcon III 4:14 2J: II 2K:'/ 2K:21
1'/:17 2.1:2 24: I spinous lit IK 15 4: 17 .13:12 Ihinking II 1 4h:4 trochanteric III 2K:23
2h:11 2h:23 27:K Spurlll 241'1 surgcry lilt 5:1 TlIOMASI" 1211 truck 141 '/:7 12:15
27:12 27:14 2K:7 53 l:1I 5:13 120 34:1'/ 35:20
2H:15 2'/:3 374 spunl1l2U2 515 l:25 (,:4 Ihoracic III 2h: 14 truCl41 40:\'/ 47:12
si,nificantlll 71K SS/l1 lK2 17:1.1 IK:22 27:1 l Ihorough 111 34K '<0:25 5K:1O
I :20 23:h starr 111 5K ,'i,1) .12K 32:15 .12,Ih 3hh trulh,ll IK.K
5: 10 .12:20 33:14 J.1 Il
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FIl.IUS &; MCLUCAS REPORTING SERVICE
I nd~x Puge 7
IN THE COURT OF COMMON PL.EAS
CUMBERL.AND COUNTY, PENNSYLVANIA
PAUL S. MONISMITH, III
lInd
PAMEL.A MONISMITH
Plalntilli;
v.
NO. CIVIL 19%
CIVIL ACTION . LAW
PAUL S. MONISMITH, JR.
Defendant
PLAINTIFF REQUESTED POINTS OF CHARGE TO THE JURY
TO THE HONORABLE EDWARD GUIDO:
Counsellor the Plaintiffs Puul S. Monismith Uland Pumela Monismith requests
that his Honor inelude in his chargcs to the jury in this mUller the following:
No.1 (5.30 (Civ)) EXPERT TESTIMONY - CREDIBILITY GENERALL Y
You will recall that Dr. Michael Duniels PPG Industries company doctor and Mr.
Bruce Kipp, the physician's ussistunt atlhe Belvedere Medical Family Practice both gave
testimony as an expert in the field of medicine and specifically physical limitations to be
placed on injured patients for the Plaintiff and Dr. John Rodgers and Dr. Michael Metrick
gave testimony on their qualifications as an expert in the field of medicine and
orthopedics. Dr. Paul Anderson also gave testimony as an expcrt in the field economics
and vocational rehabilitation.
A witness who has sp,:cial knowledge, skill, experiencc, training or cducation in a
particular science. profession or occupation may givc his opinion as an expcrt as to any
malleI' in which he is skillcd. In detel1nining the weight to be given to his opinion. you
should consider the qualilieations and the reliability of the expcrt and the reasons given \
for his opinion. You arc not bound by the expert's opiniol'. merely because he is a,\ .
expert; you may accept 01' reject it. as inlhe cuse of any other witness. \ :'
No.2 (5.31 (Civ))- EXPERT OPINION - BASIS FOR OPINION GENERALLY
In general, the opinion of an expert hus value only when you accept the facts upon
which it is based. This is true whether the fuets ure assumed hypothetically by the expert,
or they come from his personul knowledge. from some other proper source, or a
combination of these.
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No.3 (5.32 (Civ)) - HYPOTHETICAL QUESTIONS-
If an expert has made it clear that his opinion is based on the assumption that a .\
purtieular fuet did not exist und, from Ihe evidence you find thut it did exist und thut it
wus materiul, you should give no weight to the opinion so expressed.
No.4. (6.00 (Civ)) - DAMAGES
In the cusc before you Ihe dclendanl hus admitted he is Iiuble to the pluintiffs.
therefore you must decide an amount of money damages you believe will fairly and
accurately compcnsate the plaintiffs tor alllhe physical and finuncial injuries they have
sust.ained liS a rcsult of accident. The amounl of the awaflJ today must compensate both
plaintiffs complctely for the damages they sustained in the past, us well as damages the
plaintiffs will sustain in thc fmure.
No.5. - RELATIONSHIP OF THE PARTIES
In thc case beforc you loday the defendunt is the father of the plaintiffs, his son
and daughter-in-law. The dcfendant has admilted he is liable for all dumuges caused by
his actions and the fact he is relaled 10 the plaintiffs should have no bearing on the
amount of damages you may award the plaintiffs. Your decision on the amount of
monetary dmllages should be thc same as if the defendant and the plaintiffs were not
related.
No.6 (6.00 (Civ)) DAMAGES
!fyou find that the defendant is liable to the plaintiff, you must then find an
amount of money damages which you believe will fairly and adcquately compensate the
plaintiff for all the physical and financial injury hc has sustaincd as a result of the
accident. The amount which you award today must compensate the plaintiffcompletely
for damage sustained in the past, as well as damage the plaintiffwill sustain in the future.
No.7 (6.028 (Civ)) AUTO NEGl.lGENCE: ELEMENTS OF PROOF
EXPl.ANATION OF NON-ECONOMIC' DAMAGES
The plaintiff claims to diflerellltypes or classes of damages in this case. The
clements which the plaintiff has the hurden of proving wilh respel:t to each Iype of
damages arc somewhat different. The lirsttype or class of dam ages sought by plaintiffis
generally referred to as "economic" los.~ damages an\1 includcs income loss and loss of
eaming capacity.
The second type or class of damages is generally referred to as "non-economic"
loss damages and includes such things as pain (past. present, and future). emotional
suffering, disability. loss of enjoyment of Ii Ie and lile's pleasures. embarrassment, amI
humiliation.
As Ilndicutcd. whutthe pluintil1'must prove diners somewhut depending on
which type of dumuges c1uim is hcing considercd--cconomlc or non-economic loss
dumuges. I will now instruct you regurding the clements which the plulntill'must prove.
No.7 (6.01 (Civ) ) INJURIES TO ADULT NOT RESUl.TlNG IN DEATH
The dumuges recoveruhlc hy the pluinti 11' in this euse und the items thutgo to
muke them up. euch of which I will discus sepurlltely. ure us follows:
u. I'ustlost of Eumings UJ1lllostof euming cupucity
b. Future lost cumings und eurnlng cupucity
c. Pust puin und suffering
d. Future puin und suffering
e. Emburrussmcntund humiliution
f. Disllguremcnt
g. Loss of Enjoyment of Ii Ie
You will add thcse sums of damage togethcr and return your verdict in u single,
Jump sum.
No. !l (6.0IC) (Civ)) PAST LOST EARNINGS AND LOST EARNING CAPACITY
The plainti IT is entitlcd to be compensated lor the amount of earnings that he has
lost up to the time of the trial as a rcsult of his injurics. This amount is the difference
between what he probably could have eamcd hut ti.lr the hann and any less sum which he
actually earn cd in any cmploymcnt.
No.9 (6.010 (Civ)) FUTURE LOSS OF EARNINGS AND LOST EARNING
CAPACITY
The plaintiffis cntitled to be compcnsatcd Ii.lr any loss or rcduction of futul'e
earning capacity that hc will sufler as a rcsultofthe injuries sustaincd in this accident. In
detemlining this amount. you must ascertain the differcnce hetweenthe yearly amounts
which the plaintiff probably would or could havc camcd during his life expeetuncy but
for his injuries. and the amounts he will probably hc able to eam during the period of his
life expectancy. In detennining this amount. you many consider the type of work that
the plaintiff had done. the type of work which, in view of his physical condition.
education. experience and age. he would have hecn doing and will be doing in the future.
the cxtent and durution of the plaintilrs injuries. togcther with all other mattcrs
rcasonably relevant. The amount of 10stlillure earning capacity which you detennine to
have been sustained by the plainti 1'1' should he expressed by you in a dollar amount.
No. 10 (6.22 (Civ)) FUTURE LOSS OF EARNINGS AND LOST EARNING
CAPACITY WHERE l.OSS OF FUTURE PRODUCTIVITY IS PROVEN
The plaintiff is entitled to be compcnsatcd for any loss or reduction of future
eaming capacity that he will sufler as a rcsult of a decrc(ISC in or lo~s of future
productivity.
Future productivity is the increase in lVages or compensation which plaintiff
would have reccived. had he not sustained the injury. Pluintiff submitted evidence
~
through his expcrt who has computcd his loss ofcaming, adding a productivity factor. If
you bclicvc thaI plaintiffhas sustaincd a loss ofproduclil'ity you may usc this cvidcncc as
a guide in rcaching your dccision tIS tothc amount of plaintirrs loss or rcduction of future
earning capacity.
No. 11 (6.01 E (Civ)) PAST PAIN AND SUFFERING
The plaintiff is cntitlcd to hc fairly and adcljuatcly compcnsatcd lor such physical
paiu. mcntal auguish, discomfort, inconvcnicncc and distrcss us you nud he has cndured,
fromthc timc of the accidcntuntiltoday.
No. 12 (6.01 F (Civ)) FUTURE PAIN AND SUFFERING
Thc plaintiff is cntitlcd to bc tuirly and adcljuatcly compcnsatcd lor such physical
pain, mcntal anguish, inconvcnicnce and distress as you bclicve he will cndure in the
future as a rcsult of his injurics.
No. \3 (6.0IG (Civ)) EMBARRASSMENT AND HUMILIATION
Thc plaiutiff is entitlcd to bc luirly andadcljuately compcnsatcd lor such
embarrassmcut and humiliation as you belicvc hc has cndurcd as a result of his injuries.
No. 14 (6.01 H (Civ)) DISFIGUREMENT
The disfigurcmcnt which the plaintilTsustaincd as a rcsult of this accidcnt is a
scparatc item of damagcs rccognizcd by thc law. Thcrclore. in addition to such sums as
you award for pain and suffcring and for cmbarrassmcnt and humiliation. the plaintiff is
entitled to be fairly and adcljuately compcnsatcd lor the disfigurcment hc has suffered in
the past as a rcsult of this accident. and which hc will continuc to suffer during the future
duration of his (her) Iifc.
No. 15. (6.011 (Civ)) ENJOYMENT OF LIFE
The plaintiffis entitled to bc 'uirly and adcljuatcly compcnsated for past. present
and future loss of his ability to cnjoy any of the pleasurcs oflifc as a result of his injurics.
No. 16 (6.02C (Civ)) AUTO NEGLIGENCE: ECONOMIC LOSSES
In case you hcard the dcfcndant has admittcd he was ncgligentand his negligence
was a substantial factor in bringing abol'.t injury to plaintiff: thcrefor thc plaintiffs may
recovcr ifhe can sbow by a greater wcight ofthc evidcnce that
(3) His injury resulted in ecollomie losses;
No. 17 (6.02F(Civ)) AUTO NEGLIGENCE: MENTAL OR EMOTIONAL INJURY -I
The opcration of the mind and of the nervous systcm arc body functions. Mcntal
and emotional injury which is causcd by physical injury or mcntal or cmotional injury not
caused by physical injury but which rcsults in physical symptoms may bc a scrious
impainncnt ofa body function.
No. 18 (6.21 (Civ)) DAMAGES: LIFE EXPECT ANCY
DII'DDAII'r' 8 UQU"'1'ID JOIH'!' roa CIW\GI NO. 1
against Defendant, Paul S. Monismith, Jr., and
you are hereby J,J-
'\yt'
After reviewing the law and the testimony at evidence in
the light most favorable to the Plaintiffs, you are directed to
find that the evidence is insufficient to support a verdict
directed to enter a verdict in their favor.
Highland Tank and Manufacturing Company v. Duerr, 423 Pa. 487,
225 A.2d 83 (1966), and Kuisis v. Baldwin-Lime-Hamilton ~~,
457 Pa. 321, 319 A.2d 914 (1974).
2
-.)
p.ruDlUIT'8 IUIQUB8TBD 'OI"" I'OR CuaG. HO. 3
Plaintiffs, Paul S. Monismith, III and Pamela Monismith,
have the burden of proving, by a preponderance of the evidence,
that Defendant, Paul S. Monismith, Jr., was negligent and that
such negligence was the proximate cause of Plaintiff's injuries.
If Plaintiffs in your eyea, have not established by a
preponderance of the evidence, either of these elements, then
you must return a verdict for Defendant, Paul S. Monismith, Jr.
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DII1DIDAII'f" UQUl8TBD l'O:tNT rea CIIAl\GI 110. ..
~ou should not allow sympathy, emotion or prejudice to
influence your deliberations. You should not be influenced by
anything other than the law and the evidence of the case. ~.j
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~lrllllDAlft' I HQUlITID feINT roa CIlUGI NO. .
~ou are not bound to accept or believe the evidence or
testimony offered by any party, fact witness or expert ~itness,
even if no other evidence or testimony is o!f~red to contradict
it. The credibility of witnesses is solely for you, the Jury, to
determine and you are free to accept or reject any testimony in
whole or in part.
Gaita v. Damula, 385 ~a. 171, 122 A.2d 63 (1956)/ Gottlob v,
Hillegu, 195 ~a. Super. 453, 171 A.2d 868 (1961).
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Dlramwrr'. UlQUI.TID 'OINT roa CIIMGB NO. .
The credibility of witnesses is always a matter for the
jury. It is the province of the jury to appraise the testimony
and to accept or reject the evidence given by the witness. A
jury need not believe the testimony of a Plaintiff and his
witnesses concerning injuries/ otherwise. there would be no way
for a Defendant to protect himself against fraudulent claims for
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injuries which never occurred or are unrelated to the accident.
Gottlob v. Hillegas, 195 pa. Super. Ct. 453 (1961).
DlnMOAMT'1 UQU.I'l'ID to~1l'l' roa CBUGI MO. II
In determining the amount of dama~es, there should be no
attempt by you to punish the Defendant.
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Murray v. P.T.C., 359 Pa. 69, 71, 58 A.2d 323 (1948).
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DlnMDANT' 8 UQua.TaD 'OINT roll. CIlAl\QB NO. 13
You will recall that Dr. Michael Daniels and Bruce Kipp,
P.A., testified as expert witnesses for Plaintiffs in this case,
and that John Rodgers, M.D. and Michael Mitrick, D.O.,
orthopedic surgeons, testified as expert witnesses for Defendant
in this case. A witness who has special knOWledge, skill,
experience, training or education in a particular science,
profession or occupation may give his opinion as an expert as to
any matter in which he is skilled. You, as jurors, determine
the weight, if any, to be given to the testimony of experts. In
doing so, you should consider the qualifications of the expert
weight to be given to his opinion you are not bound by an
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with respect to the opinion he has given. In determining the
expert's opinion merely because he is an expert; you mdY accept
or reject it, as in the case of other witnesses; or give it the
weight, if any, to which you deem it entitled.
Griffith v. Clearfield Truck Rentals, Inc., 427 Pa. 30, 233 A.2d
896 (1967); Reardon v. Meehan, 424 Pa. 460, 227 A.2d 667 (1967) 1
Steele v. Sheppard, 411 Pa. 481, 192 A.2d 397 (1963).
,I',
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PAULS. MONISMITH, III,
and PAMELA A. MONISMITH,
PlaintiffR
20
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
V.
PAUL S. MONISMITH, JR.,
Defendant NO. 96-3708 CIVIL TERM
IN RE I PRETRIAL CONFERENCE
A pretrial conference was hcld on Wednesday,
August 25, 1999, before the Honorablc Edward E. Guido, J.
Present for the Plaintiffs was Joseph D. Buckley, Esquire,
and present for the Defendant was Stephen E. Geduldig,
Esquire.
This is an auto accident case involving an
emancipated child suing his father. The Defendant has
admitted liability. The only issue is damages.
This case should take approximately two days to
try including jury selection. There are no scheduling
conflicts aside from the fact that defense counsel has
another case on the list.
Any motions in limine with supporting authority
shall be submitted to the Court by Wednesday, September 8,
1999. Any responses with supporting authority shall be
submitted by the commencement of trial.
The parties are directed to submit suggested
pOints for charge by the commencement of trial. Any trial
briefs the parties desire the Court to consider should also
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Paul A. Anderson, D.Ed. 2418 North Second Street Harrisburg, PA 17110
Bruce Kipp, P.A. Belvedere Family Practicc, Carlisle, PA 17013
Jon E. Mincr 2200 North 25 th Strcet, Camp Hill, PA 17013
Robert A. Hollen, M.D. Belvedere Family Practice, Cl1I"lisle, P A 17013
James Schippa, PPO Industries, Mount Holly Springs, PA 17013
William Turicik 227 Acre Drive, Carlisle, PA 17013
Bruce Rustieck 133 Chester Street, Carlisle, PA 17013
Pat Brannan 116 Locust Way, Dillsburg, PA 17019
James Cump I Orough Lane, Newport, PA 17074
Any witness identified by Defendant in its Pre-Trial Memorandum
IV. PLAINTIFFS EXHIBITS
Plaintiffs Complaint
Defendant's Answer
Plaintiffs Medical Reports
Plaintiffs Tax Peturns
V. EXPERT OPINIONS
Paul A. Anderson, D.Ed report dated June I, 1998
VI. STIPULATIONS OF PARTIES
I. Stipulation as to the authenticity of all medical records.
VII. ESTIMATED LENGTH OF TRIAL
Two (2) days.
~
principal question in the case is to what extent are there any
ongoing physical problems related to this accident and, to what
extent, if any, they prevent Plaintiff from engaging in his work
and other daily activities.
II. LIST 01' TnaS AND AMOUNTS or ALL DANAGZS CLll.INlD
Defer to Plaintiff.
III. LIST or NANlS AND AIlDIIZSSIS or ALL PlasONS NHO NAY .1 CALLID
AS WITNlSSIS, CLASSIFYING TRIM AS LIABILITY OR DANAGI
~TNlSSIS
A. Liability
Plaintiff, Paul S. Moniomith, III, as on cross-examination
Defendant, Paul S. Monismith, Jr.
Any witness identified by any other party in discovery
Any witness identified Py any other party in its
Pre-Trial Memoranda
Defendants r.eserve the right to supplement this list
prior to trial
B. Damag..
Plaintiff, Paul S. Monismith, III, as on cross-examination
Plaintiff, Pamela A. Monismith, as on cross-examination
Defendant, Paul S. Monismith, Jr.
Records Custodians for all health care providers identified
in discovery and as follows
Any health care provider identified in discovery and as
follows
2
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VUI.ICIIDULIHG faa.LIMB
None anticipated other than the faot that Defense counsel is
number 14 on the current list in the matter of Thielemann v.
Centimark Corporation, No. 96-1985.
IX.SfaCIAL IVIDINTIARY ISSUlS
None anticipated.
X.lUIALISTIC SITTLIMIN'l' ornl\ 01\ DIHAHD
Plaintiff's settlement demand is $100,000.00. Defendant ha~
already advance roughly $26,000.00 in advance wage payments.
Defendant offers on top of that amount already advanced
$50,000.00.
Respectfully submitted,
THOMAS, THOMAS , RAnI\, LLP
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:153777.1
BYI
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STEPHEN E. GEDULDrG, ESQUIRE
Attorney I.D. No. 43530
Attorneys for Defendant,
PAUL S. MONIS'J.CITB, JI\.
5
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CBaTI'ICAT. 0' l.aVIe.
I hereby certify that a true and correct copy of the
foreqoing document was served by depositing the same in the
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,
United States Mail, postage prepaid, at Harrisburg,
Pennsylvania, on the&1rl.ay of Augu.'3t, 1999, on all
of record as follow5:
counsel
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Joseph D. Buckley, Esquire
1237 Holly Pike
Carlisle, Pennsylvania 17013
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10 and to pull over to the side of the highway If he were tired and unable to continue to
drive.
6. While driving east on said highway with Illalntltf as a passenger and while
traveling at a rate of speed ofllf\y.f1ve or more miles per hour, Defendant fell asleep at the
wheel of his vehicle. Defendant's vehicle lell the highway and stuck severalllxed objeclI,
throwing plaintiff forward in his seat and crushing the body of the vehicle in on Plaintiff
with such force that Plaintilf fractured his pelvis, sustained multiple lacerations and
contusions and injured other parts of his body
7. As a result of the impact of the vehicle with llxed objects, Plaintiff suffered
severe injuries.
8. The proximate cause and/or a substantial factor in causing the accident was
Defendant's failure to pull to the side of the road as he became tired while driving and
Defendant's falling asleep while driving.
9 As a result of the accident caused by Defendant's negligent act or acts, Plaintiff
suffered a broken pelvis, multiple lacerations and cOlllusions and other injuries and has
been obligated to expend large sums for medical and hospital bills directly resulting from
the accident and by reason his multiple injuries, PlaintilT will in the future be required to
expend further large sums.
10. As a reslllt of the accident caused by Defendant's negligent act or acts, PlaintilT
was for a period of seven or more months unable to work in his former capacity, that
being a mechanic at the PPG Plant in Mt. Holly Springs. PA and farmer and although he
has now returned to work, Plaintill'is not as productive and he is unable to withstand long
hours of labor due to his injuries.
11. As a result of the accident caused by Defendant's negligent act or acts, PlaintilT
has been disfigured and walks stilT legged with a limp, has reoccurring headaches and
does not have full motion in his neck and other accident related problems.
12. AI I relUlt oflhe Iccident clulICd by Defendant'a nellllllent ICt or acts and the
multiple Injuries IUstalned Iherefrom, PlaintilT will have to endure Ilradually intensilYlng
pain in his pelvlslnd neck.
13. PlalntilThas Incurred medical bills In excess of twenty-five thousand dollars.
14. Plaintiff will Incur future medical bills In excess of twenty-five thousand
dollars.
IS. PlalntilThas suffered loss of wages In excess of twenty-five thousand dollars.
16. PlalntilT will sutTer future loss of wages in excess of twenty-five thousand
dollars.
17. Plaintiff has sutTered pain and suffering in excess of twenty-five thousand
dollars.
18. Plaintiff will suffer future pain and suffering in excess of twenty-five thousand
dollars.
19. Plaintiff has suffered loss of enjoyment of life In excess of twenty-five thousand
dollars.
20 Plaintiff will sutTer future loss of enjoyment of life in excess of twenty-five
thousand dollars.
WHEREFORE, Plaintiff prays that this Honorable Court enter a judgment in his
favor as against Defendant in an amount in excess of twenty-five thousand dollars,
together with interest and the costs associated with this action.
B. COUNT TWO- LOSS OF PROPERTY
21. Paragraphs ).20 are incorporated by reference as though they were more fully
set forth herein.
22. As a result of the accident. Plaintiff suffered a los~ of property including two
pairs of eye glasses, clothing and other personal property in the amount of 725 Dollars.
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PAUL S. MONISMITH. III and
PAMELA MONISMITH.
Plaintiffs
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 96-3708 CIVIL TERM
v.
PAUL S. MONISMITH, JR.,
Defendant
CIVIL ACTION - LAW
DEFENDANT'S REQUEST FOR PRODUCTION
OF DOCUMENTS DIRECTED TO PLAINTIFFS
TO. PAUL S. MONISMITH, III, and PAMELA MONISMITH, Plaintiffs,
and JOSEPH D. BUCKLEY, ESQUIRE, their attorney:
PLEASE TAKE NOTICE that, pursuant to Rule 4009 of the
Pennsylvania Rules of civil Procedure, Defendant requests that
Plaintiffs produce the documents hereinafter described and permit
Defendant, through its attorneys, to inspect them and copy such
of them as they may desire. Defendant requests that the
documents be made available for this inspection at the offices of
Defendant's attorneys located at 7th floor, 100 Pine Street,
Harrisburg, Pennsylvania, within thirty (30) days of the date of
service hereof. Defendant's attorneys will be responsible for
these documents as long as they are in their possession. Copying
will be done at Defendant's expense and the documents will be
promptly returned after copying has been completed.
This request is intended to cover all documents in the
possession. custody and control of Plaintiffs. their agents"
employees. insurance carriers and attorneys and is considered to
be continuing. Plaintiffs' response to the Request should be
modified or supplemented as Plaintiffs. and/or their attorneys.
obtain furthur or additional documents up to the time of trial.
Requested documents ar~ more particularly itemized and described
as followsl
1. All Iltatements, signed statements, transcripts of
recorded statements or intervi~wB of any person or witness
relating to, referring to or describing any of the events
deocribed in the Complaint.
2. All ,"<pert opinions, reports, summaries or other
writings in your custody or control or your attorney or insurers,
which relate to the proposed testimony of the preparer of such
opinion, report, summary or other writing.
3. All documents prepared by you, or by any insurer,
representative, agent, or anyone acting on your behalf, except
your attorney Is) , duri~g the investigation of the incident in
question or any of the events or allegations described in the
Complaint. Such documents shall include any documents made or
prepared through the present time, with the exclusion of the
mental impressions, conclusions, or the opinions respecting the
value or merit of the claim or defense or respecting strategy or
tactics.
4. If not already provided, all medical records, charts,
reports, opinions and correspondence of any hospital, physician,
osteopath, chiropractor, therapist, dentist or orthodontist that
provided treatment for the injuries you sustained in the
accident.
- 2 -
S. If not already provided, all bills for medical
treatment rendered by any hospital, physician, osteopath,
chiropractor, therapist, dentist or orthodontist.
6. All documents which support any claim for lost earnings
or income.
7. A copy of your automobile insurance policy and/or
declaration sheet in effect at the time of the accident.
s. Copies of your federal income tax returns for the past
five years.
9. All documents which you intend tu use as exhibits at
trial.
NOTE: As referred to herein, "document" includes
written, printed, typed, recorded, or graphic matter, however
produced or reproduced, including correspondence, tel.egrams,
other written communications, data processing storage units,
tapes, contracts, agreements, notes, memoranda, analyses,
projections, indices, work papers, studies, reports, surveys,
diaries, calendars, films, photographs, diagrams, drawings,
minutes of meetings, or any other writing (including copies of
any of the foregoing, regardless of whether you are now in
possession, custody, or control of the original) now in your
possession, custody, or control, your former or present counsel,
- 3 -
Exhibit B
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Exhibit C
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McNEES, WAL.L.ACE & NURICK
ATTORNEYS AT LAW
100 PINE IS TREU
p, O. BO)C IIl1e
HARRI5BURCl, P/J>. 17100.11150
TUl'HOIWl171712,".BOOO
,..17171237.5300
http./twww.mwn.com
MICHAEL R. KEllEY
DIIl!CT DIAL: (717) 237.'322
E.MAll ADDIll!SSI MKELLEYCMWN,(OM
January 30, 1998
Joseph D. Buckley, Esquire
1237 Holly Pike
Carlisle, PA 17013
In ReI Paul S. Monismith, III and Pamela Monismith
v. Paul S. Monismith, Jr.
Cumberland County Civil Action No. 96-3708
Pear Mr. Buckley.
Thank you for your letter of January 20, 1997. I have
forwarded your correspondence to Erie. However, I do not
anticipate, based upon my previous conversations with Tom Heim,
that any further settlement offer will be forthcoming.
I would like to clear up some apparent confusion based upon
your letter. According to the records, your client was unable to
work from the time of his accident for, basically, the rest of the
calender year. The $26,000 in lost overtime that has already been
paid by Erie represents the overtime that your client allegedly
lost for that same calender year. The $12,000 figure that we
mention in our settlement letter refers to the base salary which
your cl ient received for the remainder of the year. Because he
lost the vacation and sick time which he had built up in sufficient
amounts to cover his base salary while he was off during that
period of time, we believe that amount is appropriate compensation.
This figure was not "arbitrarily chosen" as you state in your
letter. Our calculations specifically do include, contrary to your
letter, the six months or so of sick time which had accrued and
which he used due to the accident.
Our dispute is over whether your client is entitled to ~
future lost wages for overtime beginning the year after he had the
accident. As I mentioned to you in our phone conversation, and set
forth again in our letter, we believe that any future wage loss is
minimal, as his wage information indi.cates that he was making about
the same amount of money post-accident as he was pre-accident. You
may certainly argue that his income would have been considerably
higher, given his intentions with regard to working overtime. We
do not believe that thi.s will be persuasive before the jury.
. COLUMBUS, OH
W"SHINGTON, D.C,
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PAUL S. MONISMITH, III and
PAMELA A. MONISMITH,
Plaintiffs
IN TilE COURT OF COMMON PLEA$
CUMBERLAND COUNTY, PENNA
v.
No. 370U CIVIL 1996
C I VI L AC'rlON -- LAW
PAUL S. MONISMITH, JR.,
Defendant
CERTIFICATE
PREREqUISITE TO SERVICE OF A SUBPOENA
PURSUANT TO RULE 4OO9.ZZ
L
As d prerequlslh> to sl'I,in' of subPOPn,lS for rlr)('uml'l1ts and things pursuant to Rule 4009.22,
Defendant certifies that:
1.
A Notice of Intent to Serve A Subpol'na with a copy of the subpoena a<<ached thereto
was mailed or delivered to each party atleastlwenty days prior to the day on which
the subpoena was sought to be 51'rvl'd;
2.
A copy of the Notice of Intent, Indudinllthe proposed subpoena, Is a<<ach~ to this
Certificate;
J.
No obJecllon to the subpoena h.1S b"I'11 recelv.>d; and
4.
Thr: subpoena which will be ,,'rvl!d is Identical 10 the subpoena which 15
a<<ached to the NolieI' of Intent to SI!rve A Subpoena.
it
THOMAS, THOMAS & HAFER, LLP
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STEPHEN E. GEDULDIG, ESQUIRE
305 NORTH FRONT STREET. 6TH FLOOR
ttARRISBURG, PA 17108
(717) 237.7119
ATTORNEY FOR DEFENDANT
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CERTIFICATE OF SERVICE
I, STEPHEN E. GEDULDIG, ESQUIRE of 11ll' law f1rlllllf THOMAS, THOMAS, &. HAFER, LLP
do certify Iholt I served Ihe foreKolf11l dOCllnll'nl on Ihe followlnK person(s), by ch?poslllnlllhe same In
Ihe Uniled States Mall, postage prepaid, 011 Harrisburg, Pl'nnsylvanlol addressed as follows:
Joseph D. Buckley, Esquire
1237 Holly Pike
Carlisle. PennsylvBf1la 17013
THOMAS, THOMAS & HAFER, UP
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IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYL VANIA
PAUL S. MONISMITH, III
and
PAMELA MONISMITH
Plaintiffs
v.
NO.3708 CIVIL 1996
CIVIL ACTION. LAW
PAUL S. MONISM IT", JR.
Defendant
PRAECIPE TO SATISFY JUDGMENT
TO THE PROTHONOTARY:
PlellSe satisfy the judgment in the above captioned matter lIS it hIlS been paid by
the Defendant. Thank you. .:z-", lu'/" Ih It. /I~d,"r'.
October b 1999
.
CERTIFICATE OF SERVICE
I hereby certify that a true and correct copy of the foregoing Praecipe 10
Discontinue Action WIIS duly served via United States First elllSs Mall, postage prepaid
upon the following persons:
I,
Stephen E. Geduldig, Esquire
ThomllS, Thomas & Hafer, LLP
305 North Front Street
Sixth Floor
P. O. Box 999
Harrisburg, P A 17108
c/
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Date: October 11 1999
"-
Jos h D. Bucliley, Esqulr
Attorney for the Plaintiff
\.D. #38444
1237 Holly Pike
Carlisle, PA 17103
(717) 249-2448
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PI.AINTlFF'S
EXHIBIT
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IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
PAUL S. MONISMITH, III
and PAMELA A. MONISMITH,
PLAINTIFFS
VS
NO. 3708 CIVIL 1996
PAUL S. MONISMITH, JR.,
DEFENDANT
VIDEO
DEPOSITION OFI
TAKEN BY.
.., BEFORE.
.-3
DATE:
PLACE I
MICHAEL O. DANIELS, M.D.
PLAINTIFFS
TERESA K. BEAR, REPORTER
NOTARY PUBLIC
TORR PIZZILLO, LEGAL VIDEO
SPECIALIST
SEPTEMBER 13, 1999,5:20 P.M.
OFFICE OF DR. DANIELS
303 NORTH BALTIMORE AVENUE
MT. HOLLY SPRINGS, PENNSYLVANIA
APPEARANCES:
LAW OFFICE OF JOSEPH D. BUCKLEY
BY: JOSEPH D. BUCKLEY, ESQUIRE
FOR - PLAINTIFFS
THOMAS, THOMAS & HAFER
BY: STEPHEN E. GEDULDIG, ESQUIRE
FOR - DEFENDANT
.,
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GEIGER & LORIA REPORTING SERVICE
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TABLE O~ CONTE~
WITNESS
fQR PLAINTIFFS
Michael O. Daniels, M.D.
DIRECT CROSS REDIRECT
3 (qual) 6 (qual) 17
7 15
Q~IELS EXHIBIT NO.
1 - Office notes
PRODUCED AND MARKED
9
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STIPULATION
It is hereby stipulated by and between counsel
for the reapective parties that reading, signing, sealing
and certification are waived.
MICHAEL O. DANIELS, M.D., called as a witness,
being sworn, testified as follows:
DIRECT EXAMINATION AS TO QUALIFICATIONS
BY MR. BUCKLEY.
Q Good afternoon, Dr. Daniels. Would you please
tell the jury your full name and location of the office
where we're located now.
A Michael O. Wayne Daniels and we're at 303
North Baltimore Avenue, Mt. Holly Springs, Pennsylvania.
Q And you understand that this videotape is
going to be used in a trial that we're in the process of
doing tomorrow or the next day --
A I do.
Q -- true? And I want to thank you for taking
your -- away from your busy schedule so you can give us this
deposition. Now, could you please tell the jury the nature
of your profession.
A I'm a family physician in a two-man
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a company doctor?
A
My obligations generally are to see patients
for new hire interviews and physical exams and to assist in
the management of illnesses, the supervision of illnesses,
particularly in return to work settings or in making
disposition when there's a question of whether the patient
is allowed to work with their illness.
Q
And why would that be important?
Well, PPG is, like any industry, a
A
non-permissive environment. There are things that people
need to do that are not part of their activities of daily
living, climbing, lifting, twisting, turning in confined
spaces, exposure to hazards and sometimes medical illnesses
or injuries would preclude safe or appropriate employment.
Q
Now, in the course of your being associated
with PPG Industries as one of the company physicians, are
you familiar with Paul Monismith, sometimes known as Sam
Monismith?
A
Yes.
MR. GEDULDIG: Excuse me, Counsel, are you
going to offer the Doctor as an expert?
MR. BUCKLEY: Yes, I am.
MR. GEDULDIG : Okay.
MR. BUCKLEY: I I d like to offer him as an
expert in occupational -- occupational and - - strike that.
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I would like to offer him as an expert in the field of
occupational medicine.
MR. GEDULDIG: I just have a couple
questions.
CROSS-EXAMINATION AS TO QUALIFICATIONS
BY MR. GEDULDIGt
Q Doctor, when Y01J say you supervise and manage
return to work of employees at PPG, are you actually
rendering treatment to them?
^ Generally speaking I don't. For illnesses
that occur on site or that are of a minor nature, then I may
provide treatment, but, no. As a general rule, no.
Q Do I take what you're saying to mean that if
somebody is injured out of work but they come back to work,
you want to make sure that they can safely accomplish their
job within PPG so that they don't get hurt worse or hurt
other people or maybe give rise to a worker's comp claim or
something like that?
A Right. Safely and effectively do their job.
Q So would it be fair to say that you defer to
the principal treating doctor or doctors?
A For management of their illness, that's true.
MR. GEDULDIG: I have no objections to the
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Doctor -- Doctor's qualifications in any way.
MR. BUCKl,EY I Thank you.
DIRECT EXAMINATION
BY MR. BUCKLEY.
Q Now, Doctor, I had asked about -- do you know
Paul Monismith as Sam or Paul?
A Paul.
Q Paul, And how long have you known him?
A I'm not sure that I can answer that
accurately. I mean, I have records having interviewed him
at least till -- starting in 1995, but it would not be
unusual to see him for other things that perhaps weren't
apropos of this particular discussion prior to then.
Q So you were aware that in 1995, in April, that
Paul was involved in a motor vehicle accident?
A Yes, sir.
Q And what was your understanding as to what
happened in that accident?
A I don't have any specific recollection of the
details.
Q I'm going to give you some facts I'd like you
to assume as fact that we hope to introduce later. Would
you assume for a moment that Paul was involved in a motor
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vehicle accident during which time the truck in which he was
riding left the highway at a speed in excess of 55 miles an
hour and struck a tree on the right passenger side.
A Okay.
Q Can you assume that. Also, would you please
also assume that as a result of that impact that Paul
suffered the following injuries: One, abrasions and
lacerations to his mid-forehead, abrasions and contusions to
his right shoulder, abrasions and contusions to his right
upp~r femur, fractures of his right inferior ramus pubic and
fractures to his superior right ramus pubic, also a fracture
to his left pelvis and a fracture to his sacrum.
A Okay.
Q Make those assumptions. And also I'd like you
to assume that Paul spent ten days in the hospital in
recovery after the accident at which time he was sent home,
stayed in a hospital bed on the first floor of his home.
A All right.
Q I'd also like you to assume that following his
recovery, as soon as he could begin to walk utilizing
crutches or a walker, that he began to experience pain in
his right upper hip area.
A Okay.
Q Now, did you see Paul prior to him returning
to work?
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I would have -- either I or my partner would
have had to see him prior to his return to work.
Q
And if you recall, what was his condition at
that time?
A
It would help me if I could refer to my
notes.
MR. GEDULDIG: I just happen to have a packet
of your not~s there.
THE WITNESS, That's a help.
MR. BUCKLEY: You beat me to it, Steve.
THE WITNESS: That's good.
MR. GEDULDIG, Do you want to mark those as
Exhibit 1 in general?
(Office notes produced and marked as Daniels
Exhibit No.1.)
THE WITNESS: It looks like Dr, Dell saw him
in August of '85 (sic) and the first time that I would have
seen him before his return to work was the 1st of September
1995.
BY MR. BUCKLEY:
Q And what was his general condition as far as
his pelvis at that time?
A What I can say is that the physical exam was
1 imited to a brief review of what happened to him, an
examination of his manne r of walking, which I described as
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limping, and felt at the time that he was really not yet
ready to be able to return to work.
Q
And I note in your record you state that he
was walking and has significant pain.
A
That I S correct.
Q
Was that pain while he was walking, is that
what you mean there?
A
My notes say that he was walking and working
at home with significant pain.
Q
And when did he return to work on a part-time
basis?
A
It looks like he would have returned to work
sometime between the 1st of September and the 15th of
September, and I'm not sure exactly of the date.
(Indicat ing . )
THE WITNESS: It looks like the 5th is when
work restrictions began. Thanks.
MR. GEDULDIG: Sure.
BY MR. BUCKLEY:
Q
And he came back to work working a few hours a
day?
A
He was restricted by me to four hour days.
And how did he do when he first came back?
Q
A
I can only tell you what my notes say, which
is that he was tolerating the work environment, that about
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half of the time was sitting at a computer, was having by my
notes pain when he was walking. The notes say that he went
up to the tank. The tank is a location remQte from where he
normally would be working and therefore would involve
walking a longer distance and that that caused him more
discomfort.
Q
A
And I believe he was seen again in September?
I saw him on the 15th and Dr. Dell saw him on
the 22od.
Q
And how was he doing then?
A
Dr. Dell's notes say much the same, continuing
to work at the computer.
Q
Now, Doctor, given the facts that I had asked
you to assume, would this be normal?
A
I think that it's normal, yes.
And, again, you saw him in October of '95.
Q
A
Yes, sir.
Q
Was he still complaining to you about pain?
My notes say that at that time he was having
A
minimal pain, less pain.
Q
And it also mentions that he had managed well
vn a hunting trip.
A
Yes, sir. It says managed hunting trip.
And was this something that you and Paul had
Q
discussed?
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A
I'm sure we must have talked about it. That's
Paul's nature to talk about things anyway. And if I put it
in the notes, he would have discussed it with me to some
degree.
Q
Do you recall him discussing it with you prior
to him leaving for his trip?
A
I think it's very likely that he might have
told me that, but my notes don't reflect that and I don't
have any independent recollection of doing that with him.
o
Would you have advised him not to take such a
hunting trip?
A
That's probably easier to say in retrospect,
but, no, I don't think there was any reason why he shouldn't
have done that, but typical conversation would probably have
included discussing what are appropriate and inappropriate
activities. Again, it's beyond my responsibilities with PPG
to tell him what he should or shouldn't do outside of the
workplace.
Q
Now, Doctor, over the next two years, how
often have you seen Paul?
A
I think the visits probably would have been
somewhere in excess of twice a year and probably less than
five times a year.
Q
And during that time, can you tell the jury
how Paul has been physically?
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A He's been working full time with the except ion
of a period I guess associated with some low back complaints
and a problem related to his low back. In my experience,
Paul tends not to be a complainer. He came for scheduled
visits and he generally does his job and unless there's some
specific difficulty he just does it.
Q Now, if Paul was complaining that he had
problems to someone else in the plant that his hip was
bothering him or if he was complaining to his family, would
that mean that he didn't necessarily have it if he didn't
complain to yoU?
A That's sort of a rhetorical question, but the
answer is if he didn't tell me that doesn't mean he didn't
have it.
Q Now, I note in the records that Paul did have
a disc problem --
A Yes, sir.
Q -- in the back.
A Um-hum.
Q And are you aware that he had taken off
approximately five months from work?
A That would be probably in another part of his
PPG record, but, yes, I'm aware that he was away from work
for that.
Q
And that he subsequently was able to return to
,t
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work?
A
Yea, sir.
Q
And is he back to full time?
A
Yes, sir.
Q
And do you know what condition his hip is in
at the present time as far as his work?
A
Without current notes to refer to, I can't
speak with, you know, a hundred percent assurance. I know
that I've seen Paul within about the last four months. He
still has a modest limp and I know that he has restricted
his out-of-work activities simply because he's too
uncomfortable or too tired at the end of his workday to be
able to do the farming-related activities that he normally
used to do.
Q
And what do you attribute his problem to based
on a reasonable degree of medical certainty?
A
I don't think there's much question that the
chronic back and hip pain is something that has occurred
since his accident and is appropriately attributed to his
accident.
Q
What about his neck pain that he has mentioned
in his reports as well?
A
I gUess I -- the best way I can anawer that is
to say that because my primary responsibility is, to decide
whether someone has an illness or injury that would preclude
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their effective or safe employment, I don't always try and
invest igate the causat i va relat ionship, for instance, the
accident and his neck pain. So my notes don't reflect
whether the neck pain is said to be related to his accident
or not. That's the best I can offer.
MR. BUCKLEY: Thank you very much, Doctor.
THE WITNESS; Sure.
CROSS-EXAMINATION
BY MR. GEDULDIGI
Q Doctor, thank you. That was very fair of you,
that testimony. I have a couple follow-up for you. Is it
your testimony, so I understand correctly, that you do not
have an opinion whether the neck problems are related to the
accident?
A From the notes that I have in front of me, I
have no way of making a judgment.
Q And that's all you have to rely on. You
didn't see Dr. Hamsher's records? Dr. Hamsher treated him
for his pelvis.
A I woul.d typically receive information from the
physician to support return to work recommendations. Often
times that includes a summary of the care that's given.
Those are not part of this record. I don't know whether
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they would be found elsewhere in his PPG records.
Q You don't recall - -
A No, sir.
Q - - anything off the top of your head?
Basically, if I understand correctly, what you recall is
what you've read from your notes in front of you?
A
Well, that's a five -- almost five year period
so
Q Sure.
A -- that's correct.
Q Sure. With respect to the low back problem --
A Um-hum.
Q -- is it your opinion that the low back
problem he had at the end of 1997 for which he had surgery
early in 1998 which took him out of work for five months is
related to this accident?
A I have no way of knowing that, again, for the
same reasons we talked about.
Q And with regard to his ongoing hip complaints,
do you have an opinion whether that's related to the
accident?
A To the degree that those complaints started or
that I was aware of them when he attempted to return to work
and had not been a problem before his car accident, I would
presume that they are related to his accident, but that's a
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presumption, not a fact.
Q So you can't say that to a reasonable degree
of medical certainty?
A I had no reason to have pursued it in that
fashion.
MR. GEDULDIG. Tbat's all the questions I
have. Thank you.
MR. BUCKLEY~ One follow-up.
REDIRECT EXAMINATION
BY MR. BUCKLEY:
o Doctor, the question that Mr. Geduldig asked
you was whether you believe based on a reasonable degree of
medical certainty that Mr. Monismith's hip problem was
related to his accident and your answer to that was?
A My answer is that I know Paul did not have
that prior to his accident. I koow that that was a
complaint when he returned to work following the accident
and it has been an ongoing complaint since that time.
I think that's a reasonable basis on which to
assume the,t it is. But not being the diagnosing or treating
physician, but making judgments based on his work
suitability, it's surely not something that I would have
pursued like I would for a patient I'm primarily managing.
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MR. BUCKLEY: Thank you.
MR. GBDULDIG. That I s all I have, thanks.
THE VIDEO OPERATOR. This deposition is now
4 concluded. The time is 5:38.
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IThe deposition was concluded at 5138 p.m.)
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19
COUNTY OF DAUPHIN
COMMONWEALTH OF PENNSYLVANIJI.
SS
I, Teresa K. Bear, Reporter-Notary Public,
authorized to administer oaths within and for the
Commonwealth of Pennsylvania and take depositions in the
trial of causes, do hereby certify that the foregoing is the
testimony of MICHAEL O. DANIELS, M.D.
I further certify that before the taking of
said deposition, the witness was duly sworn; that the
questions and answers were taken down stenographically by
the said Teresa K. Bear, a Reporter-Notary Public, approved
and agreed to, and aft~rwards reduced to typewriting under
the direction of the said Reporter.
r further certify that the proceedings and
evidence are contained fully and accurately to the best of
my ability in the notes taken by me on the within
deposition, and that this copy is a correct transcript of
the same.
In testimony whereof, I have hereunto
subscribed my hand this 14th day of September, 1999.
I.L\~""- \<( ~v~
Teresa K. Bear, ep ter
Notary Public
My commission expires
on April 13, 2004
GEIGER & LORIA RF.PORTING SERVICE
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PPG IN.. .STRIES MEDICAL EVAWATJON . _.,M
Work 1.I.phon. number
~p' 01 .xamlnlllon P"plec.m.nl
(mork on.. or nil In blink) 0
Pul . m.rk In 80x A or 8, .nd II 8 com pl... lurth..
o A B...d on Ihe Inlormallon avallabl. 10 nlf Ills my opinion Ihalthls Individual does nol have a detecled medlcsl condlllon
or IIndlng which would plac. Ihls Individual or Olh.rs at Increased risk of mlllll.llmpllrm.nl 01 h.a1lh lrom anllclpaled
or pot.nllll occupallonal 'Mpotures Ot Ictlvlll.s,
,;t! 8 Bued on Ih. Inlormatlon av.llabl. 10 m. It Is my oplnlun Ihel Ihls Individual has I d.,ected m.dlcal condlllon(s) or
IIndlng(s" (Check .pproprlal. slellm.nl., compl.t. all appllcabl. responl.s, and IIn.through _d. which ~o nol apply):
o Which would plac. Ihls Individual or others ., Increaled risk 01 material Impalrm.nl 01 heallh Irom anllclpaled or
pot.ntlal occupallonal actlvlll'l or 'Mposures 10 asb.llos, lremolll., anlhophylll., scllnolll., b.nz.n., vinyl chlorld.,
lormald.hyd., 'Ihyl.n. oold., hazardous waltea, or other chemical or physical ag.nts which may b. aggrevaled by
anticipated occupallonal .Mposurel or aetlvlll.s,
ill Which may Int.r/er. wllh ..I. and/or .Hecllv. performance 01 antlclpaled aetlvlll.s,
~ Which needs lollow,up (Including chang.s which may b. within .Mptcted limits, bul which n"".rth.leas represent
dlHerences from what would b. eMptctlld for the Individual.)
o Olher - eMplaln:
Periodic
o
PIg. 1
MIDICAL RICORD COPY
Social Security No, aCt). 3, - / d 0 ~
First nlm., Inlllll ftw..C # ~ J2,~
S'M -1'hA1tt
Job Aaelgnm.nl J:l...n..........
Sup.I1I11I<lr ;/.Je..k,-
Other O(.pec/!y) Ii- , " ' I
nrw.~ '?I.WA
,
Tb~aY'1 date
LIS' name
Oall of birth
BUlln.ulocatlon
Q,/9-;
~~~
On Ih. bull 01 Ihe above, I recomm.nd (mark Ih. approprlal. bOM or complet. III appllcabl. responsel,)
o No rellrletlons In Ih. currenVproposed work aaalgnm.nl,
~ Th. following reslrlctlonl or IImltallons are recomm d ' J ~
g) Llmlled 'Mposure(I), specifically: /1-0 . .) ~ 41 /.A.AJ ~- ~
o Prollctlv. measures, speclllcslly: ,Ii ....1,1 -L.:L :-::.:;~
o Theae recomm.ndellonllT' perman.nt ,/ "....t:1'11l.s'ff.r.;m .ndatlO;;;;;l;';';;;r;';', and will
la Medical follow.up II Indlcat.d: "f ' . eMpire
.
R"plrtlor o.rtlllolllon: IRequlred I a resplralor will b. worn,) Bas.d on the Information available to m. Ills my opinion thai
Ihls Individual has no m.dlcal condlllon or IIndln9 which may Inter/." wllh sale or .Heetlve p.rtormen~ while w.arlng any of
th. following relplralors: (Check only thole /or which use Is .pprowd,)
o Olspolabl. paper respirator 0 Self-conlalned breathing apparalus
o Negatlv. preaaur. half.muk 0 Self.encapsulated sull wilh supplied air
o Positive prel8ure resplralOt 0 Olher (.pecl!y):
o The Individual has a medical condlllon or lindlng which may Inlerfe" with sal. or .Heetlve p.r/ormanee whll. wearing cartaln
resplralory prot.ctlon devices, lor which Ihe following restrletlons ar. recomm.nded:
DOT C.rtlllo.llon (Compl.1I only II required lor Iransport drlv.rs or operatora of hazardous mobll. equlpm.nt)
o Mells minimum physical requlrem.nts for Iransport drlv.rs as defined by O.partm.nt 01 lransporlallon.
o 0081 nOI milt minimum physlcat requlrem.nts 01 OOT rules for ~Insport drivers.
o Further medical Information Is n.eded b.fore final medical recomm~. oHer.d.
~
Physician's Ilgnalure
Physlclan's prlnl.d name
9/9(-
Dafe ...
fHE SEcnON BELOW IS NOT INCWOEO WlfH fHE COPY GOING ro SUPERVISION
I h.ve advised Ih. Individual 01 Ih. following d.rected m.dlcal dlagnoSlI and/or Ilgnlllcant flndlng(s), end I h.v. dlscul8.d the
polslbl. n.ed lor follow up medical I".nllon by hllllher personal phy1IClan.
0;
Physlclan'S prlnled name
Physlclan's ~Ignalure
Oal.
~''''''.II' .......,
&. r,rN-
'Al1L ~1Il~ft
'-0 9-15-95
372
4 Iboa NO" DAYB "
110 lID IIIIDIla 'BI 0 LIrr. GR.IA?IIR 20 LBS
, '1' PDIODICALLY
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PPG INL .STRIES MEDICAL EVAWATION . ."... Plga I
~. MEDICAL RECORD COPY
Today's dale
Last nama
Oale 01 birth
BUSIness locallon
Work lelephone number
\8 - ~\ -'is
~\'SrvU,~
Social Securlly No,
First name, Inlllel
Se.
Job Asslgnmenl
Supervltlf)r
~~~~
~1'Y\~_clv
~pe 01 eumlnallon Preplacemenl
(marit one. /If nil In blank) 0
Put a mark In 808 A 0' 8, and II B complela lurlhe,
o A Baaad on Ihe Informallon avallabla 10 ma Ills my opinion Ihatlhls Individual does nol have a detected medical condlllon
or finding which WOUld place thla Individual or olhars at Increased risk 01 materlallmpaJrmantlll haalth from anllclpaled
/ or potanllaJ occupallonal a.posuras or ac1lvllles.
or 8 Bued on the Informallon available to me II Is my opinion Ihat this Individual hes a detected medical condlllon(s) or
flndlng(s), ICheck &pptOprlale statemanla, complete all applicable rssponses, and line through WOlds which do nol apply):
o Whloh would place this Individual or olhers at Increued risk of material Impalrmenl 01 heallh lrom enllclpaled or
polenflaJ occupallonal ac1lvllles or e.posures to asbeslos, tremollle, anthophyllle, ac1lnollle, benzene. vinyl chloride.
formaldehyde, ethylane oxide, hazardous wastes. or olher chemical or physical agenla which may be aggravated by
anllclpeled occupallonal e.posures or acllvilles,
o Which may Inlerfere wllh sale and/or elfec1lve performance of anllclpated acllvllles,
o Which needs follow.up llncludlng changes which may be wllhln expected IImlla, but which nevertheless represent
dlllerences lrom whel would be e.pec1ed lor the IndlvlduaJ.) /,... ~ <.. ~ "7
o Olher-explaln: H~ itI'~FA.~%~,<.dO~ ~J~.r:r6.~
On Ihe buls of the above, I recomm d (mark the appropriate box or complete all applicable responses.), 'tJ
Q No restrlc1lons In the current/proposed work ualgnmenJ. ~ JiI""
~ The following restrlc1lons or IImllellons are raco~~de~ I .:f-J-,.., ""TV;"" ?-~ A--:. . -
o Llmlled exposure(s), speclllcally: / , ., . ~ -.. Jr- e.. / I".. t), '7 - tv' rt--I~ ~
o Protective meUIJreS, speclllcally: f1'l I ~~
o These recommendallons are permanenl t1-b ' / , Ie. [:j7. The.. recommlllndallons 8/e temporary, end will
Medical follow. up Is Indicated', expire /5'..P ~ II,! r -
Ra.plrator carllflcallon: (Required II a respirator will be worn.) Based on tha Information available 10 ma It is my opinion that
thla Individual haa no medical condlllon or finding which may Inlerfere wllh sale or ellecllve perform8l]l:e whlll!W9arlnll..!."~f
Iha fallowing respt/alora: (Check only thou /or which use Is epprCMId.) /t.A-- /0$ , ",,~- :)
o Olsposable paper resplralor 0 Sell-conlalned brealhlng apparalus ~
o Nagellve preuure half,muk 0 Sell.encapsulated sull wllh supplied elr ,111 fillV' tC ~
o F'oslllve pressure reaplrator 0 Olher (specify):
o The Individual has a medical condlllon or finding which may Interlere with safe or e"ecllve performance while we8/lng certain
respiratory prolectlon devices, for which the following. r,strlcllons e recommended: d1. ~ n:.s---
,1/ ,s..LL ~ ",v" ,r/'Ff . S " - ,~ ___ 'T.
DOT Cer1l1lc."on (Complete only II required far transport drivers or operalors of hazardous mobile eqUipment)
o Meela minimum physical requlremenla for Iransport drivers as defined by Oepartment 01 l1'ansportallon.
o Does nol meat minimum physical requirements of oar rules for Iransport drivers,
o Further medlcallnlormallon Is needed before final mer.llcal recommendallons can be ollered,
Periodic
o
s
'f"~
-
~
/ r/. R" .JH/5
Physician's printed name
H2J
'fJl<.ff~ ~
F'f1yslclan's signature
, pjJl/1.f
Oele
TlfE SECTlOr! OELOW IS NOT INCWOEO WITH TliE COPY GOING TO SUPERVISION
I hava advised the Individual of the fallowing detecled medical diagnoses andlar significant "ndlng(s), and I have dlscuaaed the
poaalbla need for follow up medical allenlion by his/her personal physician.
....
.
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ORIGINAL
..
<)
PAUL S. MONISM['l'It, [ll, AND
PAMEI,A A. MONISMI'l'II,
PLAIN'l'[FF
[N 'rill,; COlJH'l' OF COMMON p[,EAS
CUMBL':HLAND COUNTY, pENNSYLVAN [
v
NO. :1'100 C[VIL 1996
C I V [L AC'[' [ON LAW
PAUL S. MONISMI'l'It, ~JR.,
DEf'ENOANT
JUHY TH[AL OEMANDED
VIDEO DEPOSITION OF: JOliN C. RODGERS, M.D.
'rAKEN BY: DEFENDAN'l'
BEFORE: KAREN C. ALBR I GII'r , RPR
NOTARY PUBLIC
," ,
DATE: SEPTEMBER 13, 1999, 4:32 P.M.
C) PLACE: ONE DUNWOODY DRIVE
CARLISLE, PENNSYLVANIA
APPEARANCES:
JOSEPH D. BUCKLEY, ESQUIRE
FOR- PLAIN'l'IFFS
THOMAS, TIIOMAS & IIAFER, LLP
BY: STEPHEN E. GEDULDIG, ESQUIRE
FOR -. DEFENDAN'l'
ALSO PRESEN'l':
JOE VENGOECHEA, VIDEOGRAPHER
PAUL MONI SMI'l'lI, [[ [
PAMELA MONISMITf!
'.
'V
WHO l.ingbtown Road . Sltit~ Illl · tbrrishurg, I'A 17110
717.)40,0220' fax 717.)40,0221 · LlIl(N~r 717,\9\.1101
2
0 WI'rNESSES
2 NAME: F.:XAMINA'r rON
3 .JOIiN C. RODGE:RS
4 BY: MR. GF.DULDrG 3, 15
5 BY: MR. BUCKl,!;:Y 12, 16
6
7
8
9
10
11 EXHIBITS
12 DR. RODGERS EXHIBIT NO. PRODUCED AND MARKED
0 13 1. MEDICAL RECORDS 3
14
15
16
17
18
19
20
21
22 , I
23
24
25 ,
,
0
__'_'__'.4___'_'~_'..___..__'~_.._.'.~._".'----~~...-..- .
J
S't'lI'ULA't'toN
It is hereby :;tlpu lnted by find botwoon coun:;el
for the ro:;pective parties thnt reading, :;Igning, sealing,
certification and filing are heroby waived, and that all
objection:; except as to tho form of the qu.stlon are
reserved to the time of trial.
(Medical Records, 12 pages, produced and marked
Dr. Rodgers Deposition Exhibit No.1.)
JOHN C, RODGERS, M.D., called as a witness,
being duly sworn, testified as follows:
EXAMINATION
BY MR. GEDULDIG:
Q Good afternoon, Doctor.
A Hi.
Q Thank you for accommodating us with your busy
schedule. As I think you're aware, this case is presently
in trial, and we're video taping your deposition with your
permission, is that correct?
A That's correct.
? With the understanding that it will be used at
trial so the jury can see your testimony. Is that okay?
A Yes.
Q Doctor, Attorney Buckley has agreed to
5
A No. other than at the time of that first
,
visit, that was January Bth, 199B visit, part of tho
history was that he had been involved in an automobile
accident, he was a restralned passenger and sustalnod a
fractured pelvis and had developed srnne neck problems.
Q But the problem he came to SOo you for, the low
back, your understandln'l from speaklnq with him was that
that came on suddenly and it came on about soven weeks
before the first time you saw him January of 1996?
A Yes.
Q Did you try to twat him conservatlvely, in
other words, without doing surgery?
A We started off wllh a series of epidural
steroid injections, which Is a conservative treatment for
a herniated disc, which Is what I was suspecting. He had
an MRI, which confirmed that diagnosis as well. And also
he was also started at physical therapy for a program of
flexion exercises and modalities to help control pain
along with the epiduraL steroid series.
Q Ultimately you had to do surgery on him because
those didn't work?
^ That's correct.
Q His prinCiple complaint would be paIn in his
back? This is before the surgery.
A Dofore the surgery he had pain in his back, and
(,
also had dovelopod
ll'l. III I! /H!Il. On hili .)ilnlHHY 20th,
'96 viliit, he hnd conUrIlwd with pdn!lil.hllliiilli, which IIro
numbness and tinql1nq ilkll you wouid h!I!1 11: your fool.
fell asleep, or 80melhinq tilw lhilt. 'l'hal.'s whal iI
paresthesia is. HI! had it on his Il'll. sidl!, on his loft
leg. 'l'hat was his lIIi1in l!xtrl!IIII,l.y ns filr as lwinq involved
with that. On the .Januilf'y 20th, ''lll visit, he also
reports some occasiondl eplso(](/,,; of linglinq on the right
leg, but sUll It was mdinly left. leg, leftnsided
symptoms.
Q
23, 19911?
A
Q
A
Q
A
Q
A
And ulUmill<!ly did surqery, [ see, on January
'l'hat's correct.
Was that at Carlisle Hospital?
'l'hat's corror:l..
Was hll hO/lp Ilillll.l!lj'?
Yes.
How milny dilY/l? r~l 11I0 help you out here.
I don't havI' UlilL. IJsually i1bout two or three
days. Hiqht? Yoah.
Q Your rllcords Indlcille it WilS th[(!G days, does
that sound reilsonah I I'?
A Sorry, [ don't hilvo all t.hat stuff in front of
me, so I don't have the exact dato.
Q Not a problem.
7
A nuL usually IL would have been by tho socond or
third postoperaLlvD day going home.
Q '1'0 speed thlnqH up, you BOW him again on
February 2nd'?
A 'I'hat's c;orr(!ct.
Q And on Man:h 3rd'?
A 'l'tliJt' s cor'n!ct. .
Q And on Apr'll 9Lh, 19907
A 'l'hat's cor'recL.
Q Was he havinq any ongoinq problems with regard
to his back and his leq af t('r Lhe surl/ery"?
A fie had a fairly Lyplcal post'operative course
as far as still havlnq some pain In the back, and problems
like that. fie had some numbness In his lefL leq that was
remaining. And by the 9th, April 9th, sLIIl had some
numbness In the left fooL, whIch wus worse by Lhe end of
the day. It was a little bIt bottor In tho morning, but
the more he was up and on IL, tho more sympLoms he had.
At that poinL we had dIscussed ubout golnq buck to some
type of limited duty work laLer on In the month.
Q And, Doctor, I think the records will reflect
that he wont back Lo work some tlmo the end of April of
1998.
A
Q
Okay.
Would that be consistent with what you would
~
8
1
expect from Homubody who haH that kind of injury and that
2 kind of surgery, to be off worl~ for four or fiVll months'?
3
4
A
Q
5 whether the numbness and the occasionaL tingling and pain
Did you telL him whaL to llxpecL in terms of
Yes.
6 he had in the left leg ~-
7
A
6 the same.
9
Q
10 problem was gone?
'rhat's corn!ct.
11
A
....
,~J
12
13
A
Q
14
Q
15
16
A
Q
17
A
18
Q
Basically thaL it could either improve or stay
But the pain he had in his leg from the back
That means It was a successful surgery?
'rhat's correct.
After April 9, 1998, did he come back to you?
I sow him again on December 10th.
And that would be about eight months later?
Yns.
At any time belore he come bock to you on
19 December 10, 1998, did he complain to you of any problems
20 with his right hip, any pain In his right hip, or anything
21 like that'?
22
23
A
No.
24 because It's important to keep accurate records and put
Q
If he had, you wouLd have documented that,
25 down all of his complaints?
~
9
1\ [ wouLd hope ltwt [ would ha'/E! donE! that. [
don't know if I dld that or not.
Q [n any l!vl!nL, on Oecl!mbE!r 10, 1998, was he
sU 11 complalnin'l of lnl<!rmitl<!nt left foot and leg pain'~
1\ Jle /lULl had numbn<!/ls in the foot.
Q L'm read itICj from your records, December 10,
1998. 'l'hat's why [ brou'lht. thi/l alon'l.
A Okay, now 1 have! that.
Q Para'lraph 1, I!nd of the line, intermittent left
foot and leg pain?
A Make /lurE! we're on the same page.
Q Sure.
1\ Yes, [ 'lot you.
Q You indicate in there he st.ates that after he
has been on his leg for a while it feels like it is
swollen, especially walkin'l on concrete at --
A Should be work. It say walk. That's a typo.
Q ThE!n for the first t.ime we see a complaint of
right hip pain?
1\ That.'s correct.
Q You say In there secondary to an antalgic gait
on the left. side. What does t.hat mean1
A 1\n antalglc <jalt Is a 'lait that someone would
have if they had a painful or an affected extremity that
they were tryin'l to unweight. Basically somebody who is
"""'"
"..)
4
5
6
7
6
9
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12
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21
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23
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25
.-..)
10
limping. 'l'hey're Limping, In Paul's case, on t.he left.
2 side, that would be an antalglc gait on the left side. So
3 you're trying to get off that left foot and back on the
right foot as quickly as you can.
Q Was he favoring his left side?
A Yes.
Q And putting more weight on his right side?
A 'l'hat's correct.
Q [n your experience, whatever the cause, if
somebody favors one side it means thuy put more wait on
the other side, do they tend to develop more aches and
pains, and so forth, on the side that they're compensating
on?
A 'l'he side --
Q
A
That they're compensating on?
1'he side -,-
That is taking the weight?
The side that is taking the weight, yes, you
Q
A
can do tha t .
Q Is that what you felt was going on here?
A Yes, I did, at that time.
Q With the type of problems that he was having
eight months after you last saw him, would you expect
those things to give him lingering problems in the future?
A Could you restate that, please?
l'l
1
2
3
4
5
6
7
8
9
10
1 1
1 2
, ) 1 3
...,,,,
14
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25
~
________.___.__..___.._____ ~____....._.._.__.___._._.__u+___.__.. _.________.. ... ._____. _. _.____~____._____
11
Q Yeah. Do you expect that intermittent numbness
and pain in the left foot and leg to give him intermittent
problems into the f.uture?
A I t can.
Q With somebody who has a back in1ury and surgery
like that, is it reasonable to put some restrictions on
their activities?
A As far as lifting and things like that.
Q Yes.
A Yes, to a -- certainly initially
post-operatively you want to have somebody restrict their
lifting activities, which is what we did. And then after
a while, the patient is able to progress to what they can
tolerate, and those restrictions are basically on what the
patient can tolerate at that point.
Q Do you want a patient of yours who had this
kind of surgery to be lifting on a regular basis anything
over, say, 50 pounds?
A It depends on when after surgery you're talking
about.
Q How about now, if the surgery you did was in
January of 1998?
A If the patient can tolerate lifting like that,
then they are -- then they could do it.
MR. GEDULDIG: Cross examine.
,~
--------- ---,--.--_.----~-------_._._.._.-.-
1 2
EXAM I NA'l' ION
2 BY MR. BUCKLEY:
3
Thank you. Hi, Doctor. Doctor, are you aware
Q
4 of the type of accident, motor vehicle accident, in which
5 Paul was involved?
6
7
8
9
other than what I stated in the history.
A
Q
I'd like you to assume some facts.
A
Okay.
Q
Let's assume that Paul was in a car, in the
10 passenger seat traveling in excess of 55 miles an hour.
11 The car left the highway and struck a tree on the
12 passenger door side.
,..-....
\~\~)
13
14
Okay.
A
Q
I'd also like you to assume the fact that as a
15 result of that, Paul suffered a contusion to his right
16 shoulder, abrasions to his right shoulder, contusion to
17 his right upper hip, and a fracture of his pelvis in three
18 places, two on the right side, one on the left, as well as
19 a fracture to the sacrum.
20
21
22
23
24
25
'...)
A Okay.
Q I'd also like you to assume that once he had
his fractures healed, that he then began to feel pain in
his right upper hip. He also felt that he had a ball-size
knot within the upper femur area. Okay?
A
Okay.
rl
2
3
4
5
6
7
6
9
10
11
1 2
) 13
..,-
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15
16
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22
23
24
25
~
1 3
Q I'd also like you to assume tho fact that once
he began walking on his feet after he used a walker, that
he began feeling pain inside his right hip o~ea.
Inte~nally, I mean approximately two Inches down f~om the
mid thigh and two inches in f~om the sldo.
A Oka y .
Q I would like you to assume the fact that ove~
the course of through 1995, that he complained of pain In
his hip when walking, climbing steps, et cetera. Also, I
would like you to assume that through 1996, that he made
complaints to his famiiy, to his worke~s, and
intermittently to his docto~s, that he continued to have
this pain.
Your opinion earlle~ was that he suffered from
a pain in his right hip, which was called by anyl --
A Antalgic gait.
Q Antalgic gait. Assuming those facts r told
you, would that chango your opinion at all as to the cause
of that pain?
A If he had continued to have pain fr'om tho
start, like you're describing, then I think you can draw a
correlation to the fact that the pain he'S experiencing is
related to that accident.
[f there is a period, an
interval of time that the~e's, you know, no reported pain
or no symptoms like that, thon that would be a little bit
.']
2
3
4
5
6
7
B
9
10
11
14
harder to draw that conclusion. But giv.n those
circumstances, yeah, you could certainly have that from
that accident.
Q What would be your diagnosis of that? Would it
still by synovitis?
A Yes, I still think it's synovitis.
Q Would that be a chronic synovitis?
A It can be, yes.
Q Is trauma a cause of chronic synovitis?
A Yes.
12 had been in motor vehicle accidents and have had multiple
Q
NOW, Doctor, have you dealt with patients who
'oj
13
14
1 5
traumas, multiple fractures?
A
Q
Yes.
Have you had patients who have had multiple
16 fractures of the hip area?
17
1 B
19
20
21
22
23
24
25
'....;
A
Yes.
Q What has your experience been with the pain
that people have? By pain, I'm asking if someone has pain
in the fractured area, is it the case that after that pain
dwindles they feel pain elsewher.e in their body?
A I don't quite understand your question.
Q Simple case, if I have a problem in my toe, and
you hit my hand with a hammer, I don't generally feel the
toe pain any more, I feel the current and the most -~
'J
2
3
4
5
6
7
8
9
10
11
12
.,") 1 3
14
15
16
17
18
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20
21
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,....)
15
A So you're saying you're distracted by some
other greater pain.
Q Greater pain, yes. Have you seen that in
patients that you've had?
A People can have certain pains that are
distracting them from other areas. You get rid of
especially in a multiple trauma patient, that sort of
thing, they huve one particuLar injury that may be causing
them the greatest deal of pain, and once that's dealt with
and that pain is no longer an issue, then they can
certainly feel pain in other areas that they would have
already had there, maybe not paying as much attention to
it.
Q So that would be a normal thing?
A If I understand your question correctly, yeah.
MR. BUCKLEY: t have no other questions.
EXAMINA'rION
BY MR. GEDULDIG:
Q Doctor, I just want to make sure one thing you
said. You said -- correct me if I'm wrong -- it's tough
to draw a conclusion between hip pain and the accident If
there's an interval or intervals when thero ure no
reported pain symptoms in the hip?
A An interval. An interval of lime. If I woro
involved in a car accident five years illlO /lnd I didn't,
1
~)
...)
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3
4
5
6
7
8
9
10
11
12
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14
15
16
1 7
18
19
20
21
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25
16
have pain for a coupie years, then all of the sudden I
started having pain, I think sometimes that can -- that
can be a little difficult to draw a conclusion. But if
you continue to have pain after the you know, after
that accident, even on an intermittent basis but if it was
some sort of a regular source of reoccuring kind of pain,
then I think you can probably draw that conclusion.
Q What happens if somebody has pain like that,
they return to work, then they go for a year, year and a
half without any reported complaints of hip pain, then the
pain is first documented again after they had this back
surgery where they get that limp. What about then?
A Well, I mean, if -- again, that goes back to
the issue of whether or not there is an interval of time
at which there hasn't been any. I assume you're talking
about in Paul's case, you know, when I had seen him for
the back problem, then he was having the hip pain
afterwards, and that's what I was basing my assessment on
at that time was that, you know, without a continuum of
pain from the time of accident, that's why I'm saying that
I thought it was from the antalgic gait, from that
problem. Does that answer your question?
MR. GEDULDIG: It does. Thank you.
EXAMINATION
BY MR. BUCKLEY;
,-~
2
3
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5
6
7
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9
10
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14
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17
Q Doctor, Mr. G~duldlq hus boen Huytnq reported
pain. By that I tuke It that hu nmuns reported to a
doctor. Is it the cuse thHt a purson hus to r~port his
pain to a doctor rather than to his fumlly members or his
friends, if he doesn't report, he doesn't havu the pain'?
A No, ubsolutely know what you're saying.
No. Just because he didn't report it to the doctor
doesn't mean that he doesn't huve the pain. What I'm
basing what I'm saying on Is the medical record which I
have to go on, but that doesn't mean that he didn't have
pain in between. That's what I have to base my decision
on. If he's reporting pain to his family, to any other
physicians or anyone else, then that obviously -- that's
equally as valid.
MR. BUCKLEY: Thank you.
MR. GEDULDIG: Thanks, Doctor.
VIDEOGRAPHER: This video taped deposition of
Dr. Rodgers is now concluded. The time of day is 4:53
p.m. .
C)
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10111 H 1'1 '11 1112 corn:ctly III 151S
acute III 4 IH 421 -c- correlation III 1322
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12111 25 3 S affccted II I 92>l lJ .111 IH 3 IS 15 IS II!
affiliated III IS 23 COUNTY III 12
13111 113 4 III
caption III IS 1.1 IS I
13th III IS22 af"'rnoon III .11<
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15111 24
IH III 1"5 coursc III 7.12 IlS
16111 2S agalnl'l Carlislc III I IS COURTIII 1.1
1995111 45 IJK 73 S 15 411 I! 1,\
11.11 lId 3 Cross III II 25
1996111 I 5 13111 ago III Iq< casCIII 1 IS 1111 CUM8ERLAND III
1997111 14211 1423 II! II!
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19981111 ,IS 52 J7J
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~--~_._-----.__._-
1999111 I 13 IH 22 answcr III II. 22 In 15 II 0111 I 17
answcrs III IM,9 certification III .14 date 111 11.1 4:12
_0______--_..._-..-----
-2- antalgic III '121 ccrtificd II I 4S 1124
---~--_.__._..-._---- '12.1 102 13 II! certifr 1'1 days III I!:IS 1!:211
20th III I! I 1!7 1.1 17 11!21 Ih5 IS7
IS 14 IS 1'1 I! 21
23111 I! 12 anylrll IS.I.
13.15 cetcralll 139 dcallll IS'I
2ndlll H APPEARANCES III changclll131S dcaltlll 14:11 IS'I
------.. -------- I It, chroniclll147 Dccemberl'l 425
___~3-=----__. Afrill'l 149
7S 7.15 circumstanccs III S 15 S: 1'1 '1:3
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3rdlll 711 I)EFENDANTIII I.S
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4:32111 1.13 assume 1'1 12 7 129 compensating III 1012 3.'1 ll'l 17:17
4:53111 171S 1214 1221 III 10:15 ISS IS:12 IS: 19
13.7 13: III 11115 complain II I H.I'I dcscribing II I 13:21
--------_.-._--
-5- Assuming II I Ill7 complaincd III IlX dcvclop III III:I!
-~_.._.~-_._- attention III complaining III
5011' II.IS 1512 94 dcvcloped III 55
5511' 12.10 attorncy III )25 complaint III 523 11.1
IS 15 IS III 'I. IS diagnosis III 5:111
---- authori7.cd II I IS4 complaints 111 S25 144
-8- ---- automobilc II I 53 IllI 111,111 difficult II I 111:3
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away II I 422 conclusion 1'1 141 directly III IS:17
-9- 15.21 1113 167 disc "' 51.5
---~-----_._---.-.--
9(11 S:14 -B- concretc (I I 9:111 discusscd III 7: 19
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9thll1 7S 7:15 ball-si7.c III IUJ conservativclIl distracted (II I S: I
7: I~ baselll 5 14 distracting (I I 15.6
17.11 conscrvativcly III 5 I I
-- basing III III IS 17.9 doctor "'1 liS 3:25
-A- consistcnt (II 725 n 421 7'21
basis III I I 17 1115 constitutes (II IS 19 123 ID 14:11
ablc(ll 11:13 began 111 1222 132 continuc (II III 4 15.19 171 17:3
abrasions (I I 12:111 IJJ 174 177 17: III
absolutely (II 17:1> better (I I 7: 17 continucd 111 11.2 doctOrKIIII112
1112 lUll
accidcnt 1'1 S4 between 1'1 12 continuum (II 1111'1 documented III M:2J
124 12:4 13:23 1521 17 I I controll1l5:IS Ill: II
14:3 15:21 152~ bit III 7: 17 1.125 docsn'll'1175 17:S
.~~
,,)
HUGHES, ALBRIGHT, FOLTZ &. NATALE
717-540-0220\717-393-5101
Multi-Pagc '"
'9M - doesn't
JOliN C. RODGRS, M.D.
Index Puge I
Ie . montb.
HN C. RODaRS, M.D.
Multi-Pqc'N
7:s 178 17:1() 118 IS .\ IS 14 I Karen/ll III IS .1
110111 91 favoring II I 1115 hereunto II I IS 21 IS 2.1
~rlll 12: 12 favors "' III ill herniated III 515 keepllJ S 24
wnlll 8:2~ 134 February III 74 Iii III .1111 123 kindl'l S I S2
S9 feelinglll 1.1.1 highway III 12 II II 17 1~1l
I'I 212 .19 feels III 'III hlfl111 S 211 H 211 knotlll 1224
7:IH fcctlll 1.12 19 12 17 122J known III 4 1.\ 4 1.1
lWI'1 13:21 14:1 felllll 114 III 1.1 9 Ill5 - ---.. .....-
5:21 111:.1 111:7 14 II. 1121 112J -1.-
llVl!IIIII4 fchlll 111211 In.1 111.111 11117 ..,. ---
IYIII .1:12 ISS fcmurlll 1224 history III I .1 1211 lastllJ 1112.1
JNWOODYIII 1:14 filing III .14 hitlll 1424 I.AWIII It,
IYII, 7:20 financially II' IS 17 home III 72 Icaning II I 4 1'1
'indlcllIl 14:21 first 1'1 412 \ I hope II I 'II Icft 1"1 115 11 \
5~ 'I. IS 11111 Uospilallll f),l) 714 7:111
.. flvc III S2 411 SIl '14 '1'1
-E- 1125 11'14 922 1111 III 2
flcxion III 51S hospitalized III Ill~ 10..1 10 I 112
II 1:20 follows III ll2 hospitals III 4.111 12'1 I 12: IS
"till 8:111 111:2.1 foot 1'1 ~ .1 7 III hOUr1l1 1210 Icft-sidcdlll 119
hcrlll 8:7 94 'II 'I ill Icgllll 1111 119
cwhcre II , ilI.1 104 112 -- _.._--_.~---~--------
14:21 -I- frl} 711 7:14
rloYCCll1 18:15 foregoing II I IS:6 __.__0--___--.- SIl K:9 9:4
:16 form III .1.5 111111 II 1.24 910 'I 15 112
~111 7: 16 7:22 forth III 11112 4:1.1 liccnsed III 4'11
.9 fOUr1l1 82 important III S24 lifting 1'1 liS 1112
idural (II 5:1.1 fracture III 12:17 improvcllJ S.7 11:17 11:2.1
:19 12: 19 inches PI 1.14 1.1:5 limited III 7:20
ilOclclll1 68 fractured III 5S indicate III 1121 Iimplll 11112
lallYII) 17:14 1420 '114 limping III 10:1
ICCialIy III 9:111 fractureSI'I 12.22 indirectly "' IS: 17 10:1
1:7 14:1.1 14: III information II I 42.1 IincllI ,}:9
QUIREIII 1:17 fricndslll 175 injcctionslll 514 Iingcringlll 10:24
:20 front III 6'2.1 injury III S:' 115 LLPIII 1'19
II 13:9 future III 1ll:24 11:.1 158 longcr II I 15111
:atlll 9:3 insidclIl III low III 511
-----
ICtlll 11:24 -G- interested III IS:17 lowcrlll 4:24
:AMINA TION 1'1 _.
gait 111 ~21 9.2.1 intermittent 1'1 '1:-1
2 3:1.1 12: I 9:9 11.1 II :2 --
1:17 16:24 9:2.1 102 1.1: III 1~'5 -M-
Ill7 11121 -
Imine (II 11:25 Gcduldiglll 1:20 intermittently II I JJ:12 M.D/l1 1.9 .1: II
:cpt (II 3:5 2:4 ll4 IUS Internally III JJ.4 ISIl
:ell (I) 12:10 I~: IS 1112.1 17:1 interval 1'1 1.124 mainlll 611
:rciscI (II ~: 18 17: III 1522 1524 1~:24 March III 711
hibit III 2: 12 .1:'1 gcncrally III 14:24 111:14 markcd 1'12: 12 l8
:HIBITS(II 2: II givcnlll 14:1 18211 intervals III 1522 may III 4: 1.1 15:8
lCCt(41 8:1 8:4 gOCIlI1 111'1.1 involved 1'1 5-J mean III 4:21 9:22
):2.1 11:1 gonclIl SIO Il~ 12.5 1~:2~ 1.14 111.1.1 17:S
ICriCDCC (I I 10:9 Good III .1:15 iS8UCIII 15111 16:14 17111
1:18 greater II' 15:2 15:1 .. means 141 4:22 8:12
ICrieDcing III -J- 10 III 172
I l22 greatelt(11 15'1 --- medical 111
.. 2JJ
n:mity(11 6:6 January 111 4: IS .1:S 17'1
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-F- HAFER III 1:19 JOEIII 1.2.1 midlll III
1['1 halflll 111:10 JOUN "1 1:'1 2..1 milcSlI1 1210
12:14 1.1:1 hammer II I modaliticS(1I
1:7 1322 14:24 III IS 11 I: IS
talll 12:7 1.1: 17 hand III 14:24 1821 JOSElPU III I: 17 Monismithl1l 1:1
r1Y(11 hardcr III 14'1 JRIII 1:7 1:2 17 1-24
7:12
healed (II 1222 jury III 125 41.1 4: 14
!Ii1l()' 13:11 17:4 I:S .1:21 month III 720
7:1 help III 51S 1l:IS
---_..-_.------_._----~------ months 111 S2 S III
(II 6:11 7:1.1 hereby 1'1 J.2 .14 -K- 102.1
-----.----0_-__-0_.___.-- .'__
ex Pagc 2
IIUGJIIlS, Al.BRIGHT, FOLTZ &; NATALE
717-540-0220\717-393-5101
-
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mornmglll 7 17 I 25 ..-._.._-.-..-
most III 1425 I'aragraph III I)&} -Q- -S-
. ____ __ ..__u_
motor 1" 12:4 14 12 paresthesia III 11 j quallflcailons III 4 I Sill II I 7
MRIIII 5.111 parestheslas III ~l ~ questions PI I ~ III 4 1.1
multirlc 141 14 12 part III <2 1t\1} sacruml'112l'l
141 1415 I~ 7 particular III I<S quickly III 42 Samlll 414
--.---.------..-. ...---- - particSl'1 .1.1 IK I< 104 saWI'1 4 12 1'1
_________:..N: n'_' passcnger III q quite III 1422 71 S I j 1023
NAMElll122 12 10 1212 -- .-. . . schedulc III 31H
ncck II I ~5 pallcntl'l 111.1 III< -R- .. scalinglll .u
normal III 15:14 II III II 2.1 1<7 rather III 174 scat II I 12111
Notary 1'1 112 IH 1 patients III 14 II reading III 3.1 'Ill second III 71
IS:24 1415 154 sccondarylll 9.21
Paull''' reason III 4 III
Novcmberlll 425 II I 7 reasonablc PI seel'l .1 2.1 5:6
I 24 412 125 II 22
now 1'1 'IS 1121 12'1 1115 1111 III 1111 ~:IH
14:11 17:IS Paul'slll 10.1 1"111 receivc III 41.1 seeing II I 420
numbncssl6' 11:.1 paying III 1~12 record III 17'1 IS20 September III 113
714 7:111 S5 IS 22
95 III pelvislll 55 1217 records 161 2 1.1 JK scriCKIII
Pcnnsylvania 1'1 " 21 721 H ,204 5:1.1 5:19
-----.-..--- 12 l)h KCtll1 IS:21
-O- I1 ~ 411 IH2
-~._- IS5 reduced III ISIO sevcn III 419 5S
oaths III Is:4 peOplClI1 14:1'1 15~ refcrred III 4111 Shcctlll IS 1.1
objections III J5 period III 1.12.1 reflcct II I 7.21 ShOCSll1 419
obviously III 171.1 permission III 320 regard III 710 shouldcrlll 12:16
occasional III liS person III 173 regular PI II 17 11111 12111
s:~ physical II I 517 related III 1.1 2.1 sidcl151 11'5 9.22
offill 5:1.1 S2 physicians III 171.1 relativc PI IS 14 102 10:2 10:5
1lI.1 107 10:10 10:11
plaCCll1 I 14 IH 1.1 IS III 1012 1014 HUll
once PI 12:21 III remaining II I
15:'1 places III 12:IH 7:15 10: IS 12:12 12:IS
PLAINTIFFIII I .1 reoccuring III 11111 135
ODCI'I 114 1010
12:IS 15H 151'1 PI.AINTlFFSIII I IS rerort 111 173 17.5 signinglll.1J
ongoing II I PLEAS 1111 I 7.7 Simplclll142.1
710 re~ortcd 1'1
onset III 4:IS point III 1.124 somconclIl 9:2.1
7:1'1 1115 ~:2.1 1610 17:1 14:1'1
opinion III 1314 post-operativc 121 72 172 somctimeslll 16:2
1.1:IS 712 Reporter( II IS II
orthopedic III 4:2 post'operativcly III Rcporter-Notary III Sorry III 11.23
1111 IS III sort III 15:7 166
- sound III
-P- pounds III II IS reporting II I 17:12 1122
p.mpl 11.1 17:19 practicing III 44 reports III II ~ sourcc II I 16:6
pagclII 'III PRESENT III 122 rescrvcd I II 1Il speaking III 5:1
pages III lS presently III liS respective" I 3.1 specified III IS 1.1
pain 1"1 41S 5.IS previous III 4:19 restate III 1025 spccd II I 7J
5:23 5:25 7:1.1 principlc III 5.2.1 restraincd III 54 SSIII IS I
S:5 S.9 S20 problem PI 420 restrict III II II start II I 1.1:21
9:4 9:10 91'1 5:fl 1125 KIO restrictions III started III 51.1 5:17
II :2 12:22 IJJ 142.1 III: 17 III 22 1111 1112
1.1:S 1.1:1.1 1315 problcmsl'l II 14
424 states III 9.14
1.1:I~ 1320 1322 .\5 710 7.1.1 result III 12:15
1.1:24 14:IS 14:19 S 19 1022 102.' return III 111'1 stay II I SJ
14:1'1 1420 1411 III rid III Ill! stenographically II I
14:2S 15:2 15.1 produccd III 2.12 right 1151 IS.'I
15.9 15:1lI ISII 4:22 Il:H STElPUEN III 1:20
.1S 11.20 H2O S211
15:21 152.1 1111 9:19 104 10:7 steps III 13'1
111:2 111:4 1116 program II I 5.17
IllS 16:10 111'11 progress III 111.1 1215 12111 1217 steroid III ~:14 5:1'1
121S 1223 III still 111
Ill: 17 1620 17J. Public 1'1 I 12 IS .1 11.9 71.1
17:4 17:5 17S 1)15 7:15 9:4 '1.5
IS:IO IH.24
17:11 17:12 putpl S24 Rodgcrs 111 1'1 145 14:11
painfulll1924 10 10 2..1 2 12 .19 stipulate III 41
1111 311 17.IS ISIl
pains III 10:12 15:5 putting III 10.7 RPRIII III IS 2.1 stipulated III 32
PAMELA III 1.2 STIPULATION 111.11
,
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HUGHES, ALBRIGHT, FOLTZ &; NATALE
717-140-0220\717-393-5101
Multi-Pagc'M
morning - STIPULATION
JOliN C. RODGRS, M.D
Index Page 3
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Mult'-PIIIC ,..
. .. . .
:111 12:11 true III IS.20 . ..
II 6:23 trylll 511 .y- ..-----......-
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typical 'II 7:12
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7:11 S:2 _._____~lJ:.._..____
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:tiDIIII 51S 11:11
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14:7 14.9 12:24
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waivcdll( N
It11JlIl:21 walk III 9: 17
II 6:19 621 walkcrlll JJ:2
walking 111 9:16
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13:10 weeks III 4:19 5:K
4:19 WCilhtll1 10:7 10:17
'II11 6:3 10:IS
8:5 WUEREOFIII 18:21
14:23 14:25 within III 12:24 IS:4
11(1111:'. 11'15 without", 5:12
111:11I 111:19 I.
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IIII 14:9 15:7 IS:8 IS:20 18:21
11111 14:JJ WITNESSES III 2:1
'DIIII 12:11I words III 5:12
I 5:11 workers "I D:II
ODtll1 5:14 worse III 7:111
12:11 wrong"1 1520
I 1:8 3:6
3:23
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HUGHES. ALBRIGHT. FOLTZ.t. NATALE
71 7-540-0220\7 1 7-393-S 101
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Orthopaedic Surgery of Carlisle, LTD.
Danlel P. Hel}', M.D.
John C. Rodgers, M.D.
orna RECORDS
DATE OF BIRlll 5/04/52
PAGE" 1
PATIENT NAME MONISMITH, Paul S. III
,
1/011/811 OV
1/20/811 OV
(
1/23/1111
,,",
2/02/811 OV
3/03/1111 OV
.
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, .
I.
5: Plelse see dictation In form 0' summary leller to Dr. Hollen, JCR/mb
5: Paul returns today for a routine preoperallve vlsll. He 15 conllnulng wilh similar
symptoms. even sllghlly worsened wllh occasional episodes of tingling In the nght leg,
Because of Increased pain an~ symptoms. he has decided to opl for surgical excision of his
disc fragmenl IS opposed to going through epidural steroid Injections and PT, This Is
certainly ecceptable. given his symptom complex and supportive MRI 51udles.
0: His physical exam conllnues essentially unchanged.
A: HNP L5.51 ,
P: We went over the nsks and benefits 0' the procedure Including. but not IImlled to
Infection. nerve damage. problems with bowels or bladder. and some continued discomfort.
He understands these and Is willing to proceed In'ormed consent was obtained. He will
follow-up back here In the office on F~b. 2" for a postop check and suture removal. JCRlmb
SURGERY; Lamlnlctomy of L5-81, uclslon of HNP L5-S1.
5: Paul returns for e 10 day postop check wllh no Inlenm complaints of pain. He does
report some mild numbness In the lateral aspect of his left fool.
0: His wound Is well healed and sutures were removed uneventfully. There are no signs
or symptoms of Infection.
A: Stable post.op course.
P: The patient was Instruded In adlv~y modifications. He will not 11ft more than 5 Ibs. .
Driving will be IIm~ed to only as necessary and will be very short dlslances only. His actlv~les
will be based on his symptoms. but will be IImlled ullllzing good body mechanics. Aerobically
~ would be beneficial for him to walk and he can do so on a treadmill at the YMCA. He can
also swim and walk In the water, He will follow. up in the office In 4 weeks for a repeat clinical
check pnor 10 any thoughts of relurnlng to regular duty work. JCR/mb
5: Paul relums for a re.chedl .of his back. He Is about 5 weeks postop. Although he continues
10 have I general relief of his pain. over the past week or so he has noticed some achy pain Into
the left laleral upect of his leg. He about a week ago a sudden onsel of pain in his back and leg
when he was walking around on the farm. bul this has resolved and is now more comfortable than
he was before that episode. He continues to have some numbness in the lateral aspect of his lell
leg. and as we talked about. this may never go away.
Contlnuld . . .
,.
ORT....fAEDIC SURGERY or CARLISI.. . L.TD.
Daniel P. Bely, M.D. 1.1..I..'.relb..1 John C. Rodgen, M.D.
CarIla1., Pol no u
1m) UI-I"2
PATIENT JILLlNO INFORMATION FORM
(lit.... rial aU 110I......"..
NAME:
SEX: D< M _F BIRTH DATE: ~b \ ~ 1. AOE: Lj S
L(:)IC.L\b\...~Q&-nO\~
~:l~J? - ?J:, b "" SPOUSE WORU: 1 L{ ... ~ ~ l., \ 6
MARlTALSTATUS: _s KM __0 _w
TClTS YOU'VE RECENTLY HAD: C>C X-ra)'l/Scan.
(Chock all Ihl! .PP'y) __ EMO (nerve te.')
~ MRI
,
ADDRESS:
HOME PHONE: :l..1..\1>"1<16~ WORXPHONE:
ss.: "1 nn ~ b. 1'1 ()<6
RErERRlNO PHYSICI,II.N: \\uU..<u.,. ~ ~_'vI~'l.W\J
EMPLOYER: ?9~
EMPLOYERADDR&'lS: !:lC1h 9~/x. \:)V\V\.
G!:)d.\.:,~,~;2~rIO\ :)
'EUON RESPONSIBLE FOR JILL:
ADDR&'lS:
PHONE NUMBER: RELATIONSHIP TO PATIENT:_
",aJMDY HEALTH INSURANCE: \V.. ~~ A'\.-,r,.'J- \r\<... i9
ADDR&'lS: .'
. JCY .: OROUP .: ....roo::r~ 'I o..QQi .
~ ..URED:~PATlENT _SPOUSE/OTHER (Name:) . INSURED'SDOB:~
.ECOIfDIJlY HEALTHINIDRUCE:
ADDRml:
POWCY.: .OROUP .:
INSURED: _ PATIENT _ SPOUSE/OTHER (Name:)
INSURED'S DOB:
IS VISIT RELATED TO: WORKMAN'S COMP:
AUTO ACCIDENT:
WORK COMP OR AUTO INSURANCE CO:
..es.. NO __-m;
_NO_YES
DATE or INJURY:
DATE or INJURY:
WORK COMP OR AUTO INSURANCE ADDRml:
POLICY.:
PHONE.:
OROUP .:
AD US1'ER HANDLlNO CWM:
".lI1horlZl Onhop..eIlc Sll1g.ry 01 Cullol., LId. 10 .ccopl w. .ign.'llro on~... ..lhorlZllion 10 ,.bmlt. clllm 10 my In.u.ran.. .0mpIllY.
My .ilJlllhll'O ..lhorlao. p.ymenl mlY be mldo cIlro~ylo Onhopltdlf SllI'g.ry of C.rU.lo, Lid. II Workman'. Comp.n..lion or A.,o A..14.nl,
I ..,horlr.lh. r.I.... 01 my m.cIl.1l r.cord. U r."".II.d 10 ItClll'. 1M\lrI1I.. p.ymenl. R.gudJe.. 01 WIlrtJl.. b.n.DI., J Wld.nlllld th.1
I r.maIn c1ally. r.,pol\llblelor aliI. . lor .em.., r.nd.r.It."
J~ ~
"-/..
y \ V~"\~~
. b.,.
MEDICAJU: PATIENTS ONLY
" roque., thai p.ymenl of ..lhorlr.d M.eIlcu. a.n.DI. b. mod. euh.r 10 m. or on my b.halllo Ol1hop..cIl. Sll1g.ry of Cullol., LId, lor illY
"M... l\lr1Ii.had m. by Ih., phYO'.'1lI or .appU.r, 1..'honZlI/lY hold.r of m.cllclllntormatlon abo.' m., 10 r.I.... to III. H.alth Cu.
Flnl/lc\ng AcImini.lr.lion IlId III .g.nll, illY Inform.tlon n.eded 10 det.mun. 'h..e b.neDII or Ilt. b.n.DII p.yabl.lor r.I.,.d ..m...."
-- -,--_.--" ._..-._---~.-
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.
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Om'!l>AEDIC SURGERY Of CARL
E LTD.
"
D"NII~ ,. HI~Y liD,
JOHN C, "OCIGIU, Io4.D,
all IIl-VIDI"1 IT"IIT
C""~II~t\ ,,, 1701~
,,,.........
,-
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J.nu.ry 11. 1111111
Robert A. Hollen, M.D.
BMC F.mlly Practice
850 W.lnul Bonom Rd.
C.rllsle, PA 17013
R.: P.ul 6. Monlsmllh, III
Deer Bob.
I h.d the pleuure or seeing P.ul Monlsmlth In Ihe olfice today, Peulls e 45-year.old whlto male
who, .boul seven weeks IgO, wu II work leaning over to tie his shoos that he had jusl put on, when
he re" I sudden onset or pain Into his back on Ihe lell sldo, The poln was In Ihe middle portion or his
b.ck .1 the belt line, Irfd IlSled for Ipproxlmalely four weeks. He had been treated Inltlllly with
Tylenol w"h codeine, Soml, Ind Relaren, wllh moderale success, He continued 10 have some plln,
however, end I MRI was ordered which revealed 0 large central disc hemlotlon ot l5.S1.
Approxlmetely 1-2 weeks .go, .round the time or,hls MRI, the patient began having leflleg pain .nd
p.resthesles. He reports no bowel or bladder problems. or note, the petlent report5 In lutomoblle
.cc1dent on April 30, 111116, when he w.s the passenger Ind sustelned I rrlctured pelvis. He Ilso 1.ler
developed lome n.ck problems. There was e question IS to whether or not the present disc problems
are rellted to the motor vehicle Iccldenl. Since Ihe patient has nol had symptoms relatad to his back
In the Interim, I would be hlrd pressed to find I correlation between these two.
His physical eXlm revllls his lower extremities to hive 5/5 motor strength, 2+ deep tendon
reflexes In .11 but the len Inkle jerk, There Is no reflex ellclted here. He has negative Babinski's
bllllerllly, .nd hiS parestheslas Into the len leg Ind fool. He has I negative straight leg rllse
bllaterllly, but does have plln Into his low back with the len leg mlneuver. Pllln x-rlYs were
reviewed, and Ire essentially unremarllable, His MRI was reviewed. end reveals 0 large central disc
hemlltlon It L6-S1.
I 1m recommending to Plul, It this point, to proceed wllh I series of epldurll steroid Injections
for relief or his plln. He will Ilso be stlrted concurrently In I Physical Therapy progr.m for flexion
exerclses .nd mod.I"les IS needed to control his symptoms, II Ihls regiment falls to Improve his
symptoms lufficlently In the next ".& weeks. then. we would consider proceeding wllh operative
Intervention for exclslon ofthe disc fragmenl.
Think you very much for the rererral, and Ihe privilege or assisting In the care of this patient.
,
Sincerely,
JQ\
John C. Rodgers, M.D.
JCR/mb
.'
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TO BE COMPLETED IV THE A1TENDING PHYSICIAN
, Nlmt.
SSN.
Dillno.l. or other pcnlnentlnformltlon dmrlblna Mlurl of IIInm or di.lblllry:
. I1t(n;C),.\e.d cl.(~e. L5"-S \
~
Si-ri~_(A,InIPb~-) M>
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ClfmlOI'AEOlC ISUl\GERY OF
CARLiSlE LTD
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Int.,n" RIII*'UI ~I.;. <1fO\95
come TI. Return (PI U~
,gU~. 01 olhlt Ip HI btQlnnlng
LII' nAme
IRS U.. 0nI~--00 1'101 will, Of "IPI' 11I11'1.' 1'''10.1
, lSUfl, ,ncMg , ,g OMB No Hl.6.()'J74
Vour lucl.1 IlCurity num",
Label
ISH
InIINchO'"
on ~.g. III
U.. lIlIlA.
l.b.l.
Otherw'".
pl.... prml
0I11P.,
PI..ld.nll.1
II.cllon Camp.lgn
B...."
Filing Sletus
lB.. pig. III
ChICk Ofll~
on, bO.
Exempllons
IB.. p.g. 12,)
II more thon SUI
a.p.nd.llla,
u. page 13.
7
..
b
g
'0
I'
12
13
14
15.
151
17
It
18
201
21
22
2:Ja
b
24
25
25
27
25
at
30
usle 31
Gross Income
Income
AII.ch
CoDy B 01 your
form. W.2.
w.za, Ind
1m." h.r..
II you die nol
g'l . W.2. ...
p.go ,.
EntIO", but do
nOlltlach. your
paym.nt and
p.1m.nl
vouth", S..
p'g' 33
Adjustments
to Income
I
L 1/-(
UU 200-36-1208 187-44-8462 528 6C
PAUL 5 & PAMELA K HONI5HITH III
3431 WAGGONER5 GAP ROAD
CARLISLE PA 17013-5326
I
I<
S
~I no
IpqUH" IOCIII,.curley numw
'or Prlv.ov Aot and
Paparwork R.duollon
Aot Nollo., ..a p.g. 7.
VI' No Nolll Ch"JeJnQ .Y'"
WI/I nol chMI", 'f04Jf
tar or redllce your
rwfund
Slngll
Marrl.d filing lolnl relun' (.v.n II Onl1 on. U.d Incom'I
Mauled filing ItPUlt. rtlum. Ent,r IPOUlt', aoeialllCUrlty no. above and lull nlm, hi". Ill>
H..d 01 hou..hold (wllh qu.llfylng ~."on).IB.. page I 2.1 If th. Quallfylllg poraon I. I child bul nol yOU' d.p.ndlnl,
ent., lhle child" nl1m, h,,., ..
Quail in widOw. with dl endent child ( IlIr II oule died'" , G 5.. 8.'2,
Yourlll'. II your Pll.nt (or ,omeon. 81ul can claim you os a tJopendenl on hll or hur 10'" }
rllum, do not che<:k bOK el. But ". lur' to check Ih, b~k on Un. 33b on pig. 2 .
b 8 UII. . . . . . . . . . . . . . . , . . . . . . . . .
c Depend,ntl: I Ipln ,nl'IIOCIII I .ptnd,nl'l 0 0 monl ·
111' I "llnlml IfCl/flfy number II botn '1lallonlhlp to 1t'J'dln~O\lI
1'0 name ~ In 1 1 II 1tI1
""'I~, ,\,Ii'l" l.H IA'., ..."'~,,, .,.'to. ..""'.." ........'
j ~.. ..... . . .
.... Pig. 11
00 yOU Willi $3 10 go 10 Ihl. fund7. . . . . .
II . 01111 ,.Iurn, dOl. ou,. u.. WillI 53 10 0 10 Ihl. lund? .
I
2
3
4
5
5.
AaIbe~III11-"
Heidi ~ Mon111111-1t
Dr~ R M~lImi.t
R4Ibecoa-L-Hom.llm-isth-
Lo~9-
~9
aU9
II
II
II
d 1I10ur child didn'! 1", willi IOU bul "cl"m.d 1I10ur d,p,ndanl U"dlll plHge! aglum."" ChICk hll' ~ 0
. Totll number 0' 1.lm t.ona claimed . . . .
Wag... ,,'"I.,. lip.. .IC. AUlch Fonnl') W.2
Ta..bl. Inl.",1 Incom. I.M p.g. 16). AU.ch Bch.dul. B If 0'" $400
T......mpllnl".'II... p'g' I ~I, DON'T Inclueo on IIn. ea 5b
Olvld.nd Incom., Attoch Bchedul. B II o,ar $400
Tlxable "Iundl, cr.dltl, or off..11 or .I,t, and local Income la~" (n. page 1~)
Alimony r'CINld . , . .
Bu.lnllllncomt or (1011). AUech Sch.dule C or C.EZ . . .
C.pII., g.ln or (lOll). If Ilqulrad. .ttach 5ch.oul. 0 (... pog. 161
Olhor g.'n. 01 (10....). AU.ch Fo,m 47g7. . . . . . . . , . . . , .
TolallRA dlol"bullon. , l!.!!J U b TlAoDI. omounll'" p.g. Ie)
TOlal ponllonl .nd .nnuillll lJ!!.1 U b rlAabl. omounllIH p.g. Ie)
R.nlal real 111.1.. loyalllll. pll1n.rahlp.. B co,po,.lIon.. I,u.t.. .Ic, AIl.ch Bchedul. E
Firm Incoml or (loa.), Att.ch S<:hedul. F . . . . . . . .
Un.mploym.nl comptnalllon ('M p.g. I 7) . . . . . . . . .
Social aecunfy b.n.lIl. 12g0 I I I b ra..blo omounllIH p.g. lei
Olhar Incom., ~1.llyp. .nd .mounl-tll p.g. Ie .... ......,.........................
Add lh. amount,ln lh. ,.,,1 ht column for IInl. 7lhrou h 21, This II our lobllncom. ~
You, IRA d.ductlon (... p.g. 19) . . . . 230
Boou..'a IRA deducllon I'" page 19), . . 23b
Moving ..p.n.... AIl.ch Fo,m 3903 0' 3903.F 24
On..hall 0' 1.i1..mpI01mlnll... , . . . 25
SoIl.empl01ed h..lth In,ur.nc. deduction I'" p.g. 21) 28
K.ogh & ..1I'lmploVld BEP pion., iI BEP. chick ~ 0 27
p.n.11y on .II1V wlthdr.w.1 01 ..vlng.. . . . 2B
Allmonv paid. RlIClpl.nl'. SSN ~ i 29
Add IIn.. 23. Ih,ou h 29, Th...... our total .d uatm.nl& . ..,. ~
SubltaCIIl.. 30 !rom Ii.. 22 Thl! I' 10ur Id1811.d OlOllln.om.. 111m than 12e,673 and. child liVId
w,lh ou 1m In.n 19,230 II a child dldn'IIIVl wlln au, ,.. 'EIIn'd Incomt Clldll' on , 1 27 ~
ell. No, 126990
HI,llbuII
chIC'" on II -J.
ani II .u
NI..I WDUf
11I1I'f"". II
.hl: JJ-
. IIn' wllft r'w -I--
. ",n'llIn willi
rOIl'1I111
'lnr".,
1I""lIanlll.
"~IOU)
O.plft.,nll on II
.tllnl""I~O'l'-
Ad' numb'"
,nll""ft
IIn'l.bl'l' ..
9
10
II
12
13
14
15
18b
17
18 () 0 .
\8
20b
'I
,
31
B~ .
n.575 1'1'
Fo,m 1040 ('801'
~:I Arnounl hom IIn. 31 IldJulttej oroll Incom.) ,. . .
>>1 Chltk II: 0 You Willi 6& or old"" 0 Blind: 0 lIpou.. w.. 6& Ot older, 0 Blind.
Add U" number 01 bo... chIC kId abo," Ind 'nler Ihl 10101 h,,",. ~ :l3I
b II youI plllnl (0' IOmoonl .,11) can claim you.. . dlplndlnl, chock her. ~:l3b
a II you '"~ n,a,li.d IIIlng IIplltllly and your IpOUI. Illml"" deducllonl 0'
you ,It I dual'llalul IlIon. "" p.gl 23 and chock h,,", ~ >>c 0
llllmll.d dlductlon, 'rom Schedull A. IInl 28, OR )
:M Enl" SI.nd.rd d,ducUon shown bile. w 101 YOUt hUng slalul. Bul If )fOu ch.C1k.d
Ih. mnv bel on IInl ~ or b, go to pOOl 23 10 find your standurd deQueUon.
I.rg., If you checked boa :J.3c, Yl,Iur standurd dlfjucllon II lifO,
01
your: I 5Inglo-$3.900 I M,,"ld hllng Jointly 0' Oualllylng wldowtor>-S6.6&0
I ~iaad 0' houllhold-S&,7&0 I MI"lld II ling IIp,,"llly-53,27&
Sublltcllln" 34 ',om IInl 32. .... . . . . .
IIl1nl 32 II 588,02& 0' II", mulllply 52.&00 by thl 10111 numb" 0' ...mptlonl cl.lmtd on
IIn. 8., IIlln. 32 II 0'"' S86.02&, "" Ihl workoh..1 on page 23 lOt thl amount 10 onl" .
ro..bl. Incoml, Sublr~lnl 38 'rom IInl 3&, IIl1n. 38 II more Ihan IIn. 3&, Inlll .0. .
TOll, Chock II "om a C!T.. Tobl., b 0 TII RII. 5<hodulll, 0 OCapual Olin TII Work.
Ihlll,Ol dO FOlm 881& (III pag' 2~1, Amounl 'rom Fo,mll) 881~ ~ . I
38 Addlllon.II..... Chltk U from . 0 Form ~870 b 0 Fo,m 4972
.. __4! ~~~1!!.!!1.<U!L.._'--,--"-'-'--'--' .'
41 C,K1lt rOt child and tJ.p'ndlnt care IJlp.n.... Attach For", 2441 41
42 Credll 'Qr thl Ild"ly or Ih. dllabled, AUlch &chldult R . 42
43 Fo,tlon I.. cradll, AlItch ~olm 1118 . 43
44 Olhll Clodlll (... P'OI 2&). ChICk II 110m . 0 Form 3800
b 0 Form 8306 cO Fo,m 8801 d 0 FOtm,"pec'lyl_ 44
Add IIn.. 4 I Ihrough 4~ . , . .
Sublltct IInl 4& I,om IIn. 40. IIl1nl 4& II more Ihon IIn, 40. Inl" .0. .
SIII'lmploym.nl tOll, Allach Schedul. SE. .
AJI'lIl1aUv. minimum 1.1)1, Attach Forni 6261 . ..,.,
Rocapluro I..... cneck ,I 110m . U Fo,m 42&& b U Form 8811 cO Fo,m 8029
5UCloIIICutlly and Medlcafll/lJl on tip Incom, not repOr1trd 10 employer. AlIuch Form 4137
Tox on qualified retltement plln.. including IAAs. It required, aUllch Form 6329 .
Advanct larned income cr,dlt paymontllrom Form W.2
Hou.ehold employment 1....1.. Attach Schedule H. . .
Add IIn.. 46 Ihrou h &3. Thl. II ou' tolalla. .
f.dlllllncoml ta. wllhh.ld.IIIMV 111,om fo,mlsll099. chock ~ 0
199~ ,stlm.led IQJI pa)'ll1onlllnd Imounl,ppllod from 1994 ilium .
I.mld Incoml cradlt. Alloch 5<hedull EIC II VOU hovI I qu,lIlylnO
cMd. NonlOllabla lamed ".:omo: Imounl ~ L I I
and IYPI ~ ........,..........................................
Amount p.ld willi Form 4868 {..Ienllon IIqu..t) .
Ex..a, aoclal ..cunly Ind RATA lOll wllhhlld (I.!!)llgl 32)
O,hll paymlnll. ChICk Illrom 10 Form 2439 b ~ Form 4138
Add IIn.. 6& throu h eo. Th'.. Irl our lolal Inti
IIl1n. &111 mOtI Inln linl 54, sublllclllnl 54lrom llno 81. Thlllllho lmount you OVERPAID.
Amount ollln. 82 you w.nl REfUNDED TO YOU, . . .. ...,
Amount alline 62 you wanl APPLIED TO YOUR 1111 tlTIMATlD TAll ~ M
II hnl &411 mOllth.n IInl 81, lublllr.llinl 61 "om IInl 64, Thill' thl AMOUNT YOU OWE.
For de'IUa on how to PlY Gnd uat 'arm 1040.V, Payment VOUCh", "I page 33 , . II-
OS elllmlltd toJC .nlll "' 8 II 33 . Allo Include on IInl 65 ee
f;,lll IIJllJtllJubl
TDlC
Compu.
tatlon
IS" pag.
23/
n )OU ....anl
In, IRS Iu
I,Qur. )'OUI
In.., bllt
nap' 35
Credits
t~'" pal.1111
;?JI
46
>Ie
47
>Ie
48
eo
81
82
&3
/Sol
Payments Il5
116
87
Other
Taxes
r~l." pllq..
;ib.1
AIIICh
For",1 "".2.
W.2G. end
10ll9.R all
Iflt rronl
Refund or 82
Amount 63
You Owe 84
66
Sign
Her.
Klrtp . cOPV
IJIIMt "turn
1m your
r>x:orCls.
Paid
Preparer's
Use Only
'.
,
,
Pogo 2
34
36
38
37
~
L---
3&
38
37
38
116
eo
eo
8'
&7
IlS
80
eo
0,"
~
-
,
UriC" Plnlllill 0' P.'IU!l. IUICII'I thlll ha'ia Illlmlned Ihll ,.lum IInd accomPlInyjno IChfdultl and 'lal.m.nla, .,ld 10 Ihl bill 01 mv Itnowlltdge Ind
Luth.1 tr.,v'" '.ua. corrlff,l. l&nd compl.la. O"llfollon 01 prapA,a. (other lhal! 'a.pa.,..,) 'a balld on a1llnlonnallon 01 whIch pi It h.. In)' Itnowlldgt.
~ 0" nil"'. ~ Yourceo".."o"
~. .- "'-'i-;'Q-;-;.uro. If" IU'''I~~I"rn. 60TH mU'U'Qn'{J
p,.p.'ar"" e ao.R
Ilgnlluf, ,
.--- -
F'''I]', no)m.lo' yUllIllo ~
I' ...U-.mlJloy'd) InO
aOI)I(I"
Chtek II
MiI.omploVed
fiN
IP c .
I
f",m
4562
Depreciation and Amortization
(Includln, Inform.tlon on Lilted Property)
oMa No. 1ll4&-OIII
~@95
Department gJ ~ l....\ll)' AII.c:hmlnl "7
',".... ......... 600>.. (01 .. "I II retl InelNoUone. .. Allaoh II1le lonn 10 our retum. Iloquonco No v
Namttll ."own on ,.luIM Bullnel.OI IcUvlly 10 which Ihllloon 1.IDtl. Idln\lt)'lng numIM,
Paul S MoniBmith III Schedule "F" 200 36 1208
Elactlon To E~pen.e Certeln Tangible Property (Secllon 178) (Notel /I you hava any "Listed Property. "
complete Part V before you complete Part /.
1 Ml1.Jlimum dollar Ilmllallon. II an enlerprise zone buslneu. see pooe I of Ihe Inslruclions . $17.500
2 Tolal cosl of secllon 179 property placed in servica during the 1l1.Jl year, See page 2 ollhe
inslrucllons. . . . . . . . . , . , , , . . . . . . . . 2
3 Threshold cosl 01 IIcllon 179 property belora reduclion In limitation. . . . . . .. a 200 000
4 Reducllon in IImlllllon. Sublraclllne 3 Irom line 2. II zero or less, enter .0. . , . ., 4
5 Dollar IImilallon for lax year. Subtract line 4 from IInll 1. IIlero or less. enler .0.. II married
filln 51 aralll . See a e 2 01 the Inslrucllons. . . , . .
(.t Ollcnphon 01 pl'optft't lbl COil Ie) Eltcltd cOil
..L-
7 listed property, Enllr amounl from line 27. ..,.... 7
8 TOlol elecled cOSI of secllon 179 property, Add amounts in column (c), lines 6 and 7 8
8 Tenlal,ve deducllon. Enllr the smaller 01 line 5 or line 8 . . , . . , . . . . 8
10 Carryover of dlullowed deducllon from 1994. Sea page 2 of the Inslructlons. . . 10
11 Taxabl.,ncomellmilallon. Enler Ihe smaller of laxablelncome (nolless Ihan zero) or hn. 5 (seelnslrucllonsl 11
12 Secllon 179 expense deducllon. Add lines 9 and 10, bul do not enter more Ihan line 11, 12
13 Car over of dlsallow.d deducllon 101996. Add lines 9 and 10. less IIna 12.. 13
Notl: fjo nor use Part /I or Part III below lor IIsr.d property (automobiles, certain Olher vehlclas, cellular telephones,
certa/O com urers. or ro e used lor enlortalnmanl. recreal/on, or amusement), Instead. use Part V lor IIsred property.
MACRS Depraclatlon For Assets Placed In Service ONLY During Your 1885 Ta~ Year (Do Not Include
Listed Property.)
Slollon A--Genlrel A..el Account Election
14 II you ore making Ihe elecllon under s.cllon t68(1){4) to group any ass. IS placed In se",ice during Ihe 1l1.Jl YOIIT Inlo one or moro
.noral assai accounls, check Ihis box, See 0 e 2 ollhe Inslructlons. . . . ..
(bl Month and (c:1 B,lll lor deptec:1I11On
(.) CIIIIIII(IIIon of p,optrty ).11 placid In (bulln.....,nv..tmen' UN ldl RKOYlry
..tvle. onl InallUellOnl penod
Section &-Generel Da raolallon S iilniTciDS (See a
!>1M S/L
!>1M S/L
!>1M S/L
!>1M S/L
(See a e 4 01 tha Inslrucllons.
S/L
12 rB. S/L
40 r.. !>1M SIL
Other Depreciation (Do Not Include Listed ProperlY.) (See pa e 4 01 the Inslructlons.
17 aos and AOS ~educlions 10< assalS placed in .e""celn lax yellTe beginning belore t99~ . 17
18 Property subject 10 soctlon 166(~(1) eleotlon. . . , 1
18 ACRS end olher de ".clatlon. . . . . . . . . . . . . . . , . . 1
IlIIIII!J Summery (See page 4 of the Instructions.)
20 listed proplrty. Enter amounl from IIna 26. . . . . . . . . . . . . . . . ., :zo
21 Totll. Add deduclions on IIna 12, IInas 15 and 16 In column (g). and lines 17 through 20. Enter hare
and on lha appropflale lines of your relurn. portner.hips and 5 co<porations-see inslrucllons .
22 For assels shown above and placed In se",ice durtng Ihe currenl year, onler
Ihe ortlon 01 Ihe basis ollflbulable 10 section 263A costs . . . , .
'or Plplrwork Rlduc:tlon Act Notic., I" page 1 0' thl I.parat. Inlln.n:tlons.
3. IBr
5. ear
7 'y~ar roport
10. eRr ro ert
e ,5.year ro ert
r 20.year .E!.operty
g Residentiel renlel
crOD.r1v
h NonreSldenlial real
orope"
27.5
27.5
39
rB.
rB.
rs.
181
b
,
21
22
elll No 1 :<'~OtSN
form 4562 119911
I 0'0 'OU "m,,"n.lI, plrtlclpl"" ,n Ihl op,,"lIon 01 Ihl. bUlln,.. OUllng I GG!? II "NO: '" pDgI F.2 101 hm,1 on p,,"'" 10.... ~ 0 No
Farm Income-C8Ih Method. Complete Portal and IIIA"'UlI m,thDd lup.y", compl'" ',nlll .nd III. and llno " 01 "n 1.1
00 not Include III.. of IIv..tock h.ld for drIft, bre,dln I' art, or dill ur auai II art thl" IDI.. on Form 4787.
I
2
, 5alll ollJvtlStock and other Itlm. you bought lor rlul' ,
2 COllar other bills 01 Uvulaek and other 111m. rlported on Hn,' , ,
3 Subtr.CI hnl 2 from hnl ,. ....
4 51111 01 IIvestoek, produc.. grllnl. and Olhtr P'OdU~"0U railed . . . , .
01 TOIII COOP""U" olllllbullon. (Form(,) lOGO.PATR) Lll. _ I tJ ~
01 Agllcullurll program plymlnll (It I plgl F.2) L~ I ~...B.l.-J
7 Commoolly Crloil Corporollon (CCCllo.n, ,I.. p'g' F.2):
. cee 10lnl 'Iported under ,llcUon
b CCC lOin. lonlll.o or II plio Wllh conllICII.. I 7b I
8 Crop insurance proc"dl and Clrtain dlult" plv.m.n1a (I" PliO' F~l:
, Amounl "colvlO In 1900 . . . . . . . I 8. I Ei2.B I. 8b TI.'bl, ,moun I
C II ,,"cllon 10 0""'0 lGGO II ,"oChIO, chICk hIlt ~ 0 80 Amounl 0.'.".0 Irom 1994 .
g CUllom till' (mlchln. workllncoml . .
10 Olht' Ineom., inct~dlng F.dlrllland Itlll' gUOII"1 gf luolln creellt or relund (ue page F.3J
11 arOIl Incom.. Add amounts in the right clJlurnn lor IInll 3 through 10. II accrual melhod IWlpllyer, enter
Ih, omounl from 1.2, IIn. 01. . ~ 11
Farm Expenl8l-Cash and Accrual Method. Do not Include personal or living expenses such as tax8S, Insurence,
r8 BIIS, 8tC., on our hom8,
SCHEDULE F
(Form 1(40)
Profit or Loss From Farming
~ "nlch to Form 10040, 'orm 10041, or 'o,m 1086,
~ SI. InllrllcUonl for Sch,dull F (FornI '040.
D"at\menl olin, '"UIIl' (T)
1n11l""'''''IfIW'''I'l'IU
Nlm. 01 ploptl.IOl
Paul S Monismisth
III
Ii PunCIPII pIO<IUCI Oue1lbt In on. 0(.1..,-0 WOld' )'01.1' pM'lp.1 ClOP Of IC\Ivll)' hJI Ih, ev".nll.. yl'"
C ~counllng m,U'IOd:
(I' ~Dlh
(21 0 AccrUDI
lSb T a.llIbl. amount
l5b Talloble "moun I
7C TUBble Imount
12 Car ano lruck ...p.nn, (,.. p.g.
F.3-li'O on.ch Fo,m ~0621 '
13 en.mlcal'.
,,. Con.I,"",lIon ,,,pIn III. Attach
Fo,m 81015.
1& Cuslom tlIr. (maChln. worj()
10 Oepreciation and IIcllon 179
exp.nlt deduction not clalm,d
,t.,wh.re (.11 page F.4) .
17 EmplOY" b.n.fll proglOml
Olhlt lhln on tin. 25.
10 F..o purch...o . .
18 F,nlllur. and Um. .
20 Freight and truckIng.
21 OIlOhn.. lu.I, and 011
22 Inauranc' (Olh.. thin hUllh)
23 lnl.rlll:
. Mortglg. (pliO 10 blnka, IIC,) .
b Olh.. , .
24 L.l)Or n.,td 1'1I.m 10 mIni crldil'
20 Pension and prahl. sharing
plBns
20 R.nl or I.... ,... pDgI F .41:
II V.hicles, machinery, and 'Qulp.
menl
b Olher (IDnO, .nim.,., .'C.) .
27 Repairs and malnt.nance .
28 5..0' .no pl.nll purch.ltO
29 Storage and wBr.housl~g
30 Supplies purchBlSld
31 T.... . , .
32 UIIIIU." . .
33 Vell/ln,l'!, brooding. and m'd'Cln, .
34 Other ...pense. (IIPlClty):
. ......................... ......
b...........,...................
12
13
14
IS
IS
6
c
...............................
o ...............................
.
f
...............................
30 Totll up.nltl. Aoo lin.. 12 through 341 . . ,~
30 N.l form p,olll or (lOll), SublroCllin. 35 Irom lin. 11. If . prohl, ,nl.1 on Form 1040, IIn. 18, and ALSO on
Sch.dul. 51, IIn. 1. II . lon, you MUST go on 10 lint 37 (1IIalts. lrusll, and pllnn'rshlpl, 'eI page F .51.
37 II you hlV. 11011, you MUST ch.ck th. bo. lh,t o.,cllb.. your Invlllm,nlln 11111 ICUv,'V ,.., pogl F.51,
II you check.o 37., Inlorlh. lOll on Form 1040.lIn. 18. .no ALSO on Sch,oul. SE.lln. I.
II you chlck.o 37b, you MUST .tt.ch Form 81g8,
for P.ptrwork Reduction Act Notlc', .11 Form 1040 Inltruetlona.
COI No 113"6H
OMU No '6cIH)OU
~@95
AlI.,nm,nl
15'Ql.I.nct No 1..
loelll ..eu"~fum~tl (IINI
200 36 2IJtI
. Inlll ~H\c.pll 1\111'1,111\,111/ ach~ll~
coo, IIoom p.g.ll .1.:2l../I.;;l.J
D Implo~" ID numb" IIIN), If .n~
3
4
Ob
Ob
~
.
71
7c
8
ad
8
10
-
~
280
20b
27
28
28
30
31
32
33
-'
lIP. '
,
34.
34b
34c
340
34.
341
35
38
37. ~lln"'"tm.nt II II fisk.
37b 0 SomllnvUlmtnl I' nolll nlk
Schloul. F (Form 1040) 1995
ItPIl\lnltll"'I~T,...\Iy 1)'1
...,~.. A,.1nYt 5Irvc.
'amtttJ Mo*n on 'arm ,0000
Paul S I Pamela k MoniBmiBth
elution: 00 nollnc/u~1 1.".nSII flrmbursld Of pI/a by o/hlrs.
Mldlceland dlntal uplnall (~II page A.1). . . .
Enllllmounllrom Form 1040, IIn' 32, I 2 I
Mulllply IInl 2 Ibo.. by 7.5% (.075). . . , . ., 3
Subl,aclllnl 3 f,om IInl ,. If Ilnl 3 la more Ihan line 1 en Ie, .0.
Slale and locel In com. laxal , , 5
R..I .1111. taxal (I.. page A.2). . , , . . ,. e
P..lonll proP'''y Illlel. . , , , , . . . .. 7
Olhl' lax... Lilt Iyp. Ind amounl . ""................
28 II Form 1040, line 32, over $'14,700 (ove, $57,350 It ma/lled IrIlng sepa,alely)?
NO, You, deduction II nolllmlled. Add Ihe amounts In the fer IIghl column }
'0' IInll 4 through 27. Also, enler on Fo,m 1040, line 34, Ihe 'IrQI, of .
Ihls amounl 0' you, Itanae,d deducllon. '
YES. Your deducllon ma be IImilld, See a e A.5 fo, Ihe amount to enler.
"'IPlIWOrk RldueUon Act Notlel, II. 'arm '040 Inll!uellonl. ell. No, 12a13Z
SQHIDULIS All
'orm 1040)
...dloal
Ind I
).nl., 2
l.p.n... 3
4
..... You 5
,.Id I
III 7
,"gIA.1.) 8
8
nt.r..t 10
'ou p.ld II
~It
Ig. A.2.1
lotll
."anal 12
11""111
01
.duellbl.. 13
14
iltl.lo 15
harlty
you midi I II
h ond gOI I
tn.fit ror II, 17
II pig. A'3, 18
nUllly Ind
~I" LOIIII 18
lb hPlnul 20
,d MOIl
Ihlr
IIOllllnlQUI
tduollonl
II
,g, A.5 10'
lptn... 10
'duel horl,)
23
24
25
21
Ihlr 27
IlollllnlOul
tduollonl
olal
.mlz.d
.duollon.
Schedule A-Itemized Deductions
OMa No, 10.41.0071
(Sohedule 8 I' on blck)
~ AII.eh to 'o,m '040. ~ ISI. InllNotlon. '0' eoh.dulll A Ind 8 'o,m'04O,
~@95
AI",hm,nl 07
6equenc. No.
Your 10cl.1 Itcu,lt)' num",
21
22
...................................................,............
Add IIn.. 5lh,ou h8, . . . . , . . . . . .
Hom. mortglg,lnltrtll,nd polnlS report.d 10 you on Form 1098
Heml mOl1glg' Intlllll nol ropollt<1lo VOU on Form 1098. If paid
to Ihl PI/fOn '10m whom you boughllhl hom., lee peg. A.3
end show Ihll PilSon's n.m.. id.llllfVlng no" and eddrell ~
.................................,..........,...................
..................................,,,...........................
11
................................................................
Polnll nOl reported 10 you on Fo,m 1098, See pAge A.3
fo, Ipeclal rulli, , , . . , , , . , . . . .
Invnlmlnllnlerel!. If requl,ed, allach Form 4952. (Sae
page A.3.) . . . . . . . . , , . . . . .
Add IInlll0 Ih,ou h 13. . , . , . . , , , .
Glftl by cash or check. If you made any gift of $250 or
mor., II. pig a A.3 , . . . . . . . , , , .
Olher Ihan by calh or cheek, If any gift 0' $250 or mora,
a.. page A.3. If over $500. you MUST attach Form 8283
CallYov., from p,lor yel' . . . . . . . .
Add linn' 5 throu h 17, . . . . . . , .
12
13
Unrelmburled .mployee expenlea-job Irevel, union
dun, job education, .tc. If required, you MUST attech
Form 2108 or 2108.EZ, (See page A-5.) . ..............
Tlllpreparltlonfa... , . . . . . . . . . ,
Olher exp.nlla-Invnlment, Bale depoalt box, ele, List
type and emount ..........................................
Add linn 20 Ihrough 22. . . . , . . . . . .
Enllllmounl from Form 1040. Iln. 32. 24
Multiply line 24 above by 2% (.02) 25
Subl,aclline 25 'rom IIn. 23. If line 25 II more than line 23 enler .0-
Olhlr-trom lilt on peg. A.5. Lilt type and emount . ..............................
ISchtdul. A (Form 1040) 'M
OM' No. 'UI.o,,,
Credit for Federal Tex Peld on Fuels
14nd Crldll 101 PUlohlt' 01 DI,ul.Power,d Hlghw,y Vlhlol..,
. ,.. th, InlINoUonllol 'orm 4'~.
. Alltoh thll lorm.o our Inooml ... "'um.
T.ap.~., Jd.nunlluon "umat"
200 36 1208
I~m4136
radiI
('I
Nllmb" or
nhlcl
~I
a,Hlt ..... .1IlI.1t
1 Ollul.powerld carl . , . . .
2 OIIUI,poWllld IIghllluekl Ind van,
1
~@95
M,"hlnlnl
lIoucnol Ho. 23
, .
hWI vlhlcll clldlt. Add IIn.. 1 and 2 column c .. ~ 3
elution: You cannot claim any amounts on Form 4t36 that you clalmad on
Form 8849, Form 843, or Schedule C (form 720).
4 Nontl.abl, Uu 01 Oalollnl (S.. InlllUellonl.)
All' Olllonl
I on.hl hWI bulln... UII $,184 )
b t'
UII on I farm 101" rarmln urpOII. ,'84 ....
0 Olnlr ,'84
5 Nont"lbl, U.. ot OalohollS" Inllluellonl.)
Type
01 uu
AlII
Olnonl
a Ollonol conlllnln 1111111 '0" Ilcohol
b Ollonol conlllnlng II lUll 7,7" Ilcohol bullllalnan
'0" Illonol
$.13
.1424
o 01101101 conlllnlng 1111111 U" Ilconol bullllllnln
77.. IIconol
Nonla.abl, U.. ot UndYld 01.." 'uII (Unal el, b, and c)
Sal.. by R,gllt'rld Ulllmlt' V,ndorl 01 Undyed DI..'I FUll (Llnl ed) (S.. InlllUellonl,)
Lln.. 81, b, Ind 01 Pu,en.." bougnl und11d dl,..1 lUll. Type All' Olnon.
CI"ilill Inlllnl 01"11 'uII did nol eonllln Vlllbll 01 UII
lY'dlnCI 01 dYI. anO ulld Inll dlllll 'uII lOf I
nonl""lbll ulI, CluUonr No clllm II a/Iowld on IIn.. e.,
b, or 0 lor UII on , lann lor llImlng pulpoll' or lor ""
by I ."t, or lacll go.'mmlnt.
.1132
e
. H.IUn oil
$.244
b On.rliQhwIY bUlln,.. u..
.244
c . ther n t..ubl, II
d Clllmanl .old undyld dl..,1 fUll (IlIa 111111 Of locII
gov"nmlnl lOf III ..elull.1 ull 01 (b) for UII br, In,
buyer on I Ilrm lor fanning PU,pol... Clllmanl I a
/lgllll/ld ulllmlll vlndor, IOld In, 'uII II I IIX...eludld
prlCI. CI"I"" tnlllnl dlllll lUI' did nol eonllln Vlllbll
Ivldlncl 01 dYI. and oblllnld In, 'equl,1d el"lne,11
Irom Inl buyer and nn no /llIon 10 blnlvl any 01 tnl
inlo,mlllon In Ihl el"lIlelll I. II'''.
.244
.244
C.I. Ho. 12ellR
Amount 01 e/ldll
fafp sf>
Amount 01 crldll
)
Amount 01 o/ldll
CAN
30'
CRN
3'2
CRN
303
lonn 4130 (,nl)
SCHEDULE SE
,Form 1040)
Self.Employment T8X
~@95
~ I.. In.""ollon. lor lohtdul. 'I (Form t04Ol.
_1NN/'lI..wf'.....,.
....... ....... "".. ~ AII.ch 10 hrm 1040.
N.m. 01 I)I/.on WII. ..1I..mplo~m.nllncome (lI"'own on Form 1040) 8ocl.1 ..cU/ll~ numbl/ 01 pI/Ion
'__1_ with ..1I..mpJo~m.nllnc:om. ·
Who Must File Sohedule BE
You mull III. Schtdul. SE II:
. You hlO nil IIrnlngl from IIU'lmplovmanl from oth.r thin church Implove. Income (line 4 01 Short Sch.dull SE or line 4c 01
Long ScheOul. SE) 01 $400 Ol morl, OR
. You .ad church .mploVII Income 01 '108028 Ol mort. Incom. Irom IIIIYlclI VOU per10rmed III mlnlellr or I member 01 I
IIhgIOU' o,der I. not church emplov" Income. S.a page SE.I.
Noll' E.ln II ~0lI hi.' e 10.. or. ""11/ .moun' ol/ncoml lrom ,,/I'lmp/oymlnl. II mlY 01 10 your olnllll 10 lill Sch.clUII SE Incl
UII IIlnll "optlonll mlrhod" In PlrI /I 01 Long SCh.dull SE. S.. plgl SE.3.
'.c,plion, If ~our onl~ ..U..mplovmlntlncoml wa. from lI,nlnge II a mlnl.llr. mlmber 0' I IIlIglou. Older. or Chrl.liln 3clanca
prachllonlr Ind ~ou iliad Form 4311 Ind rlcllvad IRS approvII nOllO blla.ld on Iho.a IIrnlng., do not fila Schedul. SE, Inlltld.
Will' "Ek.mpl-Fo,m 4311" on Form 1040, line 47.
Anlchm.ftl
I ,No 17
May I Use Short Schedule BE or MUST' Use Long Sohedule SE?
Old vou ".".. wogo. .. lip' In IHI?
Ho
y"
N' rOl.l I man.1"', mlml:ltr or. r'Ie"" 01_. Of CMIUan
kline' plIC1it1Ontr whO ttcelvld lRI ,pptOYaI no' to bt l.ald V',
on ..,nlnglltom In'lt IOijtCH. b,,' VOI.I ow. ull..mpIoym.nt
II' gn oU\tr ..tnlnQl'
WI' In. lota! or your WlpI' and Ilpl IUbIKt to &Oelll "~lM'ly Y
01 ,aUIo.d ,.","""', ,.. phil your nil .Irntng' ltom
..".""plo1"*'I_O II\In "',1001
No
All ~Ch.t wll"V 0111 of 1M opUonIl mlU\0CI1 '0 19'" rout nee v.
'11""'9' I'" Jltil. lI.m
Ho
Ho
No Olea you r'Cli~.llpllUbltCt to IOCIII HCunt1 Of' MIOIC..' tu VII
In.1 I"" did not'.... 10 \'11"' ,,"plol0t?
010 ~O\l ,,,,,.,, cnt.llcr\ emplOy" InCome t.ponecl on ,~ V..
W.I 01110'"'' _.1
No
YOU MAY UII 'HO~T 'CHIOU~I II ..~OW
YOU MUIT UII ~ONO 'CHIOU~1 II ON THI lACK
S.ctlon A-Short Schedull SE. elution: Read IboVI to '" If you Cln use Short Schedule SE.
Nel 'erm prolll or (lOll) Irom Schadul. F, IIn. 38. and farm plrtnershlps. Sch.dul. K. I (Form
1086). IIn. , 6e , . . , . . . . . . . . . . . . . . . . . . . . . .. I
2 Nat prolll or 00") Irom Schedul. C. IIn. 31: Schedul. C.EZ, IIn. 3: and Sch.dul. K.l (Form
1055). I,nl 161 (olher thin larmlng), Mlnllllrt and memb.rl of rellgloul order. III pig. SE.I
lor Imounte to report on thlllln.. SII pig. SE-2 for olhlr Incom. 10 report. 2
:3 Combine Iln.. 1 ~nd 2, . . . . . I . . . . . . . . . . I 3
4 Nt! .arnlng. from ,,'f..mplovmlnt. Multiply IIn. 3 by e2,35% (.9235). U lias thin $400.
do not hie Ihi. .ch.dul.: Vou do not ow. atU-.mplovm.nt Ilk . . . . . , , , . .... 4
5 Solf"mplo~m.nttlk. If th. Imount on IIn. " 'a:
o Sel.200 or la.., multiply IIno 4 by \6,3% (.153). Enllr thl r..ull her. Ind on }
Form 1040. IIn. 47.
o More lhen 111.200, mulllplv line 4 bv U% (.02e). Th.n. edd $7.588.80 10 Ih.
"'1.111 ;",., ,,,. 10r.1 h.,. .nd on 'a,m 1()40, IIn.47.
I O'Cluctlon 10' on.-ha" 01 1I1I'lmplovm.nt to. Multiply IIn. 5 b
. n 'or 104 tin' I~ y
'or 'OP.rwo,k "oduollon A., NoU..,... 'orm 1040 "'o""oUon..
II GROSS PENNSYLVANI... COMPENSATION............ . ,...........
'b UNRllMaURSIO IMPLOVI aUSINISS IXPINSIS ,
1c TAXAILI PA COMPENSATION. Subtract Llna 1b 'rom Llna 11,
2 TAXAILE INTERIST. Compl'" P'" Ik:hOl1ull... II OY", 1'.000 .
3 TAXAILE DIVIDENDI, Compl", P... 1k:IJ000ul. I II OY", 1',000.
. NET INCOMI or (LOlli lrom 'h, OPERATION 01 . aUSINESI, PRO~ESSION or ~ARM..
I NET GAIN or IL0661 "om 'h. SALI, IXCHANCE or DISPOSITION 01 PROPERTY...
II "'MOUNT 01 GAlN EXCLUDED on P...lk:lJlClulO PA.II..... I,
I NIT INCOMI or {LOSSI lrom RENTS, ROVALTIEI, P...TENTS 0' COPYRIGHTS ..
7 EST"'TE ond TRUST INCOMI ,....................................................................................
I GAMILING IJId LOTTIRY WINNNGS ......,.........,....... .......,................................., ...................
8 WAL PA TAXABL.E INCOME. ADd Un.. le, 2, 3, ", IS, 6. 7. .n!j I. 00 Not Deduct loIN'
'0 P'" TAX LI...BlLITY Mulllplv Lln. , by 2J~ (00211..
" TOrAL P... TAX WiTHHELD....... ..................... ................
'"IIITIIIATlD ",YIIINTI "'ND CRIDITI, R'OI1 'h. In.,..ollo.. on p.,' 20.
120 CREDIT lrom ."' P'" TAX RETURN............................. '2,
12b "" ESTIM...TlD INSTAllMENT P...YMINTS...................,...........,........ .2b
.2. P"'YMENT willi ."IIXTINSION REOUEST ............,.........................,..' '2.
12d TOrAL ISTIMATED CRIDlT. Add Un.. .2., .2tl ond .2....................,..,.........................,
TAX 'DRGlYINla. '""" '" SCHEDULI aR R....1IIo In.lNClI... boglnnl"l o. .2&.
131 HOUSEHOLD MIMIIAS from Line 4, Part II, PA Schedull ISP"........." 13,
13D ELIGIIILITY INCOME from Lint " Part III. PA Scl'ledu'l 6P ......,,,.,,....... 13b
.:)c YOUR TOr"". INCOME lrom Lln. 21, SlOp &. SP WORt<BHEET .............. .:)c
13d TAX ~ORGIYINISS lrom LI.." Pan III, P'" Ik:h.dulO SP..,..... '3d
" TOrAL CREDIT lOt TAXIS P...,D to OTHER ST"'TIS or COUNTRIES "
11 EMPLOVMENT INCENTIVE P"'YMENTI CREDIT ....................,........ .... .................. II
,e TOTAL CREDITS and PAYMENTS. Add L1nl. n, t2d, 13d, 1.. and 11S,,,. 11
17 TAX DUE (II Lln. to I. morw thin Lint "1 ,...., 10 PI8' 21 Ind compl.l. PA hymenl Vouch., on p' . U.
,. OYI"PAYMINT (Lln. 1'1, mar. tnl11 Un. 10) ............"...".". ."".",,,...... "
'80 AMOUNT 01 LINI II to be RI~UNDED """..."......".""""."......."""",.."...........
IIll AMOUNT 01 LINI II to be CRIDITED '0 vou' 'HI ESTIM...TED TAX "'CCOUNT.
.ee AMOUNT 01 LINE 1110 be DON"'TED 10 WILD RESOURCE CONSERV...TlON ~UND . .
.eo "'MOUNT 01 LINE II 10 be DON...TED 10 U.S, OLYMPIC COMMITTEE. P'" DIVISION
Th. TOTAL or Lint. 1.. through tad MUST IquII L1n. II.
I. YOUIlInUlllf. U... ........., ,.)IlI,. 1'_" III, )IU\ftII'''' UItlI [.., kM......,.., WI ''''''11, 1M1lI....... MClIII"~1 KIlNII"" Ill' .1II.~\), au If ~ "'I t1.,. I.....' ....,. III w,.................'
Your 1M' 0'1' Your (UpIllan
PA::f~~~jE~~G~M!~~,L~,~TURN :R
g,~~:.:~~ or Pt~=nj. -- ,'''' I~~ o'PIr1m;nj;;f-R;~~: 5
...........CAR-RT SORT..R003
200-3b-1208 PAUL & PAMELA MONISMITH
187-44-8412 ~431 WAGGONERS GAP RD
CARLISLE, PA 17013-832b
NAKI CORR.erloNI I.LOW
__j[jjumllio ,''1'''",,'' """l'''''''j~i.I'fjjj'' i'olitl'fIiiC . N,,;,\iot.:::Mit'r'Ili' '~"""'l'I
[OJ om ~t'4{"I~,1 .".... * ~J'-
,.. , 'f" j.:.; ~ .,./
",r"/'f'o\' ""."1/,,,
.l.,.,t,~,..l. " .",).', ~"'~i'
HIIN n_ 'nelMd~JnlItaIl ".l"":';""'~ ',. ,t...4,. ','. ." T'f .'....,f~',', . ,.t~,~ I",,"''''
,-, '-' ',' r.'" I,> i''''I~I.~" I ''''~;j'('''''''(~ "~1,..,~{,'.'/.~~1I,,,.,.~\.. ""!IJ'...
"." "". '~..,~..I,. ..\'...~"M",'~i...,.I"i:., I",' ..1'\.".... ,,:.."",.', .,~.;
" i '.', f. '" . '. '.'to 'I' ,,_ ..'1 I ~~,,,. '1 't.., '('
';:1 .:;,.t.j~l~I:I:l'~.,~.t't,~1:,~!~,;-~'I . ,r, ~ I /,lJ,,:, fh"",,-~n f,..
. '" ,.... '" .
"'. f"U"r",.I'~"..., . d';'~';: ''\~,..:';:
Iiiiii
'.
"
'b
IEIU!I IOU lAND YOU! IPOUIIIIIGN. CHICK ALL MATS. AnACH ALL ICHIDULII AND 'O!MI
.,
Il\r"""":"'V"""l'I.~~'~
.. .,..,
...............
OfI"ttAL UII ONLY
~D'.,C;DOn"J~ '0
a.w ...... _I ,.
.........
C"I(~ HI" Onl, III ""','I'Nt~ 0
',om . 'III" '...
_I Of T"I ICttOOl. OOITIllCl
(I: vou ':?Oom" .tot
~, 1<5
iIDId
CHIQ(I' 'l{)UWIL.L NQTNUOA '.,.,. 'A.IlIClOKLIT
IT
I.
INOlC.AJ1 HCM' w,NY
OIIACH POAM 0"
ICH.DULIII ATTACHID
, 01 ~OIml W.2 :l.
, of Bcntdul.. UE
, 01 Bcntdulll A
, of Bdlldulll .
, olllcllOl1ul.. C l-
I of Sct'ldulll AK.1
00. , of Icntcliul.. ,
00' , 01 S.hldul.. c;.~
, 01 S.hldul.. 0
oii , 01 SChldul.. 1).71
00 , 01 Scntdul.. PA.18 _
00 '01 Scn.4ulu E
, 01 Schedul.. J
, oIlk:hOl1ul" 0.1
'00'
00'
2
3
.
I
00"
I
7
I
I
10
.00'
"
o
Ik:hOl1ul. SP 0
(CnlCk onlV II cl.lmlng
tax lorglv.n.lI)
, ~ Scneclul.. Q
, of Scnodulll W
00'
II.
. . ......... lIb
"",..1k
lid
00
00;
'GO
0011 No '''~ "
ICHIDULI C
('onn 1040)
Profit or Lo.. From Bu.ln...
11011 ,roprIItDrlhlpl ~H5
.. "a/tnlnhlpl, joint ven_, IIO,.llIlIIt 'III 'oml tou. , MI_
.. All.." to '0111I1040 or '0111I1041. .. "llnllNollonl lor 'c"ldull C '0Im 1040. I """'II.,. Of .
loc'll ,"urilJ _..INN
187 .. 462
_ 0111IO I,MN'> lot
Inlwntll"~""'1Ot
NlmloI~'"
'a..la K HOn1..1th III
A Principii bullll... Ill' P"'I"ion, Including producl Of "Nlcll..1 plgl C.I)
. Child Care I Cl.aning
C Iklll"... naml. II no "PIII'I bUllnl.. naml, III" blank.
,
I... C.I ..
D .......,., ID ........I.INI, W '''lI
.
8UII"...1II1I1..1 (Inckldlng IUIII 01 room no.) .. ...H;J.tJi"'9.q.9.t;\""~..I.!AP..B9..."...............""",, ...................
CI lown or I' olllcI 1'111 I ZIP cod.
;~;;~~~~: (11 0:: : ~ ;;:,COI' :: ~ ;~;~;;).. ;~;'~k:i~I~~;""""~~~"'~'
w.. Ih'" any Ching. In d.lIrmlnlng qUlnllll.., COlli, or Vllu.'IOIl' bllW"" op,"lng ond clo.lng IIIvIII'0I'I1 II .V.... Ill.eh
IlIplln.Uon, . . . ., ..,... I I , . . . . , , . . . . , . . . . . '
Did you 'm.'I/I.lly pl6I1lclpIlI' In lhe ope"llon 01 W. bu.I,,"n dunng 199~111 'No," ,.. plgl c.~ lor limit on Ionll.
I' ou l'ln.a Of Ie uilld thlll bUI""" dun" 199&1 check hi". . , . . . . , ' ."
ncome
,
G
H
0...1 "c"lptl or HIM, CIUllont /I ,11I1 Incoml WI' reported 10 you on Form W.2 1I1c1/n. 'S'IMory 0
If/IP'OYH'l>o.Il on 'he/Iorm .... 'c/lIC~ed. _ pl~ C.~ II1c1 C"..~ h.,. . . , . . . . ..
2 RlMn. and 1l1ow1/lC" . , . . . .
, IklbtrlClllnl 2 Irom lint I . . . . .
4 COil 0' goodl IOkl ('rom IInI 40 on PO;I 2)
I Grool lHOIlL lubtraCl .". 4 'rom linl 3 .
. Olhtr Incomt. Inckldlng FlCIllrll and 11111 gaIOIlM Ill' ''* till crldll or ,,'und (H' plllI C.2)
7 Orolllncome. _111111 5111MlI . . . . . . . , . , , . . . ' . . .
III .... nler ell ses or Ilnass us. 0 our home on on IInl 30.
1
..
, .
."
. AdYI/IJ'lng ..., 18 P.nllon ond prolll'lhlllng pion.
. a.d dlbtl lrom HIli or 20 Rill' Of III" (IN PIgI C.4):
.....Ie.. <_ pegl C-3) .. . . VI/IIeIll. n'olCIIIIII'f, rd equip"*" .
10 CII Ind INCk I.,,,,," b Olher bu.ln... plOperly .
IHI p. C.3). ., 10 ".. 21 R,pII" IIIMl moln'IIIa11c, .
Commlll'on. IIIMlI"8. . . 1 22 SIlpplllt (nolllv;ludId In p.n 1111
Dopllllon. . . . . , . 23 T.... Ind lIeon..1 .
DOP'IC'11Ion and IIClIon 179 24 T..YIi, mllll, Ind Inllnllnmenl:
IIJPIIlII dlClUCllon (nOllncludlCl a TrIYIi. . . . . . . .
In Pon 11111..1 PIllI C.31 ' . 13 b MII'I Ind In.
14 employ" bI".m progroml Ilnllnmlnt ,
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. Alt,ch Ihll form to oUllnoomlt.. lI\urn.
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OMB No. '140-0'11 r .,::,~
~@96"'" '\
~Iadvn,", .'~~ ~.
SIO.,"" No, 23 ' '.' .
'''''' 4136
"oIn1, IU tlll,!",,'M U.\ ~OUI Incom. 1..-, Illuml
Paul S & Pamela K Monismith III
r:mJ Olnvl.Powe"d Highway Vehlcla Cradlt
C.ullolll You "OMIIO' clolm 0 cr.dlt on . dlo'."pow.,od .ohlc/o thot wo.
-..-.-----, - .., I.' 1101
Numblr 01 Credit _, v.hlcl.
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D2!lDIJ Fuul Tox C,udlt \ :';
.._.... ".~~!'!'~,-~~_conno' clolm ony omounlS on FOlm 41361ho' you clolmod on Form 8849, Form 843,0' SCMdule C (Form 720),", :;:.
4 NOl1hu.iJbht U.. 01 0810llnl I.~_ ':r~.,'"
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u,chosed .ltor Au Ult 20 7996,
I.'
Credit
eot . )II cot.
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1
2
O.8'h'l.pUWU'UO CO'I
O"..I,uow."O IlghlUuckl Dnd van I
1
2
o CiIl$OhOI (Onllllnlng It lealt tOIK Ilcohol
b GUIO/lUI conlolnlnlJ olIIQ&1 1.7% alcohol but leu Iha"
IQv.olconol
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Gillon. Amounl of crrdlt
~l
,
T~pe A'tl Olllon, Amount of ctldlt
of un
S.12U . 1
,1'142
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AlII
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Amount or Ctldll
CAN
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301
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o ql~'~~~!'~y)..~~~lnnl u.,q
b ~,~r~ .:~, I.L.'!'.~'-I(J' IOltlltnlJ pu'pUISln
._'-2!!'.!!.~:~!.!~~te use
~ Nonl.Aublo U.. 0' Gal.hol
C 1J.l'iOI,f., ';unI.Mltl\l at h,ltU 5.7% olcohollHA ttlllhln
7 I"~ .1Il"~'.hUI
6 NOIll.,ubl. U.. 0' Und~.d 01...1 Fuol (Lln.. 60, b, .nd c)
Sui.. h~ Roylll.tld UllImol. Vlnd.to of Und~ld 01..01 Fuol (Lino 60)
.'
:-..1....'111,( C\.',1i!llIlJ !Ilollnt (Jleullull dn..! nol conlpln lJlalble 'vidence or dye.
!'~I!~.L~,,;t, ~1:~~2!!nClucJl!d In thiS claim tJld contain lJlaibl. 'lJldence of d '. aUach a dftalled tk lanallon and ch.ck h.r.
LUlU liu, D. unl.l c: Clalmanl nos th. nom. and addruss
'JI tilt: p,;r'Jl,JlltS/ wlla sul(,lthl! dllJ51!1Iuel to the clulmllnt
anI,) II,\" <,JJIU\.)j ollh" pu,cnDul'S). and II exported. the
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d CI"lrn~III." reglll.r.cJ ulllmul. venlJor. lold dieUllu.1 hJr
Ulf by the buye, on I '111m 10' hHmlng purposlS. or to a
slat. l,ll tocal \lClv.lnmunl lor II, fxclu&IVI un. CIDlman'
obl'ln.,., Ihl "~ul"d cer1llicalt from thl buy.r and has
f1? rU."'.I~ II'J bthh' uny olll1e Inlo,malJon In Ihl
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Form 4138 1'"'1',' ..
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C.I.No.1262m
456~
Depreciation and Amortization
(Including Information on Listed Proporty)
OMII too l!)~!I'.'ltJ
'il~J)96
I'uu!
H
1\11'."',111'11'
Ii> 500 IU'PDUllu inlhucllullb, .. AIIDCh thi. 'orm tu QUI ,.Ium. ~..ql.l"II~l/ NI) G7
H,,',""I".!,UI,I,.I',,!,h;'..I.,,'I,I!,t,j"tl,111..' hJ"'lllf)oUI\J~'-
& pum~la K Monismith 11 Schodulo "pH 00 36 1206
. ....______.......... ___._____._.____..~...___.n'_..__+ . ___..,_
(lecllotl To Expanse Curlllln Tllnuiblo Proporly ISodion 1701 (N,)lo: /I lOll ''''''J ,till' "1t~/e(J pIV/"my"
,I,,i.lt:l,e !:.iJt~Y-_.I}_tJ!~wJl.Jl1 C.<J1.'.l/J/tJJt.> fJ~!t It" ___ __.__...___ __._
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; 11,1' 11":11.1111..11, It .I,. L,.dl'/jlll:;jl' :1~III' 1.IJ:,'"I'~.~ ",11' 1;,Hll,;1 .jlltlt! 1I1~IIlJdi'Jllb
'.j' I '~I'\.II<J'1 1 ."J fJ'UI~I'rt,' 1:I.lLl'd III ~,I'IVlt.l. ':.VI jl;njl':' c.d Illl! "l:,'rlJl'l'on~l
I!./..:' ',-,.j ,:..;~I vI S0CtlOll 1 I\J prf,)pl~11y beloll' Il!!jllc;llon 1IlIiIllItallo/l.
n..:lj~H..II' ,/I 111 IUllltallUIl, Subtract line 3 lrom I"l~ 'J.. II ,lIJrO Qr I~t.~, ontor -U-
()r:II;LI Iil1ltl.lIllJr1 lor tn;. Y~UI', Subtract lUlU 4 lrom Ime 1. It zerQ or h3S5, onter -0.. IlI1lGrneu
11111.1:..1. .." r oJlalelt- SUlI p~go ~ of the 1115tructl<?~__ . __. . . . .:..._'-.:...-:_.;_.....:_ _ I) ~':.--.~ "~-:o" ."''<:
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5
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lu ,1'1.' r J'~iLllu""'l:lJ ,JudllClllJrllrorn \~':J5 SttlJ page:! Ollhl! II1:itHJCIIUllti 10
, I 1.;....: I,'~')~ ,I, .,;1''': !IIllllallOIl fnltlr Hl~ !)rllJllcr 01 bU:iillt:55Inl.OllltllnOII€Mi \l1IlIl lOrO) or lill~ 5lsec In~II\,';lIonsl t1
12 ~l:':l,,~r.' /~J l.:,).(.,lIlrlse cJeductlon. Add IllltlS 9 and 10, but do 1101 untor rIlme lIlUllllno 11 12
,:) . ~~~! I '.i_,.:r .'.f.~~I::!!I~~eo OeOucllon 10 1997 Add lines 9 and 1 0, le~~ 1i1l~.13 C-~ \~~~\1T~~;\~WI0]
I~(.ilti~ r d ,,' ,. fl,111 II or Part f1I be/ow for 1I,5tod property (automobiles, cenom other VtthlclL)$, cellular tfJ/VphOflU:i,
. I,:' r.l,(, , .~':J ::"<'..':; 01 /JliJ!Jlifr,. (I~il() IOf 11fIhllt..Ilrln1t1lll, ftJCfO.1lI0fl,.9!...2!.nll'lOrHUfln In:';(I".tJ, ~jsa Farr V lor /wh.l<1 property,
r-JM'1WTl M^CRS Deprecilltion For Assets Placed in Service ONLY Doring Your 1996 Tax Year (Do Nollnclude
.-"Itilud Pr~p.!~:l____..___n_.__,_._._.__ __. __.._.__ n..... u.. _ n _....___________ _.__.._
,._. _..__.~..._ .." _._.,,!),.,.~~~~_'!l'=OUJ!!~~6~~_t !'!?~~~1_1.~.E.!u~_~i~-". _m__...h.~_____ _...__ _ ___
, II' ',,:1"1114 Ill': l!tI:I..:IIQII ull(j(:r ~t;-C:lun 16~(1J(4J to group Jill iJ:iSIJI~ f.!1i.l<':..llj III tiel vice dUring th~ tJ;\ y~or InlO OPt:
I' J~ II~"..:!I_~.~~.~.iK~~()Url..!~ r.h~~I~~J2~~. StJe p~~;: ~.r th(llnG~ruCII~r.~~_c__.~~~~..:.......;...-:.-:-_~_ll..
_______~ectlonJ!-~on~rul Du roclotlon Systt.llll (GOS11SC'j.!~(J~~t 1t~~IIOnS) ________
lbl Mon'" oInfJ leI Uml16 ror I'h:nll''''liltlir-;n (dl Hl'l '..~'I
,I I !.' 1--0:11) ~1tJ.f pl:lCv<) In It)USU1~r.lYl'I.....b"Il':tlt 1.It.t> ,,0.111' oj i llfl ~ (I" 111l1\ (r) M..\Il1'11 to) Ot-pl,""~11O IllJ~>UIICI..'I'
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150 _'::_':~'~~.J)~'.)Lt.~rt1.__ ;'\\",~2"'" ~ ____._ ,______ ____
b.. j... I.!'... 1 ' It:; ,~',' ,,'-, "
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:, II 11:,'l~ll ________. _________ ._____ .!~_:_ _~_ ___~_ ____._
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I, ._..___._ _n____~_ _. ___,_ 1---_
StlC;",?':'..~:-:~'.~~.~ll~lI~e-l?~pr~~:~"-lI~~:r~te"' (~:~~){;oo.l~a(!O '1J' ~h~ 1I1,51;~Cll.<l.'~r -==--=-=
~ . 1--"'---"""- . . .. T'I' :____1 "!'- n ~'+--I------
(.};Tl (11) - Ol~..r. D"prec,!,liO:nlo~. ~.9t!nci\l(l~uLI,,!.e~F'roper.tY,I.LSc" .lJ:iU:;'-:1 .l~.lt.ltJ.!.nslrvcIIO~!J_ ______
11 '_ _ : .',.",~ ~"U\;o;ll'..H15 11.11 :lS~lH~ I-lIJCli:lJ III :it?rVICI.: In la" Yt~;)I'i tqJlIlflllH,J lhllQIl' l'J'J(;. , . .. 'L ----~l-..7-:--
16 P'(I_,..,I, '~'..r;;.)c.;t to stJli:tlOn 168(~(1) CIOc.:tIOl1. . . . , . ., ,., 18 ___
19 ':"CHS ,ltld alhe. dcpre1::mllon. ' . , , , . . . , . . , , ' . , 19
~U~I!!~!:Y_I2~~P~9f~_.'!__o.!!.~_~n51.r~.ction'!:l_...____.. ---. .-. n --'-'J'-'- -.--. __.m__
20 ( 1, ~ I I 1)I'iI., , Illt'r ,IIIlUtllltlrul1llUle 2li. ..19 __..__.____.
;tl Tot..L ..,~ : ':l'lIuCIIQr\s on IIllt..' 12 Iirlt!S 15 and 10111 \;clwnn (91. JI,d lilIes 17 IhrOlltjtl 20 Fnlf!r tlldfl} .
, ,)r,I .1\(1111.< I,t'....~ ul )I)ljf rl.!furtl j-l.HlrltJr ,/IIP:; .mtJ S l oqJI.}rJh)rls" ',1''-' ItI:-i_IIUcllun~_. ___ .2L ......~:~.:t:.~~
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~"IIII 4562 1I1J'J(il
SCHeOU~ES A&B
IForm 10401
"1-"'"
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"t, I, ,',..'t (PI
Schedule A-Itemized Deductions
0MIJ NIJ It)AI'.l.001A
, ',...,,,,
r"jH" '. U ,',",111";1111 H)oIU
__Paul
Mlldlcul
Dnd
Dllntul
bpllntieti
Tales You
Paid
IS,;.,
I.J'I" A' ,
Inter"til
YQ" P"'lI
,Sl"
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'i1M96
ISchedule B 10 UIl buckl
.. AUuch '0 Form 1040, .. 5.. In'bucUolI" for SdutlJulul A IInd B (Forn1 10'-0,
AIIII..:llIIHtfll 0
til/!lU,Il(U NIJ 7
YtJur loclllt ..r:vU~ number
I
2
J
4
6
6
7
S
S & Pamela K Monismith III---
\
Caution: {)o 1I0f IflClulJl} (})pall~lJ.s ItJUIltJlJI61/tl vI J.ldld by c.;"11,'1~
MtHJlcul :.iml ul.lIlI11IlJ~ptH1S~t) tti~ij pl.1~Ju A.l) ...~... ----
bUIU JIIIIJuHl tllJIJl h..rrll IO,l!] Iilit~ J~ l_ 2__1 m. ~...J
MuHlply Iltle 2 utJOYiJ tJY 1 t.l% I O/b} , 3
~ulJlrocllll1u 3 hom hnt} 1 II hIll,! J lti OlO/lJ IIHlll lUlt~ " 1.'1llllf -0.
Sliltu an<.J IOClIl 1(l(':UllltJ liJ)l.UB
n"OI "SlOle lo,e. I,ee poge A.2)
Pel ,On a I properly III,e5 ,
Other II)xes. list type ord Illllount ..
8
I-
9 A'Ju tlnt:~ 5 ttUOlJgtl B
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10
11
Iknlt IIHJII(j;Jtjt: llllcll.:'11 JIl~ pl.lflb ,cpurll:d 10 'tlHllJll ~lJIltl 10~lH
11<..;(1)': flIQr1l),IY\:" :llll:'t!~IIil)IIl:pllrt~tJ \(1 YCJU ()Il forml0Uti tIIJd1iJ
10 HIt! p~f'.i\Jn "0111 \"'u.:tll YlJU bOlJqll! 1I1e hOIl1~. s.!~ pay!? A.~
and 51"10..... th.l1 r;~rscn's r;ijnlt:, loenlllYlng no., ana au(jr.:bS ..
Not,,: ..LL P'--'--
Pe,.,cn", 12 POllltti "01 roported 10 you on Form 1098. SlJe pUHIJ A.3
IlIh:r~':I1 I~ lor spaclul rutes . .l~_
flul
(Jl,:(j,....I.l;I, lJ Investment interest. II requIred, altilcll Form ,Hi52. l~eo
page A.3 I lJ
14 AOrJ 1I1lt!:) 1 Q lhwuytl 13
----'
Gltlti to 16 GIIt!"1 tJ'i cast1 ur ctu~ch II you nHlde till,! gill 01 $:!50 or ,.
Churlty nll.)r';!, see ~age A.:j 16 ~;3V
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11.,..l,lll,i<J1; 16 Oth~r than by c<Jsh 01 ctll..lCk If [lny gilt of $250 or IIlOIl!, ',",:..;
g,11 ,iI".~ 'J'.l .' Sl.1C pJge A-3. If over $500. yOll MUST attach I-=UIIll 820:3 .!!L
til.,w!,1 11',1 ,! 17 Carryover lrom prior y~ar 17
~I:'!j I;';(]'. A.: 18 Add "nes 1 5 Ihrough 17
Casually and
Tllell Loss~s 19 Cllsually 01 In""10S5(.5). AIIJCll Form 4684 (::;"" page A.4)
Jub E Ap.ns~s 20
ana MOSI
Olll.r
Misc~llan~uIIs
Oeducllons
21
(Set: 22
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a'.'J'.' I I;, ,.:
23
24
25
~6
....-,-.--...
OIlier 27
Mlscellaneolls
Oeductions
Tot(ll 26
itemized
Doductlol1'
19
LJnr~ltnt.JlHse(j ~1l1pIOyt.:t: u...p~ns~s-lob 1 rl.l',1;' I , union
dllt.'~', If)l) !J<hKiJll(!Il, 1:'(( II rtHllllrecJ. YOlJ MUST :Jtlact\
t(lflll :'>llJl) or :210tj.l..1 \~o:1i pa~lL' 1\ ~.I"'.
Ta... preparation le€~ .
Other expt!nses-tnvt)stlllenl, sale deposit box. etc. List
type and amount ...
~-
21
:0..~~~ -
l~2j
22
Add I,no. 20 Ihrough 22 2J
. . . . . . . . :,.~~.~,
Ente' Jlllounlllolll f01ll1 10,10 In" 31, L24 L_________1.__,",""
MlIltl~ly ltn~ :0>4 above by 2%) ( 02) 25
SutJlract line 25 II(JIII lUll! 23 If hllt:1 2G IS 1I1ultJ Itldrl hnC :!:J. t.Hller .0-
Ottwr-lrOrll list 011 ~uge A.4 LI~l lype and iJlllOlJllt ...
Is Form 1040. line 32, over $117,950 lover $50,9/5" ma",eu "linn 50porDtely)?
NO. Your dt?cJucliOn IS not llrlllled. Add the,GmOunlS ill the 1m rlnht column } .
lor IlIi~S 4 through 27 Also, onter on Form 10~O, Iiflp. 34, 1I1clorger 01 ... 28 i)i j .
lrll~ amount or your sti.lndllrd deduction ' ~ ~ ~
YES. You, deducl,on may be lim,'ed. See page ^ 5 lu. 1I1e arnuunt 10 enler "~f.~. ~~~
Fur fJap\',wu,~ R.,ductlOIl Act Nollett, seo Form 1040 in"tructions.
(;,11 No \~I,l:ll
Schedule A IForm 1040111180
.
SCHEDULE F
(Form 1040)
Profit or Loss From Farming
IJMU t11J Hi"') l.J1.I'4
101
.. AUlch to Form .o.tO. Faun 104'. 0' FO'I" 1005.
.. Sou Inlltuclio/llt 'or Schuuul. F (Fa,", 1040 ,
'\]@)96
lJtt~&""'~"r .,f II'. I .
'''11'' I" .._ ..' ..~ "'"
/l.l!.I,llIl'~!lI
SII'iIJ!tnt" t'1IJ 14
~hlll,,, ':'1' 1:1.,1,'
Paul S Honlsmith III
A~~.~~'i:~-;::'IL'li ", on,,\./ I~Q \'IO'Ub )1)'.1 P"'ll''i':li~::;~;-I~:~t;-'~;'~'''~-::-'~';''1 ':1. -~-L'~iI --
60(1.1 ..CUrley numb" tUNI
...2.0.0._JJL llO.lL....-__
U lHl,., p.", '1;,11 11'11" 1,'1',1,1' ,U.Io~II~
".._____.__ ..~~~~~'~~~LLL.J
o l/IIploW" 10 numb" IIINI. II an)'
C ACl.;uunH'IJ '1l~lIli)l.J
1\) 0 Cn,'1
(21 [J A(utJul
.1-1
1._L.LU
I OIlJ y()U ""rlH\l,,,'lully pJr11r.:1~lJht" 1/1 \IUt UI.H.!rill,otl OIUlIb tJUijlllt.'bb dut'/l\J 10Ulj'llI "Nu," b~U paUl! F.~ lot IUllIl on pillS5lv" lObUli 0 Yeb 0 No
ImI Form Income-Cash Method. Complete Ports I and II IAtcluol,,"llIod '"p','" co/llpl'l' Port. II ond III. ,nd "'" II 01 Port II
___._ _ .. o? nO'ln~~u_d....!!!~!.?!..'I~".!I~?!<uh.'!d.-'.~~.<l!utt._~~~..dlng. .,,_ort,.o!dulr}'p~r"~.'!.'l r. ~I_t~,~~ !~"! on Form!797.
I 51.1I1;"1 ",I Ii\~!,k)l':" unl.l olhijr Ihun" ~ou tHJuijl1lllll fUbU11J . . . . . , ..1- u -.___..._ _ ~~~~
2 COtll or CUll" lhl"US 01 1l\ot!6Iock umJ olher 11t!ll\1) '~lJt)'h!l1 on lItlU I 2 ~~~~:
3 Sutlltao.:llinc:! !torn 11Ilt! 1 3._
It Snle!) ul h\otSlOck, prodUCII, grOln5, and oilIer p,Qdur.11) OU fllllU]iJ . .. .. ~-:'o-
al r\,;llll CCGpt:/,III\oti (jltilnbuhon& (Form!5) lOUa.PATRl 150 =!:-J I5b TJJ"'1I011J 11l110lJllI &b
60 A\JtlLlJllural prolJram puymQnl611HJti J.HJ\jU F.:!) 60 __~I__L~ Ob TII:autllu lImount ,~6.~.~_
1 C(",r1lIflOOII~ CIl:I..III COIpotOIlOtl (CCCj IOllns. (bl'lt IJlIlJll F ':!l '<~:-:.~
. 0 eeL I~iln~ fl.!porlCO ut1dtH ulectlon 711
b eee II.Mllt> lorlt':llt!l.I . I '7b' I ~~~~ 7c "fu...uIJltt lltllQlJnl ,:"l~~
a Crq.l lIlIiIJr.ml:l! j:ruct!t:d5 CUlll (1:II,lIIl dl!)iI51t:r pil~1l1l~1111i llitJl;' pU!jlt F')l '~~:(\~
. if {,I1IL.'l!llll"_"",':d II11'J96. "., lJ!l!.....L-___.'j_.:.~~..J ab lilJlnul1] urllOlJl1l Ub_
C II l'!l.."l, I ,,-,1 I tl' IJI:I!!I II.l H}97 lb ilIlJdll'll. dmck hf!IlI" 0 ad Arnou,'lllultJ/lt1t.J 11011I 10!J6 . BJ!.
Cu~ICln !I"l' IIIHH;tlln~ workIU)(;oll1u 9
OU)I'I IIlCll/l1~, 111ctUOInl) Fttdl!IlIllInd !Slale g,hOhrltt or IUlJllaJl crelJll or rclu/llj (';at''! f;JUI.l F.;!! 10
Oroll 1111:0'"_. Alld ornt,lullla In 11113 tIlJtll colurnnlor lines :Jlll/Ullg'l 10 Il11CClUlllllllllhul) 1(J)'pJyltl, \':1111"
lilt' ,1111)unl I'(J1Il page 2, 111l1! 51 , . . , . . . . . , . . ' . . . . . . . ,.. "
ImII Farm Expenses-Cash and Accrual Method. Do notlllclude personal or liVing expenses such os taxes. Insurance,
re.ealfs. etc., on your home.
-
..
9
\0
11
12 C.lt an'J truck
F<!-al'i~ ,Ill
13 Ctl,~nllcal...
,. C(.n~I""'.J'IU
P.JYI! F.:\/
1~ CU51()1l1 hlle
1B Dl!pr~(.luIIUf
t:'-f..lt:II';l.' dc{
IJ 15 ,..... I II: r . ~ l~)
-.-------
I~Jlptlll~eb 1~l!e J;lItJl.' 26 PerHUlJll nml prolll'5horJnO
.lch Form .662) . 12 plUllb 26
13 28 HtJnl or IlJlltiU (:;.uu !Jngtl tt'..I): ~
II lj~ptln~e5 (Gee II V~hll.:II!!). mJchU1~ry. and equip. , ~ 2..2.
14 menl 2S.
ltnactllrll! work) ~ ~ b OUHH (lund, UIlUnul~. tile,) 2Sb
I ilrlU Stlcllon \79 27 RefJUlrs .Ifld IIHllnlf!flarH~e 27
Iud Ion not claimed 28 Seed!::. ilnd f)klnlS IJUlcha:;.ed 28
t'~ p.19~ F.4) \8 7~ =- 29 SIO"I~Jtt IInd wUlullOU511lU 29
b~ntllil programs :lO Supplies f)IJldlas..:d 30 1.# {QQ -
n line :l5. \7 31 TaJltlS 31
,.u \8 "!-oJd- , 32 UlllIlltls. 32 ,,...~ .
19 ~U '. ,.. 33 VflcrulLlI~ b'~~llln\J. JIUJ ll1elllcm~ , 33 13-" -
H..llim~
Ifuck,ng 20 34 Olllltt e>:pllnSe\ (!)puclly) ;;&1
" .
I, and (,11 21 /1 -:, ... . Ot;hr(l 34. j.... -
- ....... ....... ..
Iner Iflan health) 22 ",L. y. b 34b
.. ".." ..., ..... ."" ... ..
~~- 0 ... ......"., .. .....,.. .. .... 340
;Jltl to tmnks. ule,) 230 d ...... ..." 34d
... "...
23b I~ 1'-' _.::.- . ... ..... 34.
~'J ,~rl\~I().,rnltnl Cftl~~! 24 1 341
IfI. AI'1l11ne5 1;? thfOUlJh :J41 ~ 36 3"...-,1':,
: ( :l.<f 7<" '\
'it or (Ionl. Sublfad III Ie 36 Irofllllllt: 11 II a ~.HOIiI. tllll..:r l./rl Form 10401 line lB, and ALSO Oil
. IIn. 1, II :I 1055, yOIJ MUST go on to line 3;" (cslalc$, trusts. JnLJ par1fllH5hlf,lli. ')I~O page F'~l. 311
370 D,(u IIwllslmenl15 al II$k
37b 0 ~ull,f 111.~~llIltrlll~ Ilul dll'~_
17 crnpll.ytttl
Glr,t:r trl;Jn ()
1B he/J ~urCll<1
,e FcrtillltH!):lr
20 Ff~19hl arLJ
21 Ga!iOIIl1t.', fue
:22 Ir.6urall<..t: 10
:23 Iflter~s!
. Mnfl'J';'J'! q;
b Qlt'l'r
2. l.lt;{)1 rl'fe'; ,It:
3~ Tolll up.n
38 ~.I 'aIm pro
Schedul' SE
37 II )VU hJ'<l' .1Iu:l5. ~ou MUST check Ihe bOJllhat descllbes your fn~lJ5Iml:l1lln thiS ar.:ll~jly (SIlt! pilue F.5j
II yaw (,11t.!Lked 37a, enter lhe IO!'iS on Form leMO, line 1B, Ilnu ALSO on Schedule BE, line 1.
II yUu ctU!L'ked 37b. yOIJ MUST Illlnctl !form 619B.
!for Pop.rworlrl Auducllon Acl Notice. II. Form 10.0 Instructions.
C.II 11<1 1 I ~J.lIJtI
Schedule F (Form 1040) 1996
~
;1 Z P.N!!,!~!~~,!!},~,~!,M!",,!~, ~,~!URN ''''''''''A'
cc ' , I YOU WUIT flLle... MIDNIOHT, TUIIDAY "PlUL U, It,,' . .
Q. p". 4QE I lOW, Ulil Commonw..llh 1,)1 fI.nf1lvlvllIll. 1 996 PA DWVilrtm'/11 01 A.~.nu.
Ilh'U tlllh, p.pWltlliJ ",hllm,tlt,mllll ~\"II' l.b~1 ul1iJ pllU .llIllh. 1"'1 bltlo~ PIA.II, .n~ ""UUI) (Ulllt~IIl)11' oJII ,lluI1alJ.l.nd thll~k th, UHlNAMIJADDRUI Chin
tv_' L...... ~h~'11 h.....lt.. t\vowll' bl).~ !:lh>l", "...gO ,.In. t.~ ''1''''1'', ''''I 'ILIIl 1''*' Onl, Ontl
sO.... J
M 0 MauIH._... , C
&.",,'1.
E.I
. bu. b.lu~
\
2DD-3b-12D6 MO '167-44-6412
PAUL & PAM(LA MONISMITH
3431 WAGGON(RS GAP RP
CARLISL( PA 17D13-632b
'~"'I/I" Mo.Wle IfIl~~ ~~ I ,..,! PI..,. & t.\o<>>l"I~,,1 'lJo'llp ~ 101''8",,11I,)
",.,rlH'lIng ,IoflIIt
'1/1I' ~ II tll'UIII8
lIo~ , 1l"'~U Ii'll
t.-.p.,....Qt(....o
.~I" III' 0,1' III
O"Ifl. I, .).~
""Y. 0' ICNOOL OlltAte'
ICHOOLDl&UIlCfCODI
ZI/IU
~'III,I"fN.,.t'o""l':~'ItI'''''''''1
51'"
lfC()J1
O"IOH 'Oft A 1"' IOOKLlr
CJ Chll;a IlIrl rl ~0Il .111 nOlnttll. '''1 '.a 10.1III,1
o ..",..,...ll.COllllI CHA"GI It ....., 0111I' .bol' .....tOlm.hOll'. d~I.!"lI hOlft ,0111 ".. P"'11a ,,111I11 ch.I.'M'1t II tOIl! '4~1U '~'rt~'Cl II~ p'u,"" l/tf
""111Id 100 (.xiI 0111I' (.,~ IO.....~il C\IIo..r OlIl\ojM"~.Mt II/tfr, )CII ~114 01\ '21)IIM hamt /'IlCUU
1'111\',1 IH)Nl)lIIHllll 1 '41')
IHJUNIJ Tl) WI 11)1 I UOII 1\11',
III 0'015 CompenlSotlon ham W'2 lormtllllnd olh,r 1181em.nllS
,,",~PI VY ~ fLun. h.llhll blt~ III tl.lUI p,A.,.oel
tb Unftlmbuned Employe. BUIIn,,1S EJpenl5O. !tom PA Schedule UE
'"
.1. I b '7 :1'1.::>.
Ib I .
Ie I L1.51.5.
2 I .
3 I ~.
4 s 1..1577.
5 s J89~.
6 s 1~'1J..
7 s
.
6. Th.. Itlu,n mUll b. m.d on 01 b,'orl Ap,1I 15, III'
1 c Net PA TUIIOI, Compenllllon_ SublrlClllne 'b Irom IIn. 11
2 PA Tuabl. InlltOil (Complele and allllch PA Schedulu A if ov"r S 1.000)
3 PI. ru.bll OIVldlnd'. <Campl"" .nd .nlch PI. Schldull B II 0'" $1,000)
4 TOTAL PI. TAXABLIINCOMI Add I,"" Ic, 2 Ind 3
5 PI. T4X LIABILITY MUIl,ply hne 4 by 2,8~'. (0,0281
6 Tolal PA TII.I Wllhneld I,om W.2 10rmllS) Bnu Olher lillllemenll
7 Tolal Eslun8led Payment. anlJ CredllB. See 1I15Uuc:hOnl5
8a Houuhold Memberl5 from PA Schedule Sp, Pari II. IU1Q 4
8b Your Eligibility Income from PA Schedule SP, Pori II!, IIno ;.!
12c Amount OIIIl1Q " you wanllo Don.le 10 Ihll WlllJ AesourCQ Conurvallon Fund
Ob I .
Oc S .
. . . . .8d I
.
9 S 1 8 q d...I
E .
11 S .
12a S .
12b S .
12c S .
12d S .
.-_.-.- ----~---._---,---.
.
]
6c Your TOlallncome Irom PA Schedule SP, Pari tII, line 1 ,
80 To... Forgl'~QIl'u Credlll,om PA Schedule Sp, PS'11t1. line 7
9 TOTAL CREOITS AND PAYMINTS, Add IIn.. 6, 7 .nd ad
10 TAX DUE LlI1e 5 IS more than line 9 See inSUuClionlS lor How 10 Pay. U50 your PA,V
Mako ChOCk payabl, ~ DEPT, OF REVENUE
II OVERPAYMINT, Lln' 91, mora !han Ilnl 5
121 Amounl or line 11 you wlnl II a Relund Check mailed 10 you
Pi.... 10 nol ull tboul you, ,,'und unUII ...... .11., IIlIng
120 Amount 01 hne 11 you wanl C,.dlt.d to your 1997 PA EahmalecJ Tu Account
120 Amount olllnl 11 you wanllo Donlle It) Ihe U S Olvmplc Commillee, PA Ol\llSIOn
. _..1!1f.. ro 1^,".Qf..~1/l1l UA..u~_U. ANll.JU MUSI f.OUAL LIIiU.I. _..... _. ._.___ ..___ . .
~'.'MIIIlUA.lIIIII"II.,Il".I"'llIl',II".IIlIl
X""I.~"'"
r~:i' Ilgn.iut.111 ;;;;;g-j~Mlltl
~~~;;':i~-~~;i.;:;;'---'
:-I
U,lh'
Dill
1 m.II. I don.llon 01 III 01 0,,1 01 VOlol' orl'Dlvmlnllo Ihl ORGAN DONOIIt AWAlltlNllSllllUll 'UND
Nl:.IUnl~ tlY ~"'I'1IL. Ib, Itll:ll IU,
CAPITAL TAX COLLECTION BUREAU
9 5~ ~.NCVE~ ST.. $UITf 102
AIlIl.,l5L,E. p~. 1,'JO~ ~..H36
lJ~96
LOCAL EARNED INCOME
!AX RETURN (F9RM 531)
111'"1 h'IU'.llJ 11)11,.,1 tlllJlIlljl'l ..lLIU",UU In ....IL ""II,/Ii"!fU'" .,..,
.."MUl,I" ."u IoU....'..." f;QPIU "~O"G *,11" ;. 'h' UIUI,un
~1"''''.U '''Y'IIl'.
SEE BACK OF RETURN FOR
PHONE NUMBER AND OFFICE HOURS
$737) .
EM~LOVEE BUSINESS E~PENSESI,,"ach Fede,al Fo,m 2'06 & 51 ole Sch.uol. UE'J 2
TA~ABLE W.2 EARNINGS (SobllaCI Line 2 Irom Line " J
OTHER TAXABLE EARNED INCOME (NO INTEREST OR DIVIDENDSI Compl.l. SecliOn B on Bock .
TOTAL TAXABLE EARNED INCOME (Add Line. 3 ond 41 5 I
"
NET LOSS FROM BUBINESS, PROFESSION, OR FARM (ATTACH FEDERAL OR STATE SCHEDULE)
.
SUBTOTAL (SubIlOCI Lint 6 Irom Line 6)IF LESS TrlAN ZERO, ENTER ZERO ." "j
NET PROFIT FROM BUSINESS, PROFESSION OR FARM (ATTACH FEDERAL OR STATE SCHEDULE) 6
TOTAL TA~ABLE EARNED INCOME AND NET PROFITS (Add Line. 7 ond 6J e
_..~,_.-.. ~ ----....,.- ",",' .."
TA~ LIABILITY 1'10 OF LINE 9lMull'ply Line 9 by .0' I '0
TOTAL LOCAL INCOME TA~ES WlnlHELD (F,om O""C".d W2., Bo. 211 11
aUARTERL V PAYMENTS AND, OR LAST YEARS OVERPAYMENT CREDITED TO THIS YEAR 12
CREDITS FOR TA~ES PAID TO PHILADELPHIA AND, OR STATES OTHER THAN PA (ATTACH SCH GI IJ
TOTAL WITHHOLDINGS & PAYMENTS IAdd L,ne,", 12 ond .31 " I
1-
TAX BALANCE DUE (Sobl,oct Line '41'010 Lino 101 PAYMENT NOT NECESSARY IF LfSS THAN $100 15
INTEREST & PENAL TY (See In,"ucllon" '6
TOTAL BALANCE DUE (Add L,ne, 15 and 161 Moke ch"ck payable 10 'CTCB' .7 .1
OVERPAYMENT ,Sub'"cl L,n. 10 Irom L,n. '" IF LESS 7HAN ZERO. ENTER ZERO '6 I.
PAYMENT TO BE REFUNDED '9 .
OVERPAYMENT TO BE CREDITED TO NE~T YEAR'S TA~ 20 '
OVERPAYMENT TO BE CREDITED TO SPOUSE'S BALANCE DUE FOR THIS FILING YEAR
NCkTH NIOULF.TON TwP
YOUIIIOC....IICU..'" HUWl. 0
"toCW.IICURI"'HUMtl. @
TAX OJ'~I.
USE ONLY
"
UYC C JIO..... ......eCll...OT..Il.0c'.:
G20036Il0~9~0251'a
NGln SlilTtt PAlJL ~ III 01
.100 36
I,UIl
YOUR NAJ.l1
tLAST, ,tRSl,MII
ISPOU611S PUJiI(
(LAlT, 'IAIT,MII
""".
ACDAUS
NUN 151\ Illt flAI1(LA ~ 02
)4]1 WAGCCN( ~ S
'Ai/LISLE
In I "" I 8"'62
OA" /
YOUR OCCuPATION
. . L~6H-,e n'.
S"'OU5E~U'AlION IONL V" AL50 fiLING ON ,,"0' '0MI1
. ..I..,1f.~~l-(#W.---'-
PAID PflIl'AFUA IS ItHONI NUYIIA
._.._ ..)d:12~
.A10..",;,;.,,':O...., ,"'''5' '"'"Tn I ""'OS "A.E ,0" E"IE" SE ""'" ,."orioi
-.---.~-(,. K4Vtk.J4o (l ~~^~~;S' COp'y-
CAPITAL TAll COLLECTION BUREAU MEMBER MUNICIPALITIES
. The lolloWII\g mUf1lc1pahllu'i OIl} !)U'IJud by thu CIJ~llill 1.1-. Colh!t.:hUlI BUIII,IIJ SIltJWI1IJIIlow 'hlCh 01 !tIlt lwo columnl) 01 mUfllClpahl186 lIS
lhu Capital Til.ll Collactlon BuruAu olhcu Ihilt P)I!IVl.'!-i 1I1UfifII11UIlIl:IPillllll'b II thill/I\) !II,! 1,1. )'P,II you WI!I{t iI pilll yuar JU61donl 01 mumclpahllB6
lusted on bOlh Ihulttll and tight 5IJCltOlUi ~mJ III",. IItu vuw rulutll .lll..'llhlH 01 0111 olhlll~i II yuu (ltd IlVlllvlJ In nny ollhU5tt BrIlBS for Bny part ot
Ihe lall Vell" you ahould not hilt with ou' bUfUilU lbulll YIW IIIOIIVIJ II P'" ~'lflll.'(J Il't",II' IHllll tJ!, phJaM' wltHn 1110 U5 nollng wha'e you resided
during the flU yua,) If you mil un6utU WhllltJ yuu lUll II) Ill!!, pllUl111 ()nl! UllhJ' lllllt l'~i .1'111 WlJ Will hu tl,IP~Y 10 iJ~!;lsl you
DAUPHIN COUNTY
.Halllabu,o Clly
.Highaplle Bo,ough
.Re8<1 Township
. Sleullon Borougll
PERRY COUNTY
All MU'lICI~}I)hl.u~
C,I'h~ihJ IhHOIJOh
.Cuoku JOWlltitup
D,dlllhl}rl TOWIl'ihlp
l o',\'u' ~. f,UlklOld TuwrlstllJ..l
lowur MllIhn T OWIl6tHp
MI Holly SlJ'lnn~ BOIOLJgl1
Newvllhl UC)fOlJ~Jll
Norlh MldljllllU/l J OWlHitlljJ
CUMBERLAND COUNTY
Norlh Newlon Township
Penn T ownahlp
. Soulh Mlddlelon T own~hlp
Soulh Newlon Township
.Uppe, Frnnklord Townahip
Uppu, Mllllln Townahlp
WO'I Ponn.bo,o -r cwnahlp
JUNIATA COUNTY
.GltJunwood TownlitHJJ
II you were a le61denl 01 any ollhu nbovu I1lUI1IC1P"""U.
tor any part 01 Iho la, yoa" 1110 wllh Iho ollleo shown bulow
Capilli Tax Burelu Houri:
HIr"lburg Olvlllon Mon. . Thu,. 8:00 A,M. .4:00 P.M.
2301 N. 3rd 61. Friday 8:30 A.M, . 4:00 P,M.
HIr,llburg, PA 17110.1883 Phone: (717) 234.3217
II ycu WHlU.l HJ5ldunl olllny olltlU abo\lu munlc.lpalllleS
lur illly Pill' f,)llho lil~ yuar Illn WIlt! Ihu olllcu !Shown below
Capllal Tn Burelu HOUri:
Ca,lialo Olvlllon MondlY 8:30 A.M. .4:00 P.M.
19 5. Honove, 51, TUI. . F,I. 8:00 A,M, . 4:00 P.M,
5uUo 102 Phone: (7171 243.3725
Ca,liall. PA 17013.3336
SECTION A: TAXPAYER'S EMPLOYER INFORMATION (COmplllle only il you movlJd ~/he/ax lie.,.)
1-- -.--.T.T--.--.--- ..-- ---.--~
loUt I loll " .j I I """ t,,, 1_. 'I ~I'
._.:M~LOYER.:' NAM.E. .. ." " .' fMPI UYfll S LOCAL AOOflESS GROSS EARN:~~S
I $ ,
~___ ___ _ __.. _ ~ t --
,
. .
,
LOCAL INCOME TAX
rBOX 21 OF W.2)
'+-.-P ,
S I
I
,
1 ---~-
,
..,--......-!..-.-
,
,
-'---.".---r--
,
.~..~-=L__.
. j" -- ....-------+-
... ...-----i--.
.-.-__.___ .'.H....---'''-"''""t'-
I
SECTION B: OTHER TAXABLE EARNED INCOME
HIW PAYMENT FOR (WORK OR SERVICE PERFORMEDI
RECEIVED FROM (PAYOR,
AMOUNT
S
...f
_______L___..___.___.__...______.._.
SECTION C: MOVING INFORMATION (II you movlld dJuJJ1(J the/ax IIsar, also camplfl/e Section A aoave.)
PERIOD LIVED HERf
MAILING AllDfllSS
CITY, BOROUGH I TOWNSHIP
/ / TO / ___L
/ I. TO u.J /
/ / _......!...o___L_. L..
/ .L..y.C!.._L__ L .
CURRENT ADDRESS ( r' /l1~1.IIfNr '/IAN)
/A<jr/I'VIAlh)\I/
-_..-.--- -.'-
22 Add the amounts In the laf rI hi column lor Iln"a 1 rhrou ., 21 This 15 OUf totlllncom. ..,
23 IRA dlduelion 1..1 plge 161 . 23
24 Medlclllltvlngs aceount d.ducllon AlldCh Form de~J 24
25 MOVIng ..p,n..., Allaeh Form 3903 or 3903.F 2&
21 Onl.ha" 0' ",I'lmploymenl la. Allaeh Schedule SE 28
21 Sell.emploYld health inlLJfanCe deduction (aeo paue 11) 27
28 Keogh and "II. employed SEP and SIMPLE plnn. 28
21 Penally on e.,ly Wllhdraw,l 01 ,.vlng. 29
:lOa ~Imony P'I'" b Rf<:,p..nt" SSN ~ 30a
31 Add lin.. 23 InlOlJgh 30a ,
32 Subtrlct hn. 31 f,om hn. 2~. Thill IS our.d ult.d ro..lncom.
For Pm'ac~ Act and ',plMorh ",ductlon Act NOtlCII ". pig. 38,
l104
Label
,Slit
In""icl,on,
Clll.i.)~t \0 I
Uu'hl I'"
labll.
OUII'~I'6',
j,;1.,~" prlnl
, IIlJ"
FIling Slalul
':I'I!Ck onl~
.;f\.-fJI).Il.
Exempllons
" 'lIllII"' tt',JIl \1.
~J"'p~II(ltlfllr.
',1'1' 'Hl'Jl' 10
Income
A""h
Copy B 01 your
'orm. W.2,
W'2G, and
,ote.A hi",
II ,eu (110 Il'JI
JetilW,'2,
"". POll]" I;t'
~11"':ICJ!ie 0",1 lJl)
""I '111:II:n an',
1.l"l'lll."t AI~r.
1;IIJIHill' \I~l
Palm ,0000.V,
Adjusted
Gross
Income
'I "nit 32 1$ unOt!'
;;;'J ;;90 (lJIll,htr
t i,~O II J cthllJ
.~", nol It.., with
,.-,"" '3t'tt EIC InM
I!ll ~;IYII ;'1
~-~;I;~ T;~.'RNe~~~~ (~J ~~)97
1!J!JI. LA 1,1111."" .,111\1 bflllJIII/I!IIlJ
lint "Ultl~
MonilSlDith III
'1",11.,.1)"1)
'" ",'I..,I....'..,'!.." 'I I'.'
I 'J1Jf , 1t'"I"II'
._~__ ()Mil ~~~~~
Vuur luel..1 "'tun I)' numu"
200 361208
apou..'t toc:I.I..curl~ number
187448462
'0' halp In IIndlng IIn.
Inll'UClUonl. '" pI,..
2 Ind 3 In Ih. bookl.1.
':"111 ~ !:.!~u,", ~~" I,,,, nl''''' ,n. """.'
~ Pamela K
llulrlllm.,
Api flU
"
I
.
I
Horn. ,""" (numbel and ",..II II ~Oll hov. a P 0 bo.. U' PIIUIt '0
3431 We onere Ga Rd.
CIty, town Of' POll ollIe.. 1111t, anU ZIP tOd. II )"N ha.,., D IOI'IIJn IIl1tJlltU ~.. IlIlll" 10
Carlisle pa 17013-8326
00 YOlJ wan' $3 10 go 10 Ih" lund7 .
If. Oln' 'tturn, dOli 04.1" DUI' wont $3 10 010 Ihll lund?, _
v..
No Nol'l Chf(~lIlg
.v.." WIll "0'
chang. )'VIH It, 01
Itf.Nct ~w "fuml
x-.
S,n9"
Marri.d fUlng jolnl r.lurn (....en II only one hid InCom.)
Mar'lld IIllng "pl1f.l. rehJ/n EllllU 1p0UI.'. 60<.1111 ~cu'll) 110, ill)lmr "nd fuN nllll' hit" ·
H.lcj of houlehOld (Wtlh qualll~lng plrlon). (See pIg. 10) IIlh. qualilYlng pur lion II a ctllld but nol your ddpendenl,
.nler thllS child', nltn. hila, ...
5 Qualllln Wldow(or WIth dB .ndent child ( ear II OUlSe dlld'" 19 ,(Se. 8 It 10,1
81 iJ Vou,..If. II your paronl (Of 50"Hlonl 1;111)11) cnn Clill," you DlI a dependenl 01\ hilS or het IIU"} No 01 bou.
I.lurn, do nol check bOil 611. ,., , ,. ' cfttck,d 011
~ h~"
b '-' 'poua., , , . , ' , '_' , " , .", Ho. II 'ow,
c Dlptnd.n'.: ('I Uellrrl~ent to I ro'IJtn~r'lt. (I 0 nlonltli eMI.,.1l on Ie
III fll" n~rnl l,,~IIII!1I1 tUCllil ".CYllly IhlHlbtr 1~I~tIUI~,~IIP t'l r:~~I~;' l,~~r .110 _4
. Uud .lIn )Oil
&mherJJ4oniRmith___ . IIllInolII., wlll\
He ld i L .O~ au. 10 IlIVlIlCI
O'lIplt,lIon
Dru R UII"lelll
1 7 5 g""nnll on II
nOI'"IIf'd"DV'_
AddllUmlllt1
IIllll,d an
1I1111.lIan ...
1
2
3
4
2
d
7
Sa
b
.
10
It
12
13
14
18a
lOa
11
II
t8
20a
21
TOIII number 01 ...m lionl claun.d
Wig.., .llarl8ll, t1plS, etc, Attach Formtll) W.2.
Tlubl. Int.,,,t, Attlr;h Schedul. B tl rllqulled
T......mpt IMI.re,t. 00 NOT Include on line 81 .
Olvid.ndl. AlIach Schlfdule B If required ,
r.ubl. ,.fundll, credit., or 01f1l.11 ollllllle and local income llllles (see page 12)
Alimon)' 'ICllv.d
BUIIM... incoml or (1011). ~tUlch Sch.dule C 0' C.EZ
Capllal ga,n or (10"), Altaeh Sehodul. 0
Olnar gain' or (10....). Allleh form 4797 . ....,.' ...,
TOlal IR.~ dlsltlbuliona , L!~~J LJ b TI1~oble ornQunl Is" pa\Je 1 JJ
TOlal penllom, an(j annulhlS l1!!J l..-J b TII"able amounl (51. ploe 13)
Rlnl.l real .llal., royalties. por1nerahlpa, 8 corporallons, IrU$tl, ,Ic. Alloch Schedule E
FIlm Income or (Iou), AlIactl 5thtWllh! F
Unlmployment compensatIOn .
Soclallltcuflly ben.lila , I 20. I
Othll incom.. List type and amounf-IIJU pl1go 15 .".
8b
b tJ.Illllt Jmounl (Sltl? paQtt 141
.""......."..,,,,,..,,,,...,,,...,.,...,,,.....,..,,,.,,.
I
. .
ell No, 12~GOO
Fm"' 1040 "99n
felln 1040 1I~~71
Tax
Compu-
tation
II ,-VI, ,'..1111
H,It IRS IQ
t'-jUII: ',our
tJ" ':ll!l'
r,nql! It!
Credits
Other
Taxes
P~VlOenls
AllaCIl
Fc't1I~ W,2.
\',.;;0, "no
IC99.p r;n
,,,'! llonl
Refund
~'d.( ,I
'1Ir.:(tl/
';"I;\.J),ldJ'
'~':" p'Jl' 11
1n1 !,II.n 62tJ
" :1: lntJ G~'(J
Amount
You Owe
Sign
Here
,....;llp ,t COI.'Y
. p,' f..ll,,,,
.I,;,
Paid
Preparer's
Use Only
33 Amount 'ro," hne 32 (adju,t.d gron Income) . .. ....."
34. Ch.ck II: 0 Vou w'" 6~ or oldOl. 0 Blind; 0 Spou.. wao 66 0' oldul, 0 Blind
Add Ihf numbll 01 bOkIJI checked ubove and entar lhe 10lul here . . 341
36
b II VOU lit' mimed filing lepllrelelv IInd VOLJr IIpUU51! Ihmlllell dedUl;IIO/l$ or
you WI". c;Ju81.llllul 8h.", !SlUt psg!! Its and chuck 111m, .
( II.mlaed deductlonl hOIll Schl!dule A, hnu 28, OR
Ent.r Sland,,'" deduction shown l1t!low 10' ~ou, fllinl) 5Hllus But "'~l'
lh. paue 18 ,t you chuctl.lJIJ IIn',' lJo_ un hlltJ 34u u, 341J or bOllll:Ullc
I.,U" can cllal," VOU UII II dUPQIllJtitlt
01
vour: .SlnOIe-$4.160 . MamlJd IllInU IOlntlV or OualllVlng wlljO......ltlr)-S6.900
. Heed 01 houaetlold-$G,ObO . MlIffllJd Illing SUI,UlHIIl!IV-$J.450
Subtract lin. 35 Irom line 33 .
II hne 33 II 100,900 or Iln, mulhplv $2,650 by the lolul number or t1~Ulllpl.Otl15 claimed on
hne 6d, II line 33 II o~lr &90,900, lUll: the wOftl.l1tlcul on plIgu , 9 lor Ihlf omount 10 enler .
T...bl.lnooml. Subtrlcl line 37 'rom line 36, Illlne 3715 more than line 36, .,,,Ier .0.
T... See pagl 19. Check.1 any Ill" ho," a 0 FOfl1l{1S1 HUU b 0 FOflll 41H2 ,.
Credillo, child and d.pendent CB'O cltpenlSer5 Alloctl Forfll ~44' 40
Credll for the elderlv or the disabled. Allnch Schedule R. 41
Adoption C,edlt. AnBch Form 8839 . 42
Foreign lax credit. Alllch Form 1116 43
Olh". Chuck II Irom . 0 Form 3600 b 0 Form 6396
.0 FOIm 8601 d 0 Form (.puc"y)
Add !In.. 40 Ihlough 44
Sublrlctline 4!!llrom line 39. II Une 45 IS more thBn hne 39, unter .0. .
~ 34b 0
30
37
38
38
40
41
42
43
44
44
46
40
47 Sell-employment lalL Attach Schedule SE ,
48 Altern.llve minlfnUm laM, Attach Form 6251
4S SocIal 3eeu'lly and Medlcore t4M on liP Income not reponed to ernploytlr AlIllCh Form 4'37
&0 Tax on qualified retlremenl plana (IncludIng IAA$l and MSA5 Alloch For," 5329 II required
&1 Ad~once earned Income credit paymenls Irom Formlsl W'2 .
&2 Houlehold .mploVment laMIII, AlIach Schedule H.
&3 Add linel 46 through 52, This '5 your lotal tax. iii>
64
6&
601
:J ,'I'
.#
Federal Income lax Withheld from FOIIllS W.'} and 1009 54
1991ltlllmaleO lalt pl1ymrnll and ...mount J~~lietJ !rom 19% Ittllfrl . 55
~~""."
I.mld incoml crldll Atlach SchedLJh~ Ele II you ha~e J QUoJIII~lllY ~~
child b Nonlpable eamed Income: amount iii> I I I ~
and ,vpe iii> ..........,....................."...... 560
Amounl paid wIlh Form 4868 (reQuesl lor e~ten510n) 157
ElIiceu IDClsl secunlv and ARTA IBk Withheld (s~ jHlge ~7) 68
Olher plymenll. Check Iltrom 10 Fou" 2439 b [("Farro 4136 69
Add linn 54, 55, 663, 57, 58. a.nd 59, ThesI orB our total po mente
I' line 60 ia more than line 53, aublrsclline 53 from lind 60. ThiS 16 Ih" Itlllounl ~ou OVERPAID
Amount 01 line 61 you went RefUNDED TO VOU, . ·
... b Routing number ITITITITIJ . c: Type: 0 Checking 0 Savings
~7
68
~g
00
01
02.
p.2
33
g
)
'").
7i)
. rcllf."
~
~ d Accounl number
63 Amounl 01 line 61 ,ou wan I APPLI!D TO YOUR 1Ii'ISTlMA~!0 TAl ~
64 Ullna 53 III more IhBn line 60, subtracllino 60 from hnu 53. nus IS lhe AMOUNT YOU OWE.
F.. d"OIlo on how to pay.... poge 27 . . ~
15& estimated lax penalty. Also Include on Hne 64 . 85
UnO" ptnelll" 01 p.rJury. I dltclarlt lIlatl hllv. ll~amll"rJ Ihll ilIum ,lIld lIccompanYlng IlctllfdulU and IIIII.m.nll, Ind 10 Ih. but 01 my knoVloI.eg. IInlS
Utlllll. Ih'V Oft uu.. COlllel. ono compl"t. Ovclil'Ol'lon 01 i:l'otpllllr (,,'tlllt '".11\ til~payllfll~ t)llliad Of'l alllnloflnllllon 01 whiCh p'ltplIrllf tlll& (ltly knowl.dg.
You' 119n.lur. r'" Cuhl
~ _____ ~ !-:LL~
, "iPOUU!I !I''11nlllulfl II it IO,nlllllum, UUl~l n',.~.1 ',"'JI',/ :Jil'/.JI''''' ~ "'P"u~vt:::::2HP'(AL
P"P.",o" /I ~?. .L~
!llqf'lllIUI,' {lii....k ~::~~
F'Hn!l "nm"IO' youI~ ~ .. \'..,.\.,L. f.
,r ~tll..mpIOY'(lI ':lI\d I . 'T
,ilJIJIIt!tS P.';C;uulllll . (SA
:oJ. ~,. I, (" 'h~V- .)~.'4)
Boiling oI!\r1nlls. PI. I7('Xl1.{)1 rt
\:.J Jf,Mii" nf1 f"1C1,d pIp.'
DUll!
Chltt'" II
&~II '1!1llp10VlId
F"1+1!'" f!i:'~
P,t>r.;ilf('f'!I !lUCIi)1 h'('\Jrlty no
'-1-.-] 7>1 '-4 /I " 'i
fIN
liP codw r7t'.~ -'t <<'i 7'7)
'U S r"lwl'",,,,,.!,tr'lf\t,o'rOIf,C'" "l'I' -. .11).":111
SCHEDULE F
(Fo,m 1040)
Profit or Loss From Farming
. AtlaOIl to '0"" lD4O, '0,," 1041, or 'onn 1011I.
. ... InalnlClllonl 10' Ich.dul.' 'onn 1
Ooo""",,,'''IIl6'~ M
I/l(wnlll"~""'''' n
Nlm. 01 p,opttllOt
'aul S MoniBmitb III
. OrillClp" orOClUCI. O_1lllI ~ DIll 01""" _, _ pMdoal croo .. octJylly t.. Ill' ....""lIll ,,",
. 0Icl you 'mol pwUclplll'ln lilt opnUon 01 !hit bull_a during IIl87? ~ 'No,' HI P<IQO F-2 IOIIImII on pIIIlvo 10..... 0 V.. 0 No
-
F.,m Incoml-Oallh Method. Complell Pll1It and II (AoIrual ",all.. I..,a,.,a IIm,lala '111I11 "' III, "' IIna 11 01 '11t 1,1
Do nollnclud. ..I.. olllv.atook hlld lor cIr brMdln or do o..a ra or1lht.. ..'.a on Form 4717.
, Sill.. 01 IIvOlloc:k IIIld OIh.. Mom. you boughl 101 ,11III., . .
2 COli Of oth.. bUla 01 Uvllloc:llllld oth.. soma .-pollIO on 11n. 1
~ Subl1lctlln,2fromlln,1. . . . . . . . . " .
4 Sill.. oIllv"look. product. ,..ma. IIld olhtr prod~c1.ou rtlMd
k Tolol eoopwIUv. dlllrlbuUont lI'onnlll IOII.PATR) 8._
It A,ncultUltl plOQl'I/II pI~tnII (_ pa,. F.2) J ':'11
1 Commodny C,edlt CotpOIIUon (CCC) 1011I. (I" p.,. F-2):
I CCC 10on".po/l1O und.. tloc1lon . . , , . . . . , . .
b CCCIOII1Itorltlltd. . . . . . . . .1 7b I
I C,op InIU,,"C' plocHd.llld clI1t1n dllUl.. plY."'onll (HI pa,. ~-2):
I Amounl ,..lived 'n IIl81 . . . . . . . I Ie I Ib Taulll. 1lI1l0unl
c It .loc1lon 10 d.,., 10 IIl8S II./toched. cMck hlft. 0 Id Amounl dltlrred t,om 11198 .
e CUllom hIre (machln. worij InQOm.. . . . . . I . . . , . . . . . . . , . .
'0 Oln.. Incom.. Includr.g FodtraIlIId t1a1l guoh 01 fUtllall end" Of rtiIlnd (_ plgI '.3) . . . . .
" 0'0" In.om.. Add lIIlOunl,'n Ih. IIghl column lo,lIn. 31h/ou,h 10, ~ .ccruol m,'hod I"P",or. .nl81
Ih. 1I110unl "om . 2 Ilnl 81 . · - -
Firm ExpaIlH....c.1Ih and Accru.1 Method. Do nollnclude plrsonal or living expenen such al taxss, Insurance,
re sire, etc. on our homl.
12 CIIIIld IIIlCk 'JlPIII*'(HI .....
,.3-tIoo IIIIcII 'onn oISUl. ,
13 ChlmJclll.. . . . .
14 Con......llon uponHl ,(_
pI,. F"I. . . . . . .
, S CUllom hi" (mlchllll wo/tIj .
, I O'proelll1lon .nd ,lOIlon 1711
..p.n.. CIdUCIlon Ilot cIlim.d
,I..wn,," (... p.g. '-4) . . 11
17 Employ. IlIntlll progrom.
olh" Ihon cn IIn. 25.
\I F lid pu,ch..ed . .
, II F 1111111111 end 11m. .
20 F III,hl Ind lrucklnll .
21 G.lolln.. lu.l. ond 011
22 InlUllnea (olhll !hon hHllh)
U Inllllll:
. MOII,.ga(ptld 10 btnkI. IIc.) .
b Olhor .
24 lItloI h.1CI .. om
C ....countlng mtlhod:
11lli Cull
"
II) 0 ....ONII
2
, . . . . . .
8
, . . , . , .
Ib r..llIlj, .mounl
Ib T..IlIlI. .mounl
'I' . . . . . .
7c T..IlIlI. ll/1lOunl
,
25 p.naIon Ind p,.m.tI\tltng
plan.. .....
18 Ront 0,10... (," p.ga '-4):
. Vthlcl.., mlchln.ry, ond l<Iulp-
ment . . . . . .
b Othll (1Ind. Inlm.I.. 11.,1 .
27 ReplJra and mllnt.nlnel .
21 SNd..M pI.nll pu,ch..ed
at Slo..,. Ind wlllhou,'ng
~ Suppll. ,,",enl..d
SI T.... . . . . . .
SZUlllltI...,... .
Il3 Vlllrtnlry, bllldlng. and mllllclna .
1M Oth... up"'''' (.poelry):
..~.....................
.
.
~
b...............................
G...............................
"
d ...............................
.
1
U Total'KP'nI". Add li\.. 12 through:M' , . . . I . .. ...... I , ."
:II N.t '8IIlI p,oII1 Of (Iou). Subtracllnl35 tom InIII." I pIOn~ 11111/ on'onn 1040,1I1111"1IId ALSO 0/1
Iclltdul. I" 1111I 1. II. IoN, you MUST go en to IN S7 ("III1.. INIII, rd pII1norll1lpt. _ poge F.B).
31 II you hlvt .10.. you MUST chick lilt boJC Ihtl dlocllbll 'fO'Ilnvoatmtnlln ttllo ocllvlly (_ peg. '-B). }
II you chlCked 370. "',.. IIlIIoll on 'onn 1040, line 11,1Ild ALSO on Ichldulo N, line 1.
It you chlCked 37b, you MUST ./tlch 'onn .1...
'or O,polWo,k Alduebon Ao1 Noll.., "I 'o,m 1040 In.t",cllon..
137
ell. No, '13-t!SH
OMa No, 15011.0074
~@97
Alllchmen'
Slllu,"", No, 14
'rcl'b"j'W "rfd'S"Hl
. IIIlor pIInclptl6lln...kUllloctMry
_(_.mllli"'.
o ....,....' ID ....... I N),'
--LLLLU
8b
Id
II
10
281
. ZIb
Z7
Z8
, .
Ichldul. , I'o,m 1040) 1"7
-
-
,
~
.
'DIm
4136
Cr.dlt for F.d.rll Tlx Plld on Fuel,
OMI No. ,..HIN
~@97
AIl'c:llmllll
Iloq,,,,.. No, 23
. ... IhIlMtn10blll lor Po"" 41..
-.""-
."'.... ...._ _ . Altaah thlllOlm to our Incom. In r.tum.
Somo (11-" _ -.. ..lIlllnl T_IoIit~.R,.~,.....
'.ul S . pu.l. It Monil..ith III , OolUU JIl
---Caullonl You ceMOI cllJm lilY Wllounl. OIl F0I1II4'3411111)'011 c/limod on Form 8849, Form 843, Of Schedul. C (Form 7ZO).
1 Non...... U.. 01 GuoIlna
GaMOIll
I Off'hI WI llu__u..
I.~' )
II U.. on I lann lor I
o Otnor noml..bll ....
2 Non...... U.. 01 O.oho'
TWpo
01 u..
"""
GaNolll
,
a Goeonol cont II ..... 10.. oIooIIol
b Ooeonol contolNnG II IHII 7.7" oIcollo! bull_ltllll
IOllllcoho!
. Ooeono! contolnlng II .....1.7.. IIcollo! bull_ltlIIl
7.71111c0ll0l
3 Non...... UN 01 UncIvM DIo.' Putl (Un.. 3.. b, and cj
SII.. ~ R'lIIIMd UIUma.. V.ndo.. .1 Undr.d DI.I.I Putl (Una 3d)
OINOIll
LIlli. 110, b, ond 01 CI_t nil tho nome onct IeId,..
01 tno poIIon(.) v.ilO Iold tho dlllOl 'uol 10 thl cilllmonl
IIld tho dlto(lj 01 tho putdlllO(lj. onct ~ "po<1le1, Iho
roq,l,1eI ptool 0/ 1llPO/I.
. Hillin 011
II on.nl nWI llu__
. Otnor nont..oblt _ (excluding UM on I lann 10<
lonn ..
d Clllmonl.. ..gllll..., ulllmoto vondor, told dloullull
fo< oal by tho buy.. on I .orm fo< fanning pwpo.... 0< 10
I 11110 0' IoclII govommonl 10< III ..ctLIIIYI UN. CloImonl
obtllnod tho 'oqu~1eI COIIIfICOI. !rom th. buy.. onct nu
no roUGn to boIl..1 ony 01 tn. ""ormlllon In In.
..rtlflcllllo Illn.
4 Nonlallablo U.. 01 Spoolll Putla
Typo "... GaUono
0'_
, )
b
c
d
MeF
Cat. No. IW5n
:lllS
AmoulII 01 o..e111 CRN
;1~" '1 301
Amoulll 0' c..d11 CRN
)
312
Inlllon and cnICk noro .
Amount 0' crad~ CRN
303
Amount of C/'Id~ CRN
304
'onn 4138 llH7)
Depreciation and Amortization
(Includln. Inform.tlon on Lilted Property)
O.p&nlllllll oIlh1 "."~ ~llachm....1
,"I.."" MI............ (01 ~ ... .. l/IIwotIon.. ~ AIlaGIIlhl. lorm 10 our relurn, SoqUll1<t No. 87
Nam,tljlhown on taM" Butl""'OI KIMt)' '0 v.il~ lhll fotm telal.. IdtnUrylnl numt,.,
Paul S & pallela K MoniBmith Schedule "F" 200 36 1208
Eleotlon To Expenll Certain Tangible Property (Station 17111 (Notet" you havI any "".rlld property.'
com 1"1 PI" V before u com 1"1 PI" /,
, M""lmum dollllllmllallon, " an .nt"prlll zona bulln.... ... page 2 of the Inllrucllonl ,
2 Tolnl eObl 01 lIellon 179 prop.rty plac.d In IIrvlc., S.. page 2 of Ihn Instrucllonl, , ,
:.l Thrnnolcl cOil 01 ..cllon 1711 prop.rty b.fore reducllon In limitation, . . , , . . .
.. Reduction In limitation, Subtracllln. 3 from IIn. 2, " ZIIO or I.... .nlll .0. . , . , .
6 Dollar limitation for tax V.er. Subtractlln. 4 from IIns 1. It ZIIO or Inl, entar .0., It married
IiIin II 1111.1 ... .. 2 of th. In.lrucllonl .....,...
(II DNc/IpIlon 01 P/OI*f\' (bl Co.1 (bu'"'''' ulI onl,1
OMU No Ib.a.o"~
"oml
4562
~@97
1
2
I)
..
18,OOL
200 000
(el Eloclod <0.1
6
7 Llateo prop.rty, Entar amount from IIn. 27. . . . . . , . ,. 7
II TOIOI eleel8d COlt of leollon 1711 prop.rty. Add emounll In column (e). lines 6 and 7
9 T.rll~llV. oeducllon, Enlll the Imaller of line 5 or line 8 . . , , ,
, 0 Cnrryouer 01 dllallow.d deducllon Irom 1996. S.e page 3 01 the Inllruellons .
11 B"lneu Income IImitallon. Enlll the smaller 01 buallleallncome (nollen thanltlO) or line 5 (581ln5Irucllonaj
12 Section 179 expen.. deduction. Add line. g and 10. but do not enter more than line 11
13 elll 'ouer 01 diaallowed deduction to 199B, Add linn 9 and 10, Ius line 12 ~ 13
Not.: Do nOI uae Part /I or Pert 11/ below lor lIaltel property (auromoblllla, certain orher vehlclea, cellular relephonea.
certain computers. or ro uatel lor entert8lnmanl. recreetlon. or amulement). Inatead. ull Part V lor lIated pro ert ,
MACRS D.p"clltJon For Alllla PI.c.d In Sarvlc. ONLY During Your 1887 TIM Ye.r (Do Not Includ.
Llltad Property.l
Stctlon A-G.n.ral "'lit Ac~t EI.ellon
'4 II yo" ure making the election under Itctlon 188(1)(4) 10 group any Blsels placed In service during the lax year Into one
.__or more general as..l accounts, check this box, See page 3 of the Instructions. . . . . . . . . . . . ~ 0
SteUon &-G.n.ral D. reelellon S lam ODS See a e 3 of Iha Instructlonl,
IS Month on<l leI Bul. 10/ d'ptlelOllon Idl R""""IY
)'I" piKed In (bul1n.../1/w.,tm.,,' 1,1" _ (-) CorWlI'IlJon It) M,lhDd (el O.pflC11lion dedl,lcoon
Ie. onl -1M inlll'Ucllonl
q 0
""
25 rB. S L
27.5 <3. MM S L
27.5 rs. MM S L
J 9 rs, MM S L
MM S L
a e 6 of the Instructions.
S L
12 S L
40 MM S L
Other De "olltlon Do Not Include Llated Pro e . S8e a 8 6 of the Instructions.
17 GOS ana AOS dteluctronl for IIlets pieced in urvlce In tax ye"" beginning before' 997 . 17 I
18 Properly lubl.ct to Itctlon 166(1)(1) alactlon, . . . 18
19 ACR5 and olher d. IIclatlon, . . , . . . . . 18
Summa SII a e 7 of thl Instructions.
20 Lllt.d property. Enter 1IT10unl from IIn. 26, . . , . . " ."..",. 20
21 Tel.l. Add deductlonl on IIn.12, IIn..16 end 161n column (0), and lines 17 through 20. Enter here
und on tne approprlett IInal of your return. Pertn'IIhlps and S corporations-see Instructlonl . 21
22 FOI alsetl ahown .bov. and placed In "lVlce during ths current yaar, enler
Ine onion of the balll .ttributable to _tlon 26311 COltl . . . ., 22
For P.pt""O,k R,d"etlon Act Notlc.. ... Ill. llparal.lnllructlonl, Cot No 121lOaN For"' 4562 IIBB7)
PA 4011 . "'7 'I7003J.00J.5
PENNSYLVANIA INCOME TAX RETURN IIlhl. II In AMENDED _
fllurn. 1II1.ln Ihi. oval. -
Vour SoaII SIcun~ N~ Number TYPI FilII: ,'0," 0."1 """
. DrDI1."'" ','
~ c:=:J M.m.4 Filing 6,p,'".t~
. ,
.,.,Il. J _ M.m.II"!In9.kMnI/r U 0 Otc.....a
;1":1 L: . Your FUll Nam. tnlll 0,1, r)I O"lh__J__J._ M,\
I i!00-3~-:Li!DtI MO :Ltl7-LfLf-6LfJ.2 -,.''1'''\'''1 D'!
..i...l-~..... ~
~ I PI PAUL & PAMELA MONIS~IDTH 5palllt', FIliI N.m, MI.
::ll ~~~tI~~~Ci~~ER~7M~-632~ I ['Il-n-JTJ---': Tl n
:Sll ' _.l..J...L. L J.J -... L.
_ 5u [E' I,m. T,"phon' Numbtf
tjl m ~'~-r-r\:j """.r'
"\ I .-.J - ....iJ. ,..J .._..1
Ii: ' CI". ... .. ...,. f~r~' School DI.I/ICI Nlm. and Cadi SchOOl Cadi
~----'-'--r OJl--' -.-.. -""'Wh ~'2131In7 .'" ,." ......."
I ~! ' r ., I 'I I 'r' er. you "Ion iii' :it. .
. . _~....;.. !c.::.:!' ..--..:.. ~ _.....:.... _...._. .'.... Name.. lU.. l l l,f>",
c:::> .. ,m.1II WU, 0'111I, UN, NMI" AIM.N c,*", If .lNW 01 lilt ItNlllllorm,bQtI.. d1l1tt.nllrom ~0\II1'" PAtn .,II/ln t "11\I111/(110/11/ Dollars Cents
O,TI!)H '0.. A 'HI aOO.LIT. U)'OII Of ~ l&.I pltPII" 00 Nor lI'lI'il. 'HI T,_ BooilI,I IIf_' ~..r I,~ In 1tI1' Owll .... c:::;)
......I
la
lb
lc
2
3
<II
....
Q 4
Q
....
m 5
Q
Q
~ 8
C/"
7
8a
8b
Bc
9
10
11
12
13
14
16
16
17
18
Of .ICI~~ ubt' Ohl)
o QIIoni"
, 0'11I11
GIOII PA Ta.able Campen.aOon Irom W.210/mo and olhlr ""ga slallmanls .."".",..,..., 1 a
~~' '-l73. ~~
, '" ' ' ~.' .-.
Unr"mburaed Employll Bu.lnno Expenon Irom PA Schedule UE. ,.,..,."..,..,.,.,.,.,. 1 b:' . ~ I r .: '
1.[,1," l. .,.~. ,. ,'.';1 r .'" 1 . r,A,fl:l.i,t
Nit PA Tallable CompenaaUon. Subtract Line Ib Irom la, ......,.............. Ie! ;l...i.fp~~7;~J~:.~!f~
PA Tallablllnte"e'. Complete PA Schadull Allover $1,000, .................. 2 j .c/o), i :".;,.' 'Ul,~,.f
PA Taxable Dlvidenda, Compl.te PA Schadule B II ovar $1,000. . . . . . . . . . . . . . . . ., 3 . .cr
TOlll PA T...ble Income. Add LIne, 1C. 2. '3, .,..........................,.. 4
Tolal PI. Ta. Uablllly. MulUply Une 4 by 2.1% (0.028). . . . . . . . . . . . . . . . . . . . . .. 5
Total PA Tax Withheld Irom W.2 lorma and olher etatemante. . . . . . . . . . . . . . . . . . ., 8
TOIII PA Eatlmated Peymenll and C"dlll, Sea Inatructlona. ...................
OIplndlnll from PA Sc:t\IdIllI SP. Pall 8, Uno 2. ..............,..... Ba 1-1J
Totti Ellglbllily IrlCOI11elrom PA 5chodull S~ Pa~ C, Lint". . , . .. . .. , . . . . . , . .. .. , , , . , , , . . . . . . , ,
Tax Forglve",,1 Credit Irom PA Schedule SP, Part D. Line 16, .' . .,......,. , .,.,.., ....
Total PlY men.. Ind Credlte. Add Ltnl' I, 7, ond 8<:, ..................,........
TAX DUE. II Une 5 II more than Llna 9, enler the dlllerence here.
M'kl chlCkI p'Ylbllto ,1\, DIPT, 0' AIVINUI. U.. your PA.V 101m. 5.. thl In",,,\lono on HOW TO PAY.
10" ~ I
.J.. .
,
)
,'..' -, ...... "'1-",'
11" ~ ' . . .
~.J1J...t..).. ..:-.
12 i
OVERPAYMENT. II Unllll mort than Une 6. anlllth. dllleranCl herl. ,....., . . . , , , , . . . . , , ,
R.fund '" AmounI of Unl11 you want.. I chick mailecllo you. ..,.... . ......., ,. . ....... . .. ...
CredlL .Amounl" Uno 11 you Willi a.. credit 10 youl1~ E.llmItod TuAccounl. ... , . , .. .. .. . . ,.. 13
Donation. Amount" UnI " you want 10 11.1 to \hi Wild Rllource Con..rvlUon Fund, .. . . , . , . .. 14
Donallon . Amount .. UnI " you want 10 gi..1O \hi U.8. Olympic CommlU". PA Dlvlllon. .....,. 16
Donallon . Amount 01 UnI " you willi 10 II.. 10 11II Organ Donor Awarene.. TruI' Fund. ........ 18
Donallon._"Unll1 you w6nI 10 gJ.. 10 \hi Ko,..NlIlnam Mlmoriallno, ....,.....,....... 17
... .',
:~: I~l. ,
Donation. Amounl 01 UnlII you wlI1IlO gi.. 10 Brill' . Cervical C.nc.r R...arch, . . , . . , . . . . .. 1 B
TnllOlal 01 Line 12 Ihrough 1 e mull equ.1 Lln. 1'.
EC O"ICIAL. ull ONL.Y
rn
'I7003J.00J.5
.....J
L
[[iiI-rlrr-'l
..l..J_.\i.J,. !.
PIlll5
'I7003:L00J.S
d Total number of sum lions claimed
7 W.ge.. .elan... lip.. .Ic, Mach Forml') W.2 .
8a Taubla Inl"..I. Attach Schedule B If required
b T......mpt Inl..e.l, DO NOT Includ. on Iln. 8a .
e Ordinary diVidends. Attach Schedule B it required
10 Taxable relunds, credits, or oNsels of 11110 and local income taxes (ue page 21)
11 Alimony r.celved . . . ,
12 Businesa income or (tOSSI. Attach Schedule C or C.EZ
13 Capllal g"n or (Io..). Att.ch Schedul, D . .
14 Other gain. or 110....). Att.ch Fo~~I)tJ, . . . . , . . . , . . ,
1151 Total IRA distributions . ~ b Taxable amount (see page 221
1151 Total pen.,onlllld ItlnUlII" ~ b Taxable amounl (Set page 221
17 Renlll rtal 1.latl, rovaJUet, par1nlrshlplI. S corporations, 11'\151S, etc. Attach Schedule E
11 Fann Inc"",. 0' (10"). Attach Schedul. F . . . .
Ie Un.mploymonl compen..tion . , . . . , . . .
20. Beel" HCUnly ben,nta . I 20. I . i . I b rUlbl. amount('" p.g' 2')
21 Oth...lnc"",". U.t lypl and amount-... page 24....................................
22 Add Ihe amounla In the far rI hi column fo' IIn.. 71hrou h 21. 7111'" our totallncoma ~
23 IRA deduction (... paga 25). . . . . . .. 23
24 Sludent loon Inl.....1 daductlon I." page 2n. ., 24
25 Medical lIY'ngl accounl deduction, Attach Fo,m 8853 25
21 Moving ..pan..a. Attach Form 3903 21
27 On.-ha" 01 ..".amploymantl"', Attlch Schedula SE 27
21 Se".amployed h..llh Inauranca d.ductlon I"~ paga 281 21
at Keogh and nil. employed SEP and SIMPLE plan. :IV
30 Penally on .arly wlthd,awal of sa"ng. 30
31a Alimony ~d b RlClpl'nl" SSN ~ . 31.
32 Add IInas 23 through 31a. . . .
33 Subtract tin. 32 from Ilnl 22. This IS out.d Ulted rOlllncom.
'0' Dlaclolura. ",I..oy Act. .nd p'...rwork lIeducticn Ac1 NoUca, ... page 11.
,~ 1040
Label
ISaI
1t\,lruc\Jonl
01\ pogo '1.)
IJ.. Iha 1111
labal.
Otherwls.,
pI.... print
or type.
PrllldlnUl1
Illcllon Clmpllgn
I S;e I I 18
I
filinll Status 2
3
Check only 4
one bo~
5
8a
Exempllons
b
0
II more than SIX
dependents.
see page 19.
Income
Atlach
Copy B 01 your
Forme W.2.
W.20, and
1Q88.R hara.
It you du:j nol
ljel a W'2.
5M page 20
EnClOse, bul 00
nof slaple, any
payment. AIIO,
prease USI
Form 1G4Q.V.
Adjusted
Gross
IncDme
II Iln, 33 II under
$30.095 (und"
$10.030,1. child
did not live with
you). ..a EIC
Insf. on plO' 36.
PLAINTIFF' 5
EXHIBIT
L
A
I
I
L
O<op
U.
,.. ~ I I
You'" 14 <'1'1
Paul S
T;~~R~t~~~.IPI ~@98
Ihlt 10 Y'AI blQl"nlMlJ
u.tl nlm.
MoniBmith
III
,IU OMU No. 115.46.
'tOUt 10cl,I .ICurU";' numb"
_200 ;J6 , 208
Ipou..'. .ocj.l..cut1~ numb.,
Ill!) Va. O"I~- ()u 1101 ."1, l)t 11'1)1, III th" .pan
. l'JUH, ."1l1n\J
.
/.-F1.\
II IjOlnl I,lum, IP()I,j..'III,all1.m. lIno Inlllllt
UII114/ll'
Ham,JOdl'" (numbtt and .IIMII. II you h.~.. P 0 lJo.. 'u IW)' llj r~j;ln'l
3431 Waqgonors Gap Road I__
City, lown or POll artIC', 11'1., and ZIP cod. II ~cu h,v. 4 IOtelgn 40dr.n. Oil pnIJ8 III
Carlisle Pa 17013-8326
A IMPORTANTI A
You mUlt .nler
your SSN(.) abo,".
VII No Ho'tl Chtclun~
X .r". lift" tloI
Ch.ng. you, 'a.. 01
X 'tduc. )'0Ut "lund.
H
I
.
I
Do you wanl $3 10 go 10 Ihll lund? , . .
II . oint "turn, does our spoust wlnt $3 to 0 10 thllS lund? ,
51ngll
MwrllJu rlllrlij ,vllll 'l!turn (evln II onlV onlt had Income)
Mamed hhng MpIIBI. 'Itum. Enlel 'Pouse'ssoclal secunty no. QtxJve and lull nl1tne hell. .
Head 01 houaenold (with qualifying perlon). (S.. page 1 a.) If the Quoh'~jng perllon 1511 ChIld bUI nat YOtJf depfndent.
elnler IhllS chlld'l nwne here. .
Cuali In wldow(er with de Itn ent child ( ear louse died .. 19 . (Sit, (I e , 8.)
Q Vourllll, II your parent (or lomeone .110) can claim you Mil d'lpttntj"", r,n hi'! (or h", t"..} I/o. ~I bur~
'Itum, do not check box 6a, . , , , , , . , . . , , . ., ~~ukU on 2-
IllIIdlll
~;::~~~~. , . , . , . . . , l~l O:Il'~d.n;'1 ' . . ~P'~d'fI;'" , 'qY~I'~' ::iid~~~o:~ I~
l.l'1I0nr.l\11l to childloldlrlllllJ: II
11) filii nlml !.Jat nlm. IlXlII UCU/lfy number ou aHl~ itl 119 .. 0: 3
. lI..d willi rou
Amb r oni mith l! 'dld""I".lIft
He i d i 1 IOU dull. dIV"CI
ebecca 6' 398 II m "..,or"IO"
I\.J 111"11'''1
o DI'lnd.nllon'~
o "ol.nlu.d non_
o Add numb." GJ
,nllrldon
Unlllbo~. .. .
l.l
8b
2.-
,<
. .
"
1..
-
a)LlO -
ocJ
, ~
-
~.u No 125~?G
Fo.m 1040119811
Fo,", '0,&0 119U"
Tex .nd
Credit.
b
l
ISl,ndlrd II.
D'duclJon -
lor MOlt
'Iopll
SlnG"
",110
Hlld of
!1Qu6thold:
IUIO
MImed filing
JOIntly or
OUIUf')'lng
wldow(,r)'
11,100
M.mld
lillng
5I"8fll.I)I,
$3,110
Other
Taxes
Payments
Attlch
Forms W.2
and W.2G
on Ih. front.
AIIO altllch
Form 1099.R
If tax was
withheld.
Refund
HIVI It
directly
d.po~ledl ~ b
See Pl91 44
and fill In 66b, ~ d
66c. .nd 66d 87
Amount 118
You Owe
Sign
Her.
JOint retum?
See plge 18.
Keep 1 copy
lor your
r.cords.
Paid
Preparer's
Use Only
34
38a
Amount ham linlt 33 (lIdJueted grou Incomll) . . . . . . , , .
Ch.ck II: 0 You we" 81 or older. 0 Blind: 0 Spou.. woe 61 01 oldo',
Add the numb,,, 01 bO"u checlced libov, Bnd tnter th" lolal I'~fl.' ,
It ~ou "1 marrIed filing uparalsly and your apouu Ih"ntl.,a dududlllna or
vou w.re . dual.slllul allen, IIeI plge 29 lInd check her" , .. 3t5b 0
Enler thl 1"8.' of your U.mllld d.ductlone Irom SchDdule A, line 28, OR el..ndord
deduction Ihown on the 181t, But led pogo 30 to Ilnd your elondOld duduclton II you
checked any bo. on Une 301 or 30b or It aO,"80n8 con claim you 05 0; tJepondenl .
Sybtllelllnl 38 ~om IIn. 3~ .
If line 34'1 $93,400 or lOll. multiply $2,700 by th., lotal numbel 01 1f.lll!mplhm5 clnlml!d 011
IIn. 6d. " !In. 34 15 over 193,400. lee Ihe wOlkshut on page 30 101 Ih8 Bmounl It,) Qnhtt .
T...bl.lncom.. Subtract Un. 38 from line 37, It line 38 IS mere Ihnn IIno 31, IIlller -0-
T... S.. plgl 30. Chock II 'ny ta.lrom I 0 Fo,ml') 8814 b 0 Form 4972
Credit I!'), chUd Bnd d'~~nr1..nll"IH" e~p~n5e5. Attllch FOlm 2441 41
C,ldll lor thl elderly or the dl..bl.d, Attoch Schedule A . ~2
Child I.. e,edlt (... p.g. 311 43
Educotion cledll.. A".ch Fo,m 88B3 ~~
Adoption credit. A<<,ch FOIl1\ 8839 . ~8
Foreign t/1)( credit. Ahach Form 1116 If required . 4"
O!hor, Chock II I,om . 0 Fo,m 3800 b 0 Fo,m 8396 ~~~
00 Form 8801 d 0 Form (.pecllyl 47
Add linn 41 through 47. These are your tot,l credll.
Subtract Une 48 Irom line 40. If line 48 I!S mOfe thon 11M "0, tinter -0- .
II.y.2
_2..L'_'1 "=.
~
~
~8
~9
80
81
82
83
M
88
88
OB""d
~ 38.
G7
38
:It
40
41
~2
43
....
4B
40
47
40
~9
eo
Bl
B2
53
54
BB
B8
B7
B8
B91
S.II.employmlnll... Attach Schedule SE .
Altomlllve mlnlmunl tlLk. Altllch Fafm 6251
Soclll 5ecunty Bnd Medlcar. lox on lip Incom. not reported to l!",pIOYl!r Atll1ch Form .1137
Tax on IRAa, otl18r retirement plane, ond MS~. Attach Form 5329 II r"qUlred
Advance .arned Income credit payments Irom Form(5) W.'), .
Household employment taxes. Attach Schedule H.
Add IIn.. ~g throu h BB. Thl' I. our 101.1 I.. .
'"
Fedtf'lllncome tex withheld 'rom Forms W.2 Bnd 1099
1998 Ulimlled IIJI plymenl5l1nd amount applied rfom 1997 'elum .
lamod Incom. crodlL Altach Schadule EIC " you I\"e a Quahly,ng
child b NOIIII>WbI. ,amod incomo: amounl ~ I I --1
and Iypl ~ .................................................. Bg.
Additional child 18>< credit. Attach Fo,m 8812 . eo
Amount paId with Form 4868 (request lor e)ltenslon) . 81
Exce$l IOClal security and RRTA tax wllhheld (ISle pllge 4.3) 82
"'!her paym",ts, Ch'Ck II from .0 FOIl1\ 1'33 b 0 Form ~ 1 36 83
Add lines 57. 58. 159a. and 60 lhrou h 63. ThelSl ore our totll I Inti . ~
"line 641, mOil than line 56. ,ybl,"clllne 58 ~om IIn, 64, Th15 15 Ih, amoynt you OVERPAID
Amount 01 IInl BB you wanl REFUNDED TO YOU. . ~
~
Roullng number
Account number
Amounl 01 llno B5 YOU wanl APPLIED TO YOUR 1118 UTIMATlD TAll ~ 87
It Un. 56 Is more Ihan Une 64, lublrlct IIno 64 'rom line 56. This 15 Ihe AMOUNT YOU OWE.
For d.lalls on how 10 pay, ISII pig' 44 . . ..
se Estimated fax penoJl ,AlsO Includo on line 68 . eo ~
Under penalll.1 0' PfI'Jury, I dtel.fl thlll hlVI 1)I&mln,d thll r'lum and accompany.ng schldulU and IIIII.ment.. and 10 the bI.t of my knOwl.dOl and
btli.'. they.,1 lrul. corrICI. IUld com"l.t.. DlCllfatlon 01 ptll)aflr (other tl'lan IllllPay.', II blled on allll'llormallon Or which pr.p"tr 1'111 .ny knO~ltdl)"
You' ~"llur. ./ Oal. ..". OaY'lm. 1.1'1'1'101'1'
~ ' numb.' (optlcn"ll
r $pol,lM'1 IIlgnltlutl. II . 1011'11 '.Iurn. BOTH mUll' II1~ Oat. ......
eo
81
82
53
54
86
ee.o
PI'PI'.,'. ~
110nllufl ,
Firm', name (or yQurs ~
II ,.".,mployfdl and
addr'llI
ell""k " ,...".-
~.Il.~mployl(J L:J
P.o. B<i 1",~.....;i,1o'1~{l.3Q:l~l
_. II' _ _ ..... ,.. ~... "... 4 ....""'1"'\., "..,.,
PrePI,er', 'SOCIIlI 5'CIJrlly no
7. V....IIOS
EIN
ZIPr,odl
7t..,,', (~n
'us Gu..,>/"....",.IP,,.,''''1I1Uwp '''?I!- l~!i.~~~
. Old you "mllerlllly pIttIClpll."In th. oper.llon olthll bUlln,.. during 19987 " "No," II. pogo F.2 for lImit on p..ol" 10..... ~. 0 No
11IIII F.rm Incom.-ca.h M.thod. Compl.t. Part. I and II (_mol m,th.d IlIp,V'" c.mpl.I, P,rtl " tnd III, Ind IIn, 11 ., P,rt I.)
Do notlnolude lalll 0' IIv'ltock held tor dr.II, br..dln ,I ort, or d.1 u ~I'II'" ort thai' ..111 on Form 4787,
I SII.. of IIv..lock IIld 0111.. lIem. you bought 'or ".tI, , . , I
2 COli or 0111.. bul. 0' IIv..lock IIld other lI.mo "ported on IIn. 1 2
3 Subl"cllln.2f,omIIn.1 . .. .......
.. Slles of llv..tock, produce, grllln., and other PfOdtECIIOU raised . . , , .
8. Toltl cooperollv. dl.lI1butlon. (Fonn(o) lOO9.PArRl lit. U
8. Agrlcullural program plym.nll (It I p.g. F.3) lit 'Z.H)~U
7 Commodlly C"dlt Corporlllon (CCC) loan.(... pog' F.3):
. cee 10lnl reported under election ,.,...
b CCC 1011I10 lorl,II,d. . , .. .,. I 7b I
8 Crop Inauranc. proceed. and certllln dissster payments (see page F.3):
. Amounl rec,'ved In 1998 . . , . . . . I 8t I 8b 7.xobl. omounl 8b
o II "ecllon 10 d,rer 10 1999 16 ,".ched. check he". 0 8d Amount d.felTed from 1997 . 8d
. Cu,'om hi" (mlchln. wor1<llneoml . . , . . . . ·
10 Other income, Including Fed".llnl';i state QIl&Otln. or 'uellax credll or refund (lee PliO' F.3) . . 10
11 Qro..lnoo",., Add amounllln th. rlghl column for line. 3 through 10. If IcelUal m.,hod laxp.yer, enler "'7 0;>' J ;
Ih.amounlfroml.2I1n,51 , ....... ,. II -,\0""17
Farm Exp.n......c..h and Accrual Mlthod. Do not include personal or living expenses such a8 taxes, inlurance,
repairs, etc.. on our home.
SCHEDULE I'
(Form 10401
Profit or Loss From Farming
. A".uh 10 Form 1040, Form 1041, Form loea, or Form l006-B.
. It. In,tlUcllon. 'or Bch.dul. , (Form 1040.
o.~wtmtn4 "thl rt....".
Inlltt"..f'.~ttnUl5eI"'u (0
N"".oI_....
Paul S Monismith III
A PMclpll product, DtlCnbl In on. 01 two word. )l0IJ' pttnclpal crop or ICU"'tv 101 Ih, current I... )"11.
C Aceounhng m.thod:
(II KJ C..h
(2) 0 AcelUtI
ISb T8)tBble amount
lib Taxable amount
'1
70 Ta)lllble amount
12 Clr end l11Jck '>PIn... (... pag' 25 PifIlSlon and profjt~!harlng
F.4-.I.o ItttcII ponn 4882) . 12 plans
13 Chemlelll . 13 2e R.nl or I.... (.e. page F.6):
14 Conl"""lIon e.penaas (... . Vehicles, machinery. Bnd equip'
plgl F-41 14 menl
15 Cuelom hlrl (machln. work) 15 ~ b Olh.. (11II1d, tr:lm.',. .lc.1
18 Depreciation and section 179 27 A,palra and mllntenane,
I""on.. deduction nol ell"'fd B lID' 2e Sotd. III1d planll purch..ed
.I..wh". (I" p.g. F.5) IS - 211 StOl"agl and warehousing
17 Employ.. ben.1I1 programs 30 Suppll.. purcha.ed
olher rhln on Iln. 25. I" 31 Tues
18 Feed purchued 18 32 UIIIIlI.. .
" FlrllIIl'" and 11m. III 33 VlIl/lnllY, b'tldlng, and madlel", .
20 Freight and If\Jcklng . 20 34 Olher expense. (speclfyl:
21 GUOIln., lull, III1d 011 21 . .~r;.r.If},................
:t:I InllUl'lIlc' (other than h.lllhl 22 b ...............................
23 1n1"..I: 0 ...............................
I MOIIg.g. (paid to blll1k., .lc.1 . 23tI d ...............................
bOth.. 23b - .
...............................
24 UIlor hoed p,.. employmenl ertdilll 24 f
35 Total ..pen.... Add 11n.1 12 Waugh 34f . . . . .. . . . . . . ..
35 N.I 'Inn profit or ~o..), SubltaClllne 38 from IIn. I I, II . profll. enter on Fonn 1040, IIn. 18, and AlSO on
Schldult 81, IIn. I. 11.10... VOU MUST go on to line 31 ('II1aI.', 11UI1.. III1d pw_lpo. 1M plg~ F.8).
II you hey. I 10... you MUST check Ihl box Ihtl dllCnbt. YOUl inve.tmenlln th" lebvlry (... peg. F .61.
. If you chocked 371, enler th. fa.. on Form 1040, line 18, and A~SO on Schedul. II, IIn. I.
. II you chocked 37b, you MUST Itlleh Form 8188.
37
For '"perwork ...duotlon Act N.Ue., ... Form 1040 InIINotIon..
CII, No. 1'~H
OMB No_ 10.&.0074
~@98
^ltechmenl
5~IJ.n('. No 14
...111 ...."ly "".....UI.H)
D lmpfoyw ID numb., (IIN). If .,,~
1
,
28t
28b -
27
28
211
30 0
31
32 1
33 ?I
34t 00
34b
340
340
34t
341
38
38
}
37. All In_,m.., Is II o.k.
37b 0 So... ""1/1II11I11 not II nsl
S.hedul. , (Form 1040) ltl111
.
SCHEDULES AlB
("orm 1(40)
Schedule A-Itemized Deductions OMU No, 16'6.0074
(Soh.dul, B I. on back) ~@98
AIlDchm,nl . 07
~ ...lUIch t. f.rm 1040, ~ 1Io.ln'lruoU.n' ,., Sch'dul..... ,nd B (f.rm 1040, S"UIn" No
YOUI' loc:l" ..cuney numhr
Pamela K Monismith III 200 :36 1:208
o.p"tlflllll of Ih, fru''''W IIlI
Inlwnall'hllt"" 5IMc.
N_'J"""'" on fonn 10.0
Paul S &
Medical
and 1
Dental 2
Exp.n..s 3
4
Taxes You 5
Paid 6
(5.. 7
page A.2.1 S
0
Int.rest 10
You Paid 11
(5..
pao. A.3,1
Not.:
Personal 12
Intqrest is
not
deductlbl,. 13
14
Gifts to 15
Charity
If you mad, . 16
gl~ and gOI .
benafit for It, 17
s.. page ....4. 18
Casullly and
Th.ft Lo.... 10
Job Explnl.1 :zo
.nd MOlt
Dlhl'
MllClllln.oul
D.ductlonl
(Sa.
pa~. A.6 fo,
Ixpln..1 to
dlduct h.".)
23
24
25
26
Dlhl' 27
MIIClllln.OUI
D.ductlonl
Total
Itemized
Deductlona
ClutlOMl Do no' Includ. ..penslI relmlJ<Jrs.d 0' pNd by others,
Madlcal and danlaJ ,xPln..s (Bea page A.1)
Enler amountlrom Form 1040, line 34, 2
Mulllply IIn, 2 above by 7,5% (,075). . . , . .. 3
Subl,actlln, 3 f,om Iln, 1. If Ill1e 3 IB more Ihan line 1, enla, .0.
Stata and locallncoma taxaB , . 5
Real 88tale 11)(85 (Bee page A.2) , . . , . . .. 8
Personal prop.rty IlIJle~. . . . . . . . . " I
Olher IlIJl88. UsI type and arnounl . ....................
................................................................
Add IIneB 5 throu h 8 . . . , . . . , . . , .
Home monoaoelnlerest and polnls reponed to you on Form 1096
Horn. mongagelnlere.1 not reported 10 you on Fonn 1098, If paid
10 the petIOn from whom you boughl IhB home, BIB page A.3
and allow Ihal perS<ln'H name, IdenlllYlng no" and addreBs .
Points not reported 10 you on Form 1098, See page A.3
forsp.clal rulas , . . , . . . . . , , . .. 12
'nveslmenllnteresl. Attach Fo,m 4952 II required. (See
plge A-3,) . . . , . . , , . , . , . ., 13
Add lines 10 th,ou h 13, . , . , , , . . , .
Glfls by cash 0' ch.ck, It you mad. any gl~ of $250 or
more, Bee page A.4 . , . . . . . , . . . ,
Other than by cash or check. It any gill of $250 0' more,
88e page A.4. You MUST attach Form 8283 If over $500
Carryover I,om prior yaa,
Add lines 15 through 17. . , , . , , . . . .
Casualty 0' ItleflloBB(es). A~rm 4684, (See pa e A.5.)
Unrelmbul'!i,d employee expenses-job travel, union
dueB, lob education, etc. You MUST attach Form 2106
or 2108-EZ I' reqUired. (See page A-5.) ~ ...............
21
22
TI)( preparation fees , . . . , , . . . . . .
Other ,xpenses-lnvestment, safa deposit box, etc, Ust
typa and amount ~.........................................
Add lines 20 through 22 . . . . , . . . . . .
Ent.r amount from Form 1040, line 34. 24
Mulllply IInl 24 abova by 2% (.02) . , . . . ., 25
Subtrect line 25 from line 23. If IIna 25 Is more Ihan line 23, enler -0-
Other-from list on page A-8, Ust type and amount. ..............................
28
IB Fo,m 1040, line 34, over $124,500 (over $62,250 If married filing separalely)?
NO. Yo. u, d,ductlon Is nol limited. Add tho e amounts in Ihe la, right column }
fo' lines 4 Ihrough 27. Also, .ntll on Form 1040, IIna 36, tha Jerger of .
IhlB amount 0' you, standard d.ductlon, .
YES. Your deduction may be IImlled. See page A.6 lor Ih. amount to enler,
fo, 'aperwo,k "lducllon "'ct Nolle., .as form 1040 'n"Netlon..
Cif. No. 1261 3Z
Ichadul.... ('ann 1040) 11lN
RETURN BY APRIL 15, 1999 TO
CAPITAL TAX COLLECTION BUREAU
'i!i!9B
Ll..qCAL EARNED INCOME
fP8< RETURN (FORM 531)
IUl,;YPwraIlIUIl; t"IUljl ..., II~'''''' '''~ ".,., ,on"" ...... , -....." ... .". ".. ,..,
'HI IIJIUAU '0 HA-V" YOUR COpy VALID...TlD I" ....L. NarU"Hi IOIH ,....
tUJHUU" 4ND lA),PA'flN" COPIU ALONG WIfH A Ill' ADD"IIIID IfAlil'ID
INVlLUPI
1'1 ~. l!.~IIV'P '\Y., ~IJ'P'
(AnI5LI. fl. 1IOl!"Hlc.
. ..'-"
'. I.... . h....'. ..
W.2 EARNINGS (From allached W.2'J) . . . .
EMPLOYEE BUSINESS EXPENSES (Mach Federal Form 2106 & Slole Schedule UE.l) .
TAXABLE W.2 EARNINGS (Sublrecl Line 2 from Line 1) .
OTHER TAXABLE EARNED INCOME (NO INTEREST OR DIVIDENDS) Complel. Secllon B on Back
5 TOTAL TAXABLE EARNED INCOME (Add Lines 3 end 4) . . . .
6 NET LOSS FROM BUSINESS, PROFESSION, OR FARM (ATTACH FEDERAL OR STATE SCHEDULE)
7 SUBTOTAL (Subtrecl Llno 6 from Llno 6) IF LESS THAN ZERO, ENTER ZERO
8 NET PROFIT FROM BUSINESS, PROFESSION, OR FARM (ATTACH FEDERAL OR STATE SCHEDULE)
9 TOTAL TAXABLE EARN INCOME AND NET PROFITS (Add Lines 7 ond B)
10 TAX LIABILITY: 1% OF LINE 9 (Mulllply Line 9 by .01)
11 TOTAL LOCAL INCOME TAXES WITHHELD (From aUached W.2's, Box 21) .
12 QUARTERLY PAYMENTS AND/OR LAST YEAR'S OVERPAYMENT CREDITED TO THIS YEAR
13 CREDITS FOR TAXES PAID TO PHILADELPHIA AND/OR STATES OTHER THAN PA (ATTACH SCH G)
14 TOTAL WITH HOLDINGS & PAYMENTS (Add Llnos ",12 and 13)
16 TAX BALANCE DUE (Sublracll.ino 10 from Line 14) IF LESS THAN ZERO. ENTER ZERO
16 INTEREST & PENALTY (Soo Instructions) . , . .
17 TOTAL BALANCE DUE (Add Lines 15 and 16) Make check payable 10 .CTCB . .
18 OVERPAYMENT (Subtract Line 10 from Line 14) IF LESS THAN ZERO. ENTER ZERO
@
A
, "'\::::1)'
19
20
PAYMENT TO BE REFUNDED , . . , ,. ."...,
OVERPAYMENT TO BE CREDITED TO NEXT YEAR'S TAX
OVERPAYMENT TO BE CREDITED TO SPOUSE'S BALANCE DUE FOR THIS FILING YEAR
.. . ,,....- "
11. ,; I~
d/8
2
3
4
6
6
7
8
9
10
11
12
13
14
16
16
17
18
19
20
ee~t~J~D...........ECqL01..~.'
'If 'I
M
YOUR SOCIAl. SECURITY
NUMBER
SPOUSE'S SOCIAl
SECURITY NUMBER
't..! ~}
..~
.1.
l""u
YOUY NAME
(FIRST, LAS7. MI)
SPOUSE'S NAME
(FIRST, LAST. MI)
.. ';.1~" ,; "t,'IL "
1\ ~'.
@
@
!7
4~
J~l~
HAVE YOU MOVED FROM THE
SEGINNING OF THE TAlC ~ILING
YEAR TO PRESENT?
I~ YES, COMPLETE SECTIONS
A & C ON REVERSE SIDE OF THIS
~ORM
HOME
AOORESS
75510 /It UR ,ONLY IF,A,l Fill U N THIS FORM)
AI PRE PARER S NAME IPUASE PR~
r Ml-t L!._c.II/fIJ..~-
r-
", t~ ~.., ~ IlP
~......... Wlt...:fr. eT/d....--
.~~~.~~~_.._...__:~~..:~~:~~.._-~~~~:~----~~~~~~~...~~~~~._-_..~~~.~~~~~..
iRR, CARL L. 3 568 204.5 4.0 208.5 98.0n
'HHONS, DONALD C. 3 583 203.0 12.0 215 .0 94.42'
'RDA, JOHN D. 3 967 220.0 8.0 228.0 96.49'
!l'HNA, GARY' G. 3 643 228,0 3.0 231.0 98.70'
HNSON, REG.fNALD L. 3 868 278.5 6.0 284.5 97.89'
AHER, CHARLES R. 3 776 308.8 2.0 310.8 99.36'
NISHI'l'H, PAUL S. 3 37:l 722.2 1.0 723.2 99.86t
-------------------------------------------------"----------------------------
'fIN, LARRY' O.
~NER, BRADLEY D.
3
653
350.0
2.0
352.0
3
445
793.1
1.0
794.1
99.4H
99.87t
------------------------------------------------------------------------------
"
'JRGE, LEE I.
UR!l'S, DANIEL
3
884
151.0"
384.9
2.0
153.0
98.69t
3
1318
1.0
385.9
99.7H
.......---.-.-.-.-.--....---....-.-.-.....---.....--.-..--...---....---......-
!tRAGE HOURS WORKED:
353.3
..--..--.--.--....---...--.-=......___.._____......a...___....__...._.........
r
F In7 ~ inJ.
flOURS flOURS TOTAL flRS WORKED/
. TOT HOURS
iNAME CREW EMP-NO WORKED REFUSED HOURS l...........................q............................................
MICHAEL 5 535 80.0 20.0 100,0 80.00~
I, RA'!MOND L. 5 193 95.0 5.0 100.0 95.00~
DONALD W. 5 334 45.0 57.0 102.0 44.12\
WILLIAM T. SR. 5 134 88.5 17.0 105.5 83.89~
,,{DE D. 5 368 103.8 3.0 106.8 97.19t
AMUEL E. 5 348 139.5 5.0 144.5 96.54\
JOSEPH M. 5 1244 141.0 6.0 147,0 95.92~
MARC 5 508 146.5 7.0 153.5 95.44\
LTER 5 120 148.8 5.0 153.8 96.75%
PAUL D. 5 420 183.0 2.0 185.0 98.92%
ERNEST 5 166 200.5 5.0 205.5 97.57%
.,
MESS. 5 115 277.0 4.0 281.0 98.58%
CBIN 5 1412 319.5 1.0 320.5 99.69%
H, PAUL S. 5 372 48~.0 1.0 490.0 99.80%
III, ALVIN 5 447 558.9 5.0 563.9 99.11%
, THOMAS 5 227 802.5 0.0 802.5 100.00%
------------------------------------------------------------------------
NO, DENNIS E. 5 106 50.0 55.0 105.0 47.62%
NNIS R. 5 183 105.5 12.0 117.5 89.79%
--------------------------*--------------_._---------------..------------
.....................m......~....a......................................
HOURS WORKED:
232.4
........................................................................
.", 1'1'1 S . ';k fr...L
~MPLOYEE NAME CREW EMP-NO 'dORKED REFUSED HOURS TCT HOUR:;
......a.....~........a........................U..L'...........~._....~.n..........
, 99.80%
'10NISM!TH. PAUL S. 4 372 99.1] 0.2 100.0
nEMINO, KENNTH O. 4 391 flS . 7 :~ . 3 tOO,O 55. 70's
lILLER, DONALD E. 4 822 ,87.1 12.9 100.0 87.10%
JORN, JAMES R. 4 738 91.7 8.2 100.0 91.70%
.I!OUNTZ, DONALD E. 4 863 108. ;) ;'1] 112.0 %.61%
:RAMER. CHARLES R. 4 77'; 119.2 0.8 120.0 99.33%
FORBES. ERNEST 4 166 t84. ., 2.4 187.0 98.72%
~-----_._---------------------------._------_._--------------------...----------
BIDDINOTON, WILLIAM S.
4
473
as.a
17.7
1020 5
52.9C~
HESS, i<OBER:' L.
4
269
108.0
5.0
113.0
95. 58 ~
.----------------------------------.------------------~-------------------------
,~
BARNER, BRUCE
4
608
WALKER, JOHN ALLEN
4
575
1;.3
100.0
99.00%
aO.70%
MARIQUE, JOSEPH M.
4
1244
99. 'J..
80.7
I
95.3
1.0
100.0
4 ,
100.0
95.90%
.....................................................a..........................
AVERAGE HOURS WORKED:
111.3
..............~..................S.........D..=.................................
Mlllntenllnce Overtime Crew"
(08.stp-99) ~e.~ ~ .~(.
Lall Nam. flrll Naml Middll Crew Bad.1 Tltl. OT Workld OT Rlnllld Totol OT %
Flemlnl KCMeih 0 ~ J91 0:0.1:'>1 90.7 IU 105 86,38%
Miller DOlllld E ~ m O~IM ~O,~ 12,9 IOU 87.51%
Mountz DOlUlld E ~ 863 0:0.1:'>1 U6,91 3.39 I~O,J 97,58%
Campbell Alvin B ~ ~7 GMM 29~, 1 i L83 296 99,38%
Cl'IIlIIer Cherltl R 4 776 GMM 160.33 0.67 161 99,58%
Monilmiih Poul S .. 372 GMM 119.8 O,l, 120 99,83%
"
Biddinlton William S ~ 473 IT 10:.l~ 17, I 120,24 85,78%
Hels Robert L ~ 269 IT 126.58 4.*2 131 96.63%
.
Bamer Bruce ~ 608 Y " 10~ 106 99,06%
Makowski Dave ~ D02 Y 108 0 108 00,00%
1335.03 55.8\ 1390.84
.
,
> GlD
0030.,00000003720, ,1""
--HOURS HISTORY. DI'INID IINI'ITS.-
COMPANY..> 0030. IMPLOYI~ NO--> 00000003720 PLAN IO-->
ifni.. .. - > PAUL
S MONUMXTH III
Houas rlAR TO DATI--> 2711.30
MONTH HOURS MONTH
1 254.80 2
3 2U.150 ..
15 181.10 .
7 279 .150 8
, 321.00 10
11 155 .150 12
13 .00
0'/10/" 131154.37
r
ON HeDIO
rIAR.. > U,..
HOURS
240. .0
1"'.30
237.150
337.150
2150.00
1815. 00
NUL ACnOIf
1
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0030',00000003720, ,1"5
-.HOURS HISTORY. DlrINID IINIPITS..
COMPANY--> 0030' IMPLOYII NO--> 00000003720 PLAN ID..>
NAMI.. -- . > PAUL
S NONISMITH III
HOURS YIAR TO DATI--> 1582.'0
MONTH HOURS MONTH
1 318.50 2
3 347.00 .
5 .00 ,
7 .00 8
, ".00 10
11 ".70 :L2
13 .00
.0'/10/" 13,54,.3
ON HCDU
YIAR--> un
ROURI
312.30
2".20
.00
.00
41.50
11..70
N2LL ACTION 1
---
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0030',00000003730, ,UH
Olf HeDU
--HOUR. HI.TORY - D.'IN.D .11f.'ITS--
COM'ANY--> 0030. .MPLOYI. NO--> 00000003720 PLAN ID-->
YIAR-- > UU
NU......> PAUL
II MONISMITH III
HOUI. YIAI TO DATI--> 251'.40
MOIfTH KOORS MONTH HOURS
1 2U.20 2 290.110
3 235.50 4 220. .0
5 208.80 8 189.110
7 U'.50 8 1911.00
, 250.00 10 228.00
11 188.00 12 110.00
13 .00
0'/10/" 131541411
M2LL ACTIOIf ____ 1
, ,
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OK KClDl 0
00308,0000000:)7:aO, ,1"7
--KOORS HISTORY - DI'INID aINIFITS--
ClOMPAKY--~ 00306 INPLOYII NO--> 000000037:a0 PLAN ID-.>
YIAR--> 1997
KAMI - -- .. > PAOL
II MONIIlNITK It I
KOOlS YIAR TO DATI--> 1978.60
MONTH HOORS MONTK KOORS
1 :aU.OO :a :au.oo
3 :a73 .150 .. 1U.150
15 89.00 6 1063.150
7 178.80 8 1158.00
, 171.00 10 161.30
11 129.00 12 21.00
13 .00
09/10/99 13.15.....7
M:a LL ACTXOIiI
:1
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0030',00000003730, ,1"8
ON HOU 0
--HOURI HIITORY - DlrINID IINlrITS--
COMPANY--> 00304 IMPLOYII NO--> 00000003730 PLAN ID-->
YlAR -- > 19 t8
NAill.. - .. > PAUL
I NONUMITH I XX
aOURI YIAR TO DATI--> 1105.90
1I0lfTH HOORS MONTH KOURI
1 .00 3 .00
3 .00 4 U.OO
5 n.oo . 174.00
7 153.70 8 1:17.00
, U3.00 10 1".70
11 110.150 12 100.00
13 .00
0'/10/" 131154148
M2LL ACTXON
1
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~ ClD
.
0030.,000000037:10, ,un
Olf HCD"
..HOURI HIITORY - OI.IIfIO 111f1'ITI--
COKPAIfY--> 0030. IMPLOYI. If 0--> 000000037:10 PLAIf IO-->
YIAR--> 1999
_AN... . .. > PAUL
I MOHIlIMITH I U
KOURI YIAR TO DATI--> la,..'O
MOHTH HOURI MOIfTH HOURS
1 189.50 :I 11:1.00
3 141.00 . lU.50
15 1:15.00 . 120.00
7 132.00 I ua.'o
, :15.00 10 .00
11 .00 12 .00
13 .00
0'/10/" 13115.,.'
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U. t.\ \'^.0-1208 187-44-8462 S28 6P
PA.. :) & PMELA K HONISt1ITH II I
3431 WAGGONERS GAP ROAD
CARLISLE PA 17013-8326
lllM namlt
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H.nd of houaeholc1 (with Qualifying person) (See plloe 1 J J lithe 'tU8hfylng person IS . child bul nol your d.~ndent,
Inler this Chlld'5 name het. . _
OUBII In wldowler wllh de endenl chIld ( ear a OlJ~e dIed . 19 , I~,", pllgl 13)
Youn.U, II your parenl (or someone elsel cnn clnlm yOll ns a tJependent on hla or Ilel to ICI. I' '.n.
cr; return, do not check ball 611 Hul b. !'IUle to checll the lJolI on hne 33b on paQI 2, chick., 1ft II
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T...ble Interest Income (581 pnqe 16) AlIl1ch Schedule B .1 OVlr $400
T..~'Xlmpt mlerest (5.. poge 11) DON'T Include on line 88 Lab I
Dividend Income. Anech Schedule B I' OV8' $400
TIUbl1 relundS, crecJ.ls, or offsets 01 Sl81A Rnd local Income la.lll5 (see page 17)
Alimony received
BUllnlsa .ncome or (1055). Allach Schedule C or C.EZ
Caplllll gain or (loss) Al1uch Sch&dule 0
Cepltal gain dl5lrlbulloM nol "'ported on Ilnp, 13 (5lte pl1qe 17)
Other gBln5 or /105SP.!'lj AlIl1ch Form 471')1 .., . .....,
TolollAA dlSlrrbullons . Lte~L___ . ._..__.~ .__1 b T,l.l,lbll:! ,'"lOunt (~t!l' pag. tel
TOlal pen,lons and annuIII'!. ll!~.t___-q "1..l~ b T,udble nmOlJnl /"'''0 page lei
R,ntal r8ll1 .slaI8. royallles, pat1nerahlps, 5 CorpOtllllon~ trUBIs, ~Ic AlIoch SChedulq E
Farm Income or (105S1 Allach Schedule F
Un.mplovme"t cQmp"nSlIlIOn (!'ose nl1ge 19)
$oclal s.curlly bene Ills LJ.!~J______L-J b T,ll1abl'l1mounl r~.. pagl19l
Olh"r Incom.. List type and amount-see rAg' 20
Add th. IImounts In the lar rIght column lor h'If,lS llhrou h 22. Tt.,II~ IS our totellncome .
You, IRA dlduelion 1_ pig. 201 . 24.
Spou.... IRA dlduellon elM pogo 201 . 24b
On..h.1I 01 ..1I.emplovmenl'.. 1_ pig. 21) 25
Sell.employld h..lth Inlu,"ne. dlduellon (1M pig. 221 :It
Koogh rollromont pl.n Ind IIII.omploYld SEP dlduellon 27
Penally on IIrly wllhdrowll 01 living. . 29
AlimonV paid. RocIPllnl'. SSN . 28
Add IIn.. 24. Ih,ou h 29 Th... Irt ou, ,o"lld ullmonll, " ' .
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123,050 It'Id. cnl/d IllJttO WI'" yov, 5.. P8C1lt f/C.' to fmd 011' ,t you Cln c/a,m ,,,. "f.mld
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CII. No. 12595V
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you Ir. a dunl-slllus nlllm, I" page:14 And chltek h..,..
tI.mll.d deducllon, Imnl SchpdtJIp. A. It"" :'6. OR
Bllnd.rd deduction I!ohOWIl bp.low lor ,,1Il1)t IdIlHJ ~1,lIlJ" But I' you chic ked
'ny bcJ. on IIn. 33a Dr b, go 10 pIIUP. 24 10 IIntl YOu, ~llIndllld dttlhJchon,
,II you chltCkp.d bo. 33c, your 5tnndnrd QP.dIJcIIOl' I!\ 1"'0
. Slrgt.....S3.700 . Hl!'Bd 01 household-,S!J,450
. Married riling jOintly or QUAlifYIng Wldow{er}-S6,200
. M.rrllKl '1111'0 uparately-S3, 1 00
Subtract IIn. 34 Irom line 32
If Itne 32 IS S81.:U;0 or hel\s, multIply S:?:)~O by Ihe tolnl numb"r n' ,..emptlons claimed on
line 6e. It tine 3:111'1 o\'er 581 .3M. 'If,e thp workl\h...., on pliO" '5 for Ihe amount to Inler ,
T...bl. 'ncom.. SUblrBct IInp 36 from line 3!!l. If line 36 IS mor. than line 36, Mt., .0. .
TI.. Check Illrom .l1"tall T abl.. b 0 11111 Rale Schedules. c 0 Sthedule 0 Tall Work.
Iheet, or dO Form BfS1 ~ (see paOe 2!!l). Amount hom Form(s) 8814 Ill> . I
Addlllon.II".. ".. p.g' ~51 Ch.ck ""om . 0 Form 4910 b 0 Fo'm 4972
Add lines 38 Ind 39.
C,edll ror child and dependent carft '''renaes_ Allach Form 24~1
Crtdlt ror the eldenv or the dlslbled AlIech Schedule R ,
For.ign tall credit. Atldch Form 1116 ,
Olh., c,.dlll (51. p.g. 261. Chock II f,om . 0 Fll!m 3600
b 0 Form 8396 c 0 Fo,m B801 d [J Form ('poc'lvl__ 44
Add linea 41 Ih,ough 44
Subtract line 45 from line 40 II line 4') 15 mort! thon line 40, enltH -0. .
~
Z.)
"
-
32
:131
o Blind
~ 3.1.
~ 3.1b
~iI3c
Ent"
Ih.
1.1'8"
of
your:
~
,
41
42
43
48
48
41 Selt.emplovmnnt lOll. Atlnch Schedutt! SE, AhiO, Site line 25.
48 Altern_Ii\'. minImum 111.1, AlIach Form 6251 .. " .". ,
48 l10caplurt I....{... p.q, 161. Chock ,I ',om .0 Form 411! b 0 Form 861' cO Form 8828
50 Soclll SKI.Jfity and Mldlcste lall on hp Income nol reported 10 employer Attach Form 4131
51 Tilll on QuaUflllPd retirement nlnn!, Including IRA", If reQuired, oURch Form 5:329 ,
52 Ad\'Bnce ltArnl!d Incamp. cr..dll pllymf!MIS from Form W.'2
53 Add IInH!\ 4fllhrouqh~? 'h15 Ir, ollr tolll tall
e.4 ~'edl!lal Incoml! ll~ wllhheld II dlly IS hom fOlrnl"llfl99. r.l1l!ck Ill> [
55 1993 tshmaled lax payments and amoont RPphnd lrom 1q9~ rerum.
51 E.med Income credIt. AllACh Schedule EIC
151 Amount PAid With Form 4868 IIPllIen510n reQuesl) ,
58a been soelll srcunty. Medicare, and RRfA Iu wlthhp.ld (see pag' 281 .
b O,'err81 Of Idditlonat 1993 la.lt'S Allach Form 8811 . . ,
.. Oth.,~vm.nll flee pIg. 2A) Chock Illrom . 0 Form 2439
bet Form 4'36 , . " . ..,."
Add IInlS 5' through 59 These IIfI. our 10111 I menla
I' h". &0.1 mort Ihl" IIn' 53, lubtrlelll", 53 'rom hn. &0. ThllII Ihe Imounl you OVERPAID.
Amount of IIn. 61 vou w.nl I'I.FUNDID TO YOU.
Amoun' of 'In' 61 Vo" wan' A"lflD TO YOUR 191411T1MATlD TAl ~ L63J
II line 53 11\ mo,., thnn lin. t\O, ~lJblr"r:llln.. f)O trom IIne!l3 Thll\ ll'llh~ AMOUNT YOU OWl,
For detA.I~ on how 10 pAy. Inch/ding whlll to wnt" on YvJr pRyment, 1\81't pdQ" 29 .
15 ElItimdttd tftX penBlty (see R" 29 AI"o Include on line 64 15
UI'll1It' plnlllll'" or ~rIUry. I dKliltt Ihllll h..~. ,.,mln~ Ihl' '''lum i\nr1I1ccnmp"nymg 'Khl'dulH end Illlem."ll, Ind 10 IhI bI.1 01 m~ lcnowtlOgt and
bllltl, ,M'jI.... trut, correcl. IInd camp!." ()e(.IBtBllon 01 prep8fftlIOlh., than 'I.PIYIt') II NItti 0" .lIln'ormlhlJ" of ",hleh pr.pwer hi. Iny lc~ltftI'!.
~ You' ,'gn'Mo/' D.'. ,/' You' IXCUP'"'''' / _
_ --r _ ._~9~~$A
~ 8pou..'. ''<I"4Iu', " , 10'"' ,.,,,'", AOIH m"" ''<1" '" - 041' 5pou..', IXC"""""
~
84
55
IlIl
~
fl8..
Illlb
. .
68
eo
"
t2
13
...
p,ep.r.,'1 ~
5'O""lu'" ,
- ----..-
,.,m'~ "Imlllor you" ~
II ...!I-lPmployNII AM ~-_.
.ddr.,,!\
Dale
Cl'lflClcll
"~!!!,,,pIo~-
(I No
lIP code
(I
J.:..J.!>.:9~
L. ."'~-~1 I
-l'J
Boll~~X ~,. (717. :Z38.~n24J
P If'l. PA J ,/" '".,,,
'U.8, GcweItwI'IIrlI "mil". CIftIct: ,"'.- "017
Schedule A-Itemized Deductions
OMU No 1~&.OOr'
ICHIDUL!S MB
(fonn 1Cl4O)
DIpMmInI of It'll r~
InIfMl ~ Itmc. (II
II ~ on fOlm '040
'4lJ oJ. I<'
Medic.' ClUIiont Do nol Inelude ..pens.. fO/mbursed or paid hy olh."
.nd 1 Medical and denIal e.penoeo (see p.g. A.l) , ,
Den", 2 fnler amount hom form 1040, line 32. L2_L______.m L
!Xpen"l 3 Multiply line 2 eOOve by 7.5% (,0761 .
4 Sublraclllne 3 tram line 1, II lero or le55, enter .0. .
II St.te and local Income I..es . , , , .
II Real estale 1..85 (see p.ge A.2) , , . . . ,
7 Olher ta.es. 1I01-lnclu~. personal prop.rty la.es ~
Tex.. You
P.ld
(SM
pogo .... q
Int_It
You P.ld
(SM
p.g. ....2.)
Nole,
P......., 10
Intere,' I,
not
dtducllbl.. 11
12
Girt. to
Ch.rlty
(SM 13
poge ....3,1 14
111
111
lIullly Ind
Th,n Lo.... 17
Moving
Ex n..a 18
Job E.Plnlll 111
end MOlt
Other
MIII,Umou.
D,ductlon. 20
(5..
poge ....5 fOf
IXpenIH 10
deduct Mr.,)
21
22
23
24
Other 211
MIIIIUlnlou.
Dlductlon.
Tntal
itemized
Deduction,
(Schedule B I. on backl
~@93
~nlCnmtnl 07
5equencl No.
y_ ...iII.......,_
tJ(J : 16 :/b
. Allech 10 form lIMO. . lSte In.lrucllon. lor 5chtdul.. A end 8 {form ,
'0;
1
...~~- -
'"'v,
3
..II
6
';'l,.~
'~'-;
7
.~
_1"81. .
_~/2zJ -
18~
8 Add lines 5 Ihrou h 7. . . , . , . . , .
lIII Home mortgage InleleBl and pOlnl& reported 10 you on Form 1098
b Home mortgogelnlereat nolreported 10 you on Form 1098.11 pOld
10 Ihl ptr1OI1 'rom whom you boughtlhe home, see page A.3
end &how Ihel peI&on'. name, Identifying no., and address ~
9b
Points not reported to you on Form 1098. See page A.3
for special rules. . . . . . . . . . . .' J.O.
Investmentlnlerest. "required, allach Form 4952, (Se.
page A.3.) , . . ., ....,.,.. 11
Add IInesgalhrough 1,. , . . . . . . , ,
Caution: /I you made a chari fable co",,/bu/ion Bnd ~.~
r"l/ved B Mnllll in refurn, s.e p.ge A.3. ~
Contributions by cash or check . , . . . . .. 13
Other than by cash or check. II over $600, you MUST
attach Form 8283 , , . 14
Carryover from prior year. III
Add line. 13throu h 16. . . . .
-
s,S'o
,~ 16
~.
Casualt or the/llol6(es). Attach Form 4684. (See p. e A.4.)
,~ 17
Movln e.penses, Attach Form 3903 or 3903.F. (S"e page A.4)
,~
Unrelmbursed employee ..peno.s-Iob lravel, unlOI1
dues, job education, elc. II required, you MUST attach
Form 2106. (See pag. A.4,) ~ ............
,.
~~~~
~~ ~~
'Z2~~~
111
Other expenses-Investment, tax preparation, sllfe
deposit 00', elc. L1sl type and amount ~ ....
.~>..~
~',:.
,"~,~~..
20
21
~:~: ,..~ -
:-"',,~
Add lines 19 .nd 20 . . . . . .
fnler amount "am Form 1040, line 32. I 22
Multiply IInl 22 above by 2% (,02) . . . .
Subtract line 23 Irom line 21. II zero or less, enler .0. .
Olher-trom list on page A.5. L1stlype and amount ~
23
. . ~
.
lie lithe amount on Form 1040, Ilnl 32, more than $108,450 (morelhan $54,22511
marrled filing separatlly)?
e NO. Vour deducllon Is not IImlled, Add line. 4, 8, 12, 16, 17, 18, 24, and 25 }
and enler the tot.1 here. Aloo enter on Form 1040. line 34. thelerger ot thlB
amounl or your stand.rd deduclion.
eYES. Vour deductloa mo be limlled See a" A.5 Illr Ih" a,"ouallo enler,
'or '1pII'WO/1l IIeduollon Aat Natl.., ... form 1040 In.tructlon., CBl No 11330X
6ahedule A (fonn 104011_
.
I Did)'Oll "mllonally Plrtlclplll" In tlll o",","lIon 01 Ih" bu,'n... dUllng lu931 II "No." ,.. plIg1 F.2 for IImll on ,_. 0 VII 0 No
11IIII Firm Incom.....c..h Method. Complete Plrt.llnd IIIACI","I m.I~.. IIII"W"" ''''1/1'11 '.mll .... III. ....11.. II ., h~ 1.1
Do "otlnoludl .!!.I.I o.!.!!~,!~~""ld '~,~~I~ort or d!!!!J>U~""I" ort Ill... ..... on Form 4717.
I 511.. olllvlllock end olll.. 110m' yoo beuUhllor 10"'0 , , . I /1'1..
I Colt or other ball. 0' Ilv..tock Ind olh.r Ilema r.ported on fin. 1 2
I &JbllaOlllnl21rom1l1ll I . . . . . , . . . , . .
4 !leI" olllvlllock. Produc,. groin" Ind olher P'odUC~",," ,~Md. .' . . .
.. ToIII coopn~VI dlltnMOIIIIForm('II099.PATRI L" '" j.3.k-J
.. Agrlcullurol progrom ply""nl'I'" P'UI F.2) L~ .u,isi-~
7 Commodlll' C,ldll Corporollon (Ccq loon, (110 pig. F.2):
. eec loin, ,oporlld undef lllOtlon . . , . . . ,
b cee 1011\1 forfollld Of ,oplld wllh cortl',col.. I 7b I
. Crop In,",,"co proceodl end cortlln dlllll., plymonlllIN plgo F.21:
. . Amounl rocolvld In 1993 . . . . . . . I .. I 2:L11.Irl- ell TOJ<lbl. ImOUnl
c I' election 10 d.r., to 1994 lIS 8ttilchlt(J, chlJCk hu,.,,,, 0 let Amount del,n"ed 'rom 1992 .
. CUllomhlro(mochlnoworf<)Incom.. . . . , ., .,..........
10 Other Income. Including Ftderal'rnJ Ital. gaaol1ne Of 'uel tu c,t111 Of r.lund (11M pig, F.31 . . , I
11 aro..lncome, Add amounts In the right column lor lines 3lhrough 10. If uterual method taxpayer, enl.,
tho omounl from I 2 IIn.51.. . . , . . . , .. ,...,..". ~" 0 -
Firm ExpenHI-C..h Ind Accrull Method. Do not Include personal 0' living expense. luch u (pel, Insurl1lCe,
Ire. elc.. on our hom..
SCHEDULEI'
(Fonn lCNOI
Proftt or LoI. From Fermlng
~ "_h to 'orm 1040, '''''" 1041, or'orm lOll.
~ of the ''''''
___101
-Jl/-'"
1'1411'- S. I1)ONI5"'0""'" or
" ""~ $~~nbO / ~;~.;;~lc~~;~""Y ,..~: cun:'" r~
C AccoYntlng ",llhod:
, (1) [t('elsh
IIll 0 Aecrull
ell T...bll omounl
Ib Tu.abll."lounl
70 r...lble .moont
12 C.. end tnJc:k 0.pon6Ol(_ pig. 26 Pln.lon ond prolll.shorlng
F .3-0110 Inoch 'orm 4512) . 12 plenl
13 Chomlclll . 13 llt Rent or lelse (a.. pig' F.4 )~
1. Conaervlllon .Ilpen.... Attach . V,hlet", machinery, and equip.
'''''" -. 14 ment
111 CUltom hi.. (m.chln, woo). 15 '21 b Other (lInd, Inlmall. .Ie,)
It Doprtclollon ond Hellon 179 27 Repairs and mllntenanCB
..penH deduction nol claimed llt Sveds and plants purchased
oIoowhoro 1_ pog' F.4) " z.3o :IV Storage Bnd war.houllng
17 Employ.. ben,ilt programs 30 Supplies purchlaoo
oth.. Ihen on IInl 25. 17 31 Tu..
1. Fold purch..1d ~~.- Ij 32 Utllltl's.
Ie Fer1i11zerI and 11m. 1.9_ Z&#;, - 33 Veterinary, bleedmg, anlJ medicine.
:ao Froighl .nd lrucklng . 20 34 Other ..p.n..' Ilpocll)l):
21 OllOllno. lUll. ond 011 21 0 ........ ..... . . . . . . . . . . , . . . . .
22 In,"'onoo (01ho' Ihon hoolth) 22 b . . . . . , . . . . . . . . . . . . . . . . , . . . . . . . .
ItS Int....1: ,~ 0 ...............................
. Morfgego (p.1d 10 blnks. Itc,) . ~ d .....,.'......,......,.........
bOther 231> 0 .,.."..,.,.......,.,..........
1M labor hired lOll 01>, c,odll 24 ,
illI ToIaIe--. Add IInOI 12 Ih,ough 341 . , , . . . . . , . . . , . . ~
illI Not II"" pnltII or ~_I. Sulltrocllln. 35 f,om llno 11. II . profit. onlor on 'orm 1040. IlnI 1', end AlSO on
IcIIIduIo II, IIno t. II .1011, y,," MUST go on 10 1111I 37 (lIducllIl" end porInorll1lp.. _ peg. F.II. .
37 ~ you hovo 11001. you MUST chock tho be. !hili deacnbel y"",'nv.lm",1 In IhlllCbvily I... pogo F.51,
It )'OIl chockld 37.. onl.. IholOOl on 'orm 1040, llno It, Ind AlSO on Iollldulo IE, II". I.
It you c:hICkld 37b. you MUST IlIoch 'orm 11M.
'or '_""'" ,,__ Ac1 Notico. ... 'orm 1040 In._. ell No. 113_
OM' No. 1_74
~~93
Nt_,
_ No. 14
_....., _IIIHI
00 ! 31. I .
I En'. pr1nCiIlIIlIJICVlt"'lI ""wily
code Ilnlm _ II .
D ...,._ID _ 11lN),"...,
-
-
-
ell
lei
.
I
-
.,
CICI-
II
..
~
2tlI
-
27
I!lI
21
30
31
32
33
,~
-
:Mb
34c
-
-
341
-
,'7
371 Alllnv.tmont I. It nlll,
37bOSOml__nototr1tl.
10_ , I'''''" 10401 1.
OMI No, 1~1I'
~@93
AtttcNnlnI
. IUt.ch thl. 'onn 10 our Income t., relurn. __ No. 2S
IIocl.._.....,..~---
tJO.
,_ 4136
Credit for Federal Tax Paid on Fuels
lAnd c,odll lor Pu,ch... 01 DI...I.Pow.,.d Hlghw.y Vlltlc:I..1
o _ ~._J"" f,..."
1nI..w ...... s.v.c.
NetntJtu Ihown on yuut KOO'III.
Y~I.JL. S..;. ,
... Dlea"-PDw.red H.!IlhwB~ Vehh;le Cre.dlt
I.,
tI Number Qr
__~..hlcl..
I
2
Add lines 1 ond 2. column ~C" .
11I1
c_...._
_$1.92,00
198
g.
, Oiesel.powered cars ,
2 Dluel.powered light ti'bcks nnd vans.
3 Totel diesal.powe,ed highway vehicle c,edll
II!IIII Fuel T.. Credit
C'UUO"1 " you ell/mad .ny luel 'a. relunds on '0"" /H3, Clllm 10' Refund and Requesllo, II","'.",,,,,, you unno' claim "-
.moun/s.1 crwd/'s 011 Form 4'36, .
, . .. I
3 ..
11I1
TtPe 01 Fuel
4 GllIOline ~
II GllIOhol bolJght 10' nonll.able pUlposes conl.,ning: ,~,,:
. At lealt 10'K Ilcohol . , , . , , , I5e
b Allaasl 7, 7'K but I.salh.n 10% Ilcohol 5b
c Allaasl 5,7'K bulless Ihan 7,7% alcnhol !k:
. Olesalluel, . , . , , . ·
7. Special motor fuel . , . . , , , 7..
b Compressed nAtural q3S (r.rPdit rnlf! J1P.f Ihoul'iI1nd r:uhic '~el)
I G.IIOIIne used In aVlalion:
. TlXed al 15, t cents a g.lIon (19,4 cenls .her Sept. 30), lie
b Ta.ed at 14.1 cenls a gallon (18.4 cen," nile. Sepl. 301. .~"
, AVI.lion lu.1 (other than gasoline): ,~'"
a UIIed In foreign I,ade . , . , , . . . . . v_.
b UIIed on a I.,m. In certain hellcopte,s. 0' In comme,clal
aVlstlon.
'0 Gasohol blende, c,ed,t 10' gnsollne bough I nllhe lull 10'
role and used to make gasohol conlalnlng:
. 10% or more alcohol . ,
b AI least 7,70/0 but less than '0% alcohol
C AI lent 5.70/0 bullass Ihan 7,7% alcohol
l' Olesal 'uel bought atlhe 'ullla. '.'e and used In Inte,clty
0' locsl buses , , . . , . 11
'1 Total lu.1 IIX c...olt. Add IIn.s 4.1 I. column Ic) ..
'ThIs 'ale IS onl 'o,luel u,chased nnd u,ed nfle' Seplembe, 30, '993.
Tot.llncom. Ta. Credit
'3 Totallncom. tax credit claimed (add line. 3 and 1~) Enl., he,. and on Fo.m 1040. lin. 59
(also check boo b on line 59); Fo,m 1120. line 32g; Fo,m I 120.A, I,ne 2AQ, Form 11205. line
23c: Fo,m 1041. line 24 : 0' Ihe prop.' line of olhe' ,elurns , .. 13 S
P.perworl< Reduction Act Nolic..-W.
ask for the information on this form to
carry Oul Ihe Inlernal Revenue Iowa at
the United StAle!'.. You are reqUired 10 Qlve
US th. InformBtion. We need It to ensure
Ihll you are complying wllh these laW5
and 10 allow us 10 figure and collect the
rlghl.mount of tax,
The time needed 10 compl.te and hie
this form wUl vary depttndlng on Indlvu1unl
Circumstances. The estimated av~rAge lime
Is:
ReconIk..plnv 1 h,. 41 min.
Preplrin, .nd ....dlng
Ihe form to the IRS, 1 min.
II you hove comments concerning Ihlt
accurl1cy or these lime 8allmat.,,, or
5ugqestlon!\ for making Ihls h'>rm morA
~Imple, we wotJld he happy to h"iU Irom
you. You CAn write 10 bolh the IRS and the
OffiCI! 01 Management And Budget (II the
ilddressos hsted In the In5lructlOntll of the
Ill.ll relur" With whIch Ihl!\ form I!; 1.Ip.d
General Instructions
PUlpOI. of Fo,,".-Fo,m 41361s used by
Indlvld..JAls, eslAles. lrusts, 0' co'porahons
10 claim credit 'or Federal eJeCtse IA' paId
on fuels and 10 claim the credIt 'or
dlesp.t.powered hlghwBY vehlcle5.
IP.~ne'shlps clnnoll,l. this lorm; Insleed.
ell No 1 ~2&R
11
11II
eRN
312
Ihey musl a"ach I st.tern..,1 to Form
10l15, U S. PArtnership R.tum of Income.
!\hOWI"~ th. number of gallon. of fuel
.lIocaled 10 .ach partner Ind Ih.
applicable tal '1Ios)
Requlrement..-To claim. credit you muaI
III u,olhe luel for. purpose listed 'n the
Type of U.. reble, 12) bU)' lhe fuel 11 I
proc. lhel Included Ih. tIM. Ind (3) not _
,,",,,..Ied or ,ecelved a refund of the t...
Including Fuel T.. Cr9d1t In lno_.-
You must ineludl the amounl of lhe credtt
I,om line '2, Plrt II. In you, groul_1I
you took a dedUC1lon on YOAJ, tlX return 'Ot
Ih. la.es p.'d ond that dedUC1lon ,educed
you, 'IX "ability.
,..... 413111..
.0
'com
4562
Depreciation and Amortization
(Includlnalnformetlon on U.ted Property)
IJIpnnene of 1M "-..r
___ (OJ
,..".., _ on rot....
....
Ie Inllnlallonl.
. A_h IN. lonn 10
NIum.
OMI No, '11411-0171
~@93
,ltloch"*,' 17
!Io<lI*lC' No,
...~.. ""'"""
DO' '16 . 1.2.."
'HI 1.0
... Election To Eltpen.. Certeln Tangible Property (Section 179) (Nole: " you hive .ny "Listed Property,'
complete Pert V before you compleleJ?!lrt I.)
1 Mllllmum dollar limitation '(II an e"terp,'.. zone bullneee, see Instructlone.) . . , ., 1 17 500
II Total cOlt 01 section 179 property placed In eeIVlce during the tax year (s.. Inetructlonl) , 2
" Threlhold COlt ol.eetlon 179 properly belore reducllon In limitation. . . . . . .. is 200,000
4 Reduction In limitation, Sublracl hne 3 f,om hne 2, but do not enle, less Ihan .0. 4
II Dollar limitation for IIll year. Sublractllne 4 lrom line 1, but do not enler 1085 than .0.. (II
marned IllIng eeparalely, ISII Inetrucllons.) . II
II) OeICIlpl1Qn 01 property €bl C051 Ie) Elecled COlt
.
7 Llated property, Enter amounl from line 26, , . , . .. 7
. Total eleeled cost 01 aeetlon 179 property, Add amounte In column (c). IInae 6 and 7
. Tentative deduction. Enler the smaller 01 hna 5 or line B, ..."...
10 Carryover 01 dl..llowed deduction from 1992 (a.. Inatructlona). . . . . . . .
11 Tllleble Income limitation. Enter the amaller oltllllable Income or line 5 (e.. Inslructlona) ,
12 Section 179 expe""o doducllon. Add IIn.s 9 and 10, bul do not enter more than line 11
1" Carryover of dlll4l1owed deduchO!'..I,,] 9_94:~ddlll.'."~ ~ "l\dl.Q..!e-,,~ne .!L..JJiT _
Nota, Do not use Pen II or Pen 11/ below lor listed property (automobIles. cenalll orher vehicles, cellu/lf telephones.
certe/n com uters, or ro e used lor entertalllmenl, recreallon. or amusement). Ins teed, use Part V lor listed roperty.
MACR8 Depreclallon For Alaeta Pllced In Service ONLY During Your llll13 Tu Ve.r (Do Not Include
Ulted Pro
IoICI_lIonof_
(dl RlKOVery
"."0<1
14
e
b
c
d
.
,
II
h
111
a
b
O'
!?
t...
-
.~ 'I., I) Y l:; .
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17 Property .ublact to section 168(~ll) election (see Inetructlons)
18 ACAS and othar deprecletlon (see InstructIOns
_ 8ummlry
1. Ulted property. Ent.r amount from line 25. .....,.........
20 Total. Add deductIOn. on IInl 12, IInll14 and 151n column Ig), Ind lines 16 through 19. Enter her.
and on the appropriate lines of your return. (Pertnershlps and S corporatlonl-see Instructions
21 For ...... shown above and placed In ..rvlce during Ihe current year, enler
the Ion olthl bllll. annbutable to Il8Ctlon 263A costs see Inslrucllon.
'or '" worII "edV'OtIon Act Notice. ... page 1 of the 11111 ... 1MtruotIonI.
Cot. No. ,:lIOeN
,..... 4582 (11183)
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"C~IS~ITh rAMELA K
3~31 ~A~~G~t~~ ~AP
(,jOLISLL F'
RETURN BY APRIL 17. llH:lb I U:
CAPITAL TAX COLLECTION BUREAU
,9 S. hAhOyt:il H.. SUllI:' 102
;ULlSU. PA 1101]..)]36
lJW94
LOCAL EARNED INCOME
TAX RETURN (FORM 531)
SEE BACt< OF RETURN FOR
PHONE NUMBER AND OFFICE HOURS
EMPLOYEE BUSINESS EXPENSES (Anach Fed"al Form 2106 & 5'01. Sch.dul. UE.l I 2
TAXABLE W.2 EARNINGS (Sub",cl Llna 2 110m Line 11 . 3
OTHER TAXABLE EARNED INCOME (NO INTEREST OR DIVIDENDS) Compl.lo SoCllon B 0/1 Back ~
TOTAL TAXABLE EARNED INCOME (Add Line. 3 and~) . , , , . , . 6
NET LOSS FROM BUSINESS. PROFESSION. OR FARM IUSE LINE 8 FOR ANY NET PROFITS) . 6
SUBTOTAL (Sublract L1na 6trom L1na 6) IF LESS THAN ZERO. ENTER ZERO. 7
NET PROFIT FROM BUSINESS. PROFESSION. OR FARM (USE LINE 6 FOR'ANY NET LOSSES) , . , . . . S
TOTAL TAXABLE EARNED INCOME AND NET PROFITS (Add LillO. 7 And 8) . 8
TAX LIABILITY: 1%OF LINE 9 (Multiply Lln. 9 by .01) .
TOTAL LOCAL INCOME TAXES WITHHELD (From onlched W'2'.. Bo, 21) .
\0
"
aUARTERL Y PAYMENTS AND/OR LAST YEAR'S OVERPAYMENT CREDITED TO THIS YEAR, . 12
CREDITS FOR TAXES PAID TO PHILADELPHIA AND/OR STATES OTHER THAN PA (ATTACH SCH, GI. 13
TOTAL WITHHOLDINGS & PAYMENTS (Add Line. 11, 12 end 13) , , .
1~
TAX BALANCE DUE (Sublract Line 1~ Irom Line 10) PAYMENT NOT NECESSARY IF LESS 7HAN $1.00. 16
INTEREST & PENAL TV (Saa InOlructlon'l . . 16
TOTAL BALANCE DUE (Add lln.. 16 and 161 M.ke check payablalo 'CTCB' . . . 17
OVERPAYMENT (Subtract Line to Irom L1na 14) IF LESS THAN ZERO. ENTER ZERO.
18
19
PAYMENTTO BE REFUNDED. . , , , , , .. . .. .. .
OVERPAYMENT TO BE CREDITED TO NEXT YEAR'S TAX. ,
20
OVERPAYMENT TO BE CREDITED TO SPOUSE'S BALANCE DUE FOR THIS FILING YEAR. .
heATH MIOCI.ETOII HO?
YOO~ IOCIAI. OlCu~'TY NUMBIA 0 ~ 0 0 I J II 12 Q H
III'QU..UOCiAL "CU"'TV NUlI8lA @ ISl"" 8 " . Ii
TAX OfFICE
use ONLY
InCll.l80U C;&M-1I1 SCRl
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5POU61'SNAhilE
(LAliT, FIR/H. Mil
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COMMONWEALTH OF PENNSYLVANIA
19,94 Resident Indlvlduellncome llx Return .
~~ 0 AICII 'I" ,1l6I B'OlnnlnO 1994
Ending ._ 199~ P.... '11111"'11'1
., ...........CAR-R ...",,,.,,.. 1I'''~,h''oI...ItIH
200-36-1208 H T SORT**R003
1..'_ PAUL & PAMELA ~oNl~~i~~-8412
3431 WAGGONERS GAP RO
~... CARLISLE PA 17013-8326
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I. DROSS COMPlSSATIDS "
. Ib UNREIMBURSlO EMPlOYE BU51S15S IIPlN5ES 'b
, Ie. NU PA TAXABLE CDMPESSATlOS. ,
~.I TAXABLE ISTEREST
.. I TAXABLE DIVIDENDS
~. NU ISCOME OR ILOSSI fROM THE OPERATlDN OF A BUSINESS, PROFESSION OR FARM
.
l\ 5 NU GAIN OR ILOSSI FROM THE SALE. ElCHASGE OR DISPOSITION OF PROPERTY
~
~ &l AMOUNT OF EXCLUSION FADM LINE 10 OF PA SCSEDULE PA..9 5'
:t' 100 Nol Include In line ~ .bOY.)
S S KU INCOME OR ILOSSI FROM RENTS, ROYALTIES, PATENTS AND COPVRIGHTS
. 7. ESTATE AND TRUST IS COME .
B GAMBLIKD AKO LOTTERY WINSINGS
e TOTAL PA 7AXABLEISCDMElTollI L1nll Ie. I. 3. . S. S. 7 on, 8 . DO NOT DEOUCr lOSSF.S
e 10 TAl LIA81LITY Mulll I lln' e b 2 8 41 018
11 TOTAL PA INCOME TAXES WITSSELO
'1. ESTIMATED PAYMENTS AND CREDITS
II' C,.,lI F,om '993 PA Atlurn.
lib lee. Inll6l1...nl P,y..nll .
Uc Plyment wll" 1994 ReqUllt for hl.nllon
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F. Il' TOTAL PAYMENTS ANO CREDITS.
i 13. TAX 'ORGIVENESS FROM PA SCSEDULE SP
~ '31 OIptIldonll CIat..., I''''' Lint I, p,n III of PA Sehedull SP.
f lID 11I9I1lI11ty Incomo lrom Llnl 3. p,n IV of PA SelJ6dull SP .
~
lie ,""',., Adlu'llCl G'Ol,lnCOllllI,,,,, Lilli 2. P.., III 01 PA Seh""'" SP
13d TAX FORDI'IINI5S FROM LINE e. p,n IV of PA Sclltdull SP ,
14. TOTAL CREDIT 'OR TAXIS PAID TO OTHIR STATES OR CDUNTRIES
'5. EMPlOYMENT ISCENTlVE PAYMENT! CREDIT...
'8 TorAl PAYMENTS ASO CRlOITS ,Tol.ll,n.. 11 12'. 13'. " ,n' 'II
130
130
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.
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Ioclol-'!y _11IHl
!'1C !
I Enlor pMClpolognc...I...1CtIwIIy
___1l.1':<1/1~
/" 0 ........,.,1II_1IlHl,..",
C AcoounUng motIlod: .,II2I"C..,,' llII 0 AccNol , " I I I I u.J.-.L.J
. Did you 'malortli ,*,lClpal.' IIllht _lion 01111I. __ cIuri lve4? K 'No.' _ _ ,.~ '''' 1Im11 on pa..... _. ~ 0 No
Firm lncom...clah Melllod. Complete P.rta I Ind II (AI....I ........ ,...."" ,..."... "/1111 ... III. IlHIllftl " II '"" I.l
Do nollncllllle ..... 01 1I...lock "'1eI/or cII'. bNed or ...1 "" Ihe~ ..It I on 'onn 4717.
I _ of 1I...lock III1Cl other I.em. you bought f", _It. . . I
. COIl", 01.... bIIll olll...lock III1Cl 01.... 110m' ropor1ld on lint 1 .
I SublrlClIlnt21romllnt I . . , . . . . . . . . . .
4 Sal.lof II_lock. procIuc., gllinl, onct 0II\tI prod~I.'"tll4l<l. . . , .
.. TolII c_.II.. dlllrtbullonl('onnl.I 1m. PArR) .. ~ 1,;) LCtJ
.. Agr1Cullurll program pavmenll(... peg. ,.~) .. .J. ~..~ U
7 Commodity Crtdll Corpor.11on (ceC) 1otnI(... ptgt ,.al:
. CCCIoen.rtpCN1ldunder-.cuon . . I , I " ..,.,.. I . . . .
II CCC Iotnl 'or1.'1d '" ~ w"" ...,llIcIltI I 711 I I
. Crop In...._. procMClI onct cortaln dlllll.. paymenl. 1- ptgt '.2):
. Amounl _vtd In 111M . . . . . . . I .. I ~f" Ii"? I II> r.._ _nl
o II 1I..11On 10 dtI.. to , 1IlI6 II IIttchtd, clltek h<<.. 0 III Amounl dtIorrtd 110m 1 1IlI3 .
. CU.lom hire (macII.... WQIl) _. . . . . . . . . . . . . . . . . . . . .
10 0tIl0r income, Inclucllng F_1Il<I1lt1t QUOIt.. '" "* III crtdll.,_ I'" _ "3) . . . . .
" GIOII mc-. Add IITlOUnl.ln lilt rlghl column '''' II"" 3lhrough 10, lIaccNII m'lhod I"p.y", ""III ,
Ih. am01Jnl lrom 12 IInI51.. . . . . . . . .. ...,....... I I 13 ..l-
Firm Elptn..-celh Ind AccNlI Method. Do nollnclude personel 0/ hving exptf1I18S SUCh as laxes, Insurance,
II alrl, etc., on our home.
,. Ctr lWld INcIo "'~ (_ pogo
"~IO lIftIC/l'orm 4IU).. II
I
SCHIDULE F
(Form 1040)
-."'-
___ OIl
"'--
Profit or Loaa From F8rmln.
. AII8cIItD.arm ICMO, Fonn 1041, 01' '0I'TTI101ll.
f
IpOI pIOdUC\' Doo<""''' .... '" Iwo _ 'f'NI pI1IlCJIlOI ""'" or ocIlYIIy 'or tho cumlnl'" )'lit,
1m CtMNnlCalt. . . . . I ,
14 Conotrvlllon ._.... Al\ach
'onn _. . . . . . .
II CUllom hlro (mlChl.. wOtll). .
II DtprocIIlIOn onct 1IC\10f) 17e
.._ _ucllon not c_
IIHW.....(__'-4) . .
17 Employtl _'I program.
0Ih<< Ihan on lint ~5 .
II 'MCl pu,_ . .
Ie '1II1IIz... lWld 111111 .
10 FrtighllWld lNCkJng .
II ClIIOIInt. IutI. III1Cl 011
II 1_""" (_ lhon 1Itallh)
II Inl_l:
. __ (paid to _, tIC.I .
II Other .
.... l..oIlothiold om
cred"'
5b T..lbl. _nl
II> T_ llI110unl
14
III
ill "'"lion onct P<D"I.1haItng
planl. .....
ill Rani'" _ (... _ Fool):
. Vehlclel, machlnory. and equip-
menl . . . . . .
II 0Ih<< (Itncl. anlmall, tlc,) .
17 Rtptlro Ind 1111'"1"""" .
ill _I III1Cl pion" purchlMd
:It 51"'. Ind wlloIJou.lng
:10 6upplll. purch_
~I Tu.. . . . . . .
:1:1 UIIIII,". . . . . .
:sa V'l,"n,r'/, D'HtlIIlQ. .lICl mldlCtn' .
.... 01.... .__ (opacify):
. ...............................
II ...............................
..
II
.
17
18
18
10
II
,..
~
at
1311
14
a...................,.........,.
d
.."...........................
f' ..........,.....................
I
at TOIaI.r'lI'II1 AddIiMl UlIlIough34' . . . . . . .. ......... ·
. Nell""" proIII 0I1*t1. Subl..., lint 35 from lint , I. If . ptOfII. .,,1.. on 'orm 1040, lint II, end AlSO on
.........11I, lint I. If . l01I. vou MUST go on 10 lint 37 I....'... tnaI.. III1Cl ,*,,*,,,,pa, ... pogo ,.&) .
~7 If you "".. 11011. you MUST chock I'" bo,lhtl dHClllltl '(fXJI1"".tmtnt In tI\IllCllvil'/ I'" pogo '.5). I
II you chtckld 371. ani.. 1".101I Of) 'onTI 1040, lint II, _ AlSO on Iohldult II, lint 1.
II you checll.ed 37b, you MUST InKh 'orm '1..
'01' ,_"".....IItd...tlon Act NoIIot. _ 'arm.I04O....--..... Cll' No. 1l:I4IH
141
-
6
-
-
~
Ita
-
I'
ill
:It
30
~I
:1:1
33
-
.z
:140
:140
.....
I. '"
. (Z-'J ",3 73-
3'.urAll_.......
37b 0_""',........... nli
10111 ~uIt , ('_llM011'"
... ..
ICHIDULII AU
1'_ 10401
I
Schedule A-Itemized Deduction.
(Schedule lie on back)
_.....T_
___ !PI
~ _n on ,""" 1040
L
Cautlonl Donollnclude upenu. rllmbu,."d Of pilJd by Olh.ro.
1 Medical and dlntal expensea (a81 page A.\). , . .
2 Enllr .mount hom form 1040, linl 32, I 2 I
3 Multiply line 2 lbove by 7.6% (,076). . . . . .. 3
4 Subtract line 3 lrom line 1, If line 3 la mar. than line 1 enter ,0-,
a Statl and local Income taxll . 6
. Rial aatatl laxll (a81 pagl A-2). . . . . . ., ·
7 PerlOl1al property taxll. , . . . . , . . . , ~
. Other I....... U.t Iype and amount ~ .. .. ...... .. .. .. .. .. ~
Mecllcel
.nd
DenIBI
1xpBn...
T.... You
P.ld
(ISM
page "-1.1
II
InlBraat 10
You P.ld 11
(SM
page ".2,)
HoIeI
P- 12
Inler..t I.
not
deducllble. 13
14
GIf18 to 16
Ch.rlty
"y""lTIIdt I ,.
g!ftonc:l got .
_Irorlt. 17
_ poge 1\-3. 1.
CI.Ullly Ind
Thin LOll.. 1 II
Jo~ fap.n"l ao
Ind MOIl
Othlr
Mllelllenlou'
Dlducllolll
(SM
page ,,-& for
Illpanll.IO
deduct 1Iere.)
23
24
26
21
011I11 27
Mllelllen.au. 21
O.du.llon.
TolBl 28
It.mlzed
Deduction.
............,............................... ....H.............
Add linea II through 8 . . . , .
Homl mortgag. Inllflll and pOlIll. IIportld 10 you an form 1098
Hame mortg.g. Inlerlll not reported to y"" on Form 1098. If p"d
to lI1e paraon tram wham you bou9ht Ih. homl, 'H p091 A.3
end IIhOW that paraon', nlll11l. Idlnlitylng no", end oddress ~
.....................................................,..........
................................................................
................................................................
Polnle not reported 10 you on Form 1098. See page A.3
lor.peclalrul... , , . . , . . . . . . .. 12
Inv..lmll1llntare.t. II reqUired. allach Form 4962. (See
page A-3.1 . . . . . . . . . . . . . .. 13
Add line. 10 thl'Ou h 13. . . . , . . . . . .
Gill, by cuh or chacko If any gill 01 $260 or more. Il8I
paga A-3, . . . . , . . . . . . . . . ,
Other than by callh or chacko If any gill 01 $260 or more,
all page ".3. If over $500. you MUST attach Form 8283
Carryover from prior yaar . . . . , . . .
Add linea 1111hrou h17. . , . . , . , .
Cuualt or thell 108l(e' . Allach Form 4684. (See
Unralmburaed employee expenses-Job Iravel. union
dua.. job education. elc, II reqUIred. you MUST attach
Form 2108 or 2106-EZ, (See page A.6,) ~..... .........
................................................................
................................................................
21
22
Tax preparation l8Ia . . . . . . . . ; . . .
Other IXp8f1l11a-lnvealment. 118le depoSit box. etc, LISt
type and amount ~......"..................",...."......
................................................................
Add IIn.. 20 through 22. , . . . . , , . . .
En16r amount from Farm lQ,10, linl 32. 24
Multiply IInl 24 above by 2% (.02) 25
Sublraclllne 26 from Iln. 23. II line 26 ,. more than line 23. .nter -0.
MOVing ..pen..' Incurred before 1994. Alloch Form 3903 or 3903.F. (See page A.5.)
Other-from lIat on page A.5, LISt Iype ond amount ~ . . ,.. . . . . . .
la Form 1040. line 32. over $111.800 (ovar $56.900 If mamed filing s.paralely)?
NO. Your deducllon IS not limited. . Add thl amounts In the far right column }
lOf line, 4 through 28. A1,0. II1ler on Form 1040. line 34. Ihe larller ot . ~
thl. llI110unt or your standard deducllon,
VIS_ V""r deduction ma be limited, See a. A.6 lor Ihe amount to enler.
'or Peperworll ReclucIlon 1101 Hollce, _'onn 1040 1"llNOllon.. Co, No, 12&13l
21
27
~
28
OMs No. '1>4&.007.
i!@94
6/-
.r..ro -
Bcllodule " ('onn 1040)1114
,.",
4136
,
Credit for FecI.,.1 TIX P.ld on Fu.l.
lMoI CreoIII ,., ~ of DiIIII"~'/'''''' Hlghwer VeIlIGIHI
0I0lI No, 1~I.o'U
"
. AII8olIIIllIIIIl'IIIIo
.... DIeNI.'owerecl HIghw.~ VoIIIole er.dIt .
"
1"
-..
~I
-.. .....
, DiM"powered CIII . . . . . I . . .
. DlMIl-pow.-.clllghlltUeka and VIlI\', . , ,
~ Tolal dleMl- W"ed hi hWI vehlcl. crldll. Add IIn.. , and 2 column c , .
IlIIIIII 'lIII Tu er.cm
ClMItlonIIl you clllmld lilY fuel 'ulllund. on Form IilMI, CI.,m 101 R.lund 01 fllc... Till", Fonn ....... Clllm lor R.fund and Requ..'
for AMttmlnl, 01 Schedule C (Form 720), Ad/u.tm.nl.lI1d C/llml, you cannot claim rhOIl Imount.1I Credltl on FOlm 4136.
4 Non\aaabll U.. o. Gaeollne (5M Ih.lrucllonl,)
..... -..
_OIl 1_- 1,184 )
II UN I '11m lot , ,184 2- .,~ !.
o ClIhIr non...- _ 11lllClf\<) . ,'84
. Non...... U.. of GaIOllol (SM Inllrucllon..)
Amounl 01 cncIIl OliN
301
1~1 ~
.....
-
Amounlol_1
CIIH
II GuaIloI conlainl
11111117,716 _ bull... thin '016 1Ic0h0l
.1~24
)
~'2
_ GuaIloI conllinlll II 101I1 1016 llcoI1oI
1,'3
o GuaIloIcon Illollll.716llcoh01butll..\IIIII7.716_ ,'1~2
. Nontullbll U.. o. UndW.d D..... Fual (Ixcepllol UII on a 111m lor larmlng PUlpol.. 01 101 Ihe IxclulIlva UII 01 a Ilall
01' localgov.rnmefll) and Salea b~ RIIlI...,.., UIUmata Vendorl o. Di.Hl Fuel (SM ,nllrucl,onl.)
IJnH .., b, _ 01 C_l boug/ll unci,"" 0_ lull, carol... IIlIIIIlI 0_ I.... Old nol conlaln VlllbIIlVldenct 01 0,., ono uNO tI1et
d_ lull lot I nonl..lbI. UII.
.....
-..
Amount 0/_1
CIIH
._ Heo 011
1.244
b 011- WI _ UII
.244
II ClIhIr non...._ _ (__1M. .. .244
LIne IeII Cllunllll 1010 undyld 01_1 luOI(') 10 I olal. or locli
lIOVommenl 'or III ..CfuIlV. UN or Ib) lor ".. by 1111 bu,.. on I
larm for t.,mlng purpoMl, Clllmant la . rIQlat<<ed ultImate vendor.
_ till ,.... II . .......clUdId prICe, CIIIlI'.. thall/II O,...llu.1 010
no! coni... v'lIbIIlVidlIrICI 0' OY" and olll.'nod Ih. requllld
Cll\111C1I. 'rom till bu,.., IIIlO hll 110 rlllOl1lo bII.... lilY olllll
I/llormallOll In till con111CI1I1I I.....
d IIlltld ulllmatl vond... ,244
Clt No. 12~&R
303
,.... 4130 I'""
365
Bulin... Iddr_ (Including lUll. Ot ,oom no,) . . .~~. fP.!f.ii f!~ ..,.. rr.AI'l.
City, lown Of pool oltlco, .111., enct;ltP cod. ' I t 't ()
AccounUng method: ll) ~1Ih 121 0 Ace,u.1 l~) 0 Other ("",,'1)'). ............" ",,,,,.....,,......... ....".......
MIlhod(') ulld 10 Lower 01 cool Olher 1'1IaCh 4'001 opply (,,
.oJUI clOllng In.onlot'f: (1) 0 Cool (:I) 0 or ml11<ll I~) 0 oxpllll.Uon) 14) l(fChiCkOd, .klp Itn. H) Yo No
W.. thll' lilY ching. In d.llII11ln1ng qUIllIIU.., COli', or ."u.IIOI1. b.lwon oporllng lII1d clo.lI1g In..nlOt'f? II -YII,' .llIch
.....".Uon. . . . . . . . . , . . . . . . . , . , . . . . . . . . . . . . .
Old you 'mellllllly pll1k:lpal.' In Ih. operlUon ollhl. bUlln... dUring 1 S94? II "No,' _ page C.2 lOt IImll on 10.....
It ou started or Ie ulred thll bUllnln duM '9Q4, chee" h.,. . ,."......,..,.
nCOm.
ICHIDULI C
('orm 1040)
Profit or LOll From BUlln"l
(_ Propn.loIWllp)
. ,I/1nIraIllpI,loln1 ....lUII., .",., muolllll '''''" 1011.
. An.oIIlo 'ann 1040 Of 'onn 1041. .... In......IIOII. lot Icl>ldull C
-.....'-101
---
-AI proprIo/or
Vl/mtPt~ ;('. /II" AI 15",
,,' """SfII 1lull/1lll Ot prol_lon, InclUd!Pfj prodUCI Of 11I\I101 (on pig. C.t)
-1!.11d..D ~e..U=.,j. {!/.A41J I AJ Cj
C Bulln_ name. II no lIP"'" bulln... nlrlll. ill.. blenk.
I
,
o
H
Gron recelptl or ..III, C.uUoru " thiS ,ncome WIS reported to you on Form W-2 and thl .St.tutory 0
omp!oyoo' 1>0. on /hll /oml wu cllKhllCl. ... poge C.2 IIld ChICh hllf. ·
. R.luml and Iilowll1CM . , . .
a BublrlClllno 2 lrom llno I . . . . .
4 CoIl 01 goodI aold (from llno 40 on pog. 2)
I ~ pI'OItt. BublrlClllno 4 from IIn. 3 .
I 0thIr Income. including FIdIIIIl and 1111. gllOlIno Ot luol tax ClOd,I Of rolund (_ page C.2)
7 Qro..lncomo.Addlln..5I1ld5. , , , . , . , . , . . , . . . . .
n.... Enler ex naes for business use of our home onIon line 30.
a Ad.lI1lllng. . . . . . e II pon"on end ",ol,I.o/1l11ng pI,"1
a Bad dlbll from ..I.. Ot 20 Aonl or I.... (_ page C.4):
11I\I,," (on pogo C-3) . . I . V""'iII, 11\ICIIIIOIy, I'ld oq..pmonl .
10 Cor and l/lICk eJ<pen_ ,., b Olhl< bulln... ",oparty .
(_ pig. C'3). ., 10 21 Aopolrl end mIInlonenco .
Commlulonl and I.... . . 11 21 Supplll.lnollllCludod In Pill 11I1
DepleUon. . . . . . . 12 23 T.... end l"lnll'. . .
00pf1C1l1Ion and IICtlOn 1711 14 Tra.lI. mMIl. lII1d onlartalMlonl:
_ deduction (no! IncludOd . Tra..', . . . . . . .
In Pill 11I)(_ page C-3) . , 13 b M.1I1 end ono
14 Employ.. _'I progrl/11l 11I1,'nm.nl .
(o_than on Iln. 111). . . 14 0 Enl" 50% 01
II InlUrlllCl (othol' Ihan hMllhl . la line 24b ,"blOCI
10 IImlt.hona
II Inlll..I: (III _ C.41 '
. MOIlIllll' (paid 10 bankl, .tc.). lea d SubVlC1 lin. 240 from lino 241>
b Other. . . , .. lib 25 Ulillll.. . . . . . ,
17 LAgII end prolllllonoJ 21 WIIlII (11II omploymllll trOd,,,) .
......Ic... . . .. 17 ~ ..::>' 27 Olhll,'pII\..1 (Irom IIn. 48 on
Offlc... .., ., 11 plgo 21 . . . . .
To'" open... befotl ..pen... 'or bulln... UM Of horn.. Add IIn." e through 27 In columna.
Tonlll'.o prolll QOII). SublrlCllln.lll ',om IIn. 1
e.pon"l lOt bulln... u.. 01 your homl. AllIch 'onn - . . , . , . . . , . .
Net profit or (loll). SubtrlCllln. 30 'rom lin. 29.
o II. profit. onlll on 'onn 1040, line 12, end ALSO on &olledul.I.. line 2 (1IItulOl\' Imploy.."
... PaQ' C.6). htltl' and lrultl, ent., on Form 1041, hn, 3.
o ".Iou. you MUST go on 10 IIno 32,
U If you hlVI . Iota. check thl bOx that dlflcnbll vour Illv,atmenl in thiS aCllvltV (IN page C.6).
. "you ChlCked 32.. ...llIlh. lOll on 'onn 1040. llno 12, Ind ALSO on Icl>ldullll. llno 2
(11atulOt'f emploY..I, _ pig. Co5). Elllt.. Ind I'UIII, .nlor on Fo,m 1041, linl 3.
o "you chlCkld 32b, you MUST altlch fonn 11111.
'or '1pIfW0I1I RIduo1lOn ""I Notlce. ... Fonn 1040 In.ttucIIOlll.
11
I.
13
It
21
21
ao
31
e,l No. 113:WP
QhlilNo ''''001.
~@94
AttlChment
'onn 1 6IQIIIf1CI No Of
__wtly_11lH1
: ! I:L--
......
...................-..............
. ..
(.
-
3
-
I
'1
.
--
"
200
:lOb
21
21
23
1110 --
.
27
21 -
21
ao
}
}
31
1/'62- -
3Ia 0 All ,n...lmenl I. ., r1lk.
32b 0 Som. In...lmonl II nol
al'Ilk.
&oll8clull C ('onn 104011114
....!'......
.
UTILITY CUSTOMER ACCOUNTING
Customer 10: I<LABONWXOOI
Location 10: 804288
Service Locallan: 106 S. Saint Johns Dr.. Camp Hili, PA 1701\
Date Cd Srv CI RI Balance
6/30/96 BA 01 SW 02 $284.69
"
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T I.J I i(...
a:: f' ..,' it;j Q-. ~ rJ
r.!.: r,;:J '0.. ~ CJ -
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I.:.. () ~
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('..I ../
<, ]2 It) ::.!
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rr;l: t:::~
r "'; .'
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