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HomeMy WebLinkAbout97-00613 \ ~ J' ........ .... ." ... WHEREAS, it is the desire of the parties, after long and careful consideration, to amicably adjust, compromise and settle all property rights and all rights in, to or against each other's property or estate, including property heretofore or subsequently acquired by either party, and to settle all disputes existing between them, including any and all claims for WIFE'S and/or HUSBAND'S maintenance and/or for spouse support, alimony pendente lite, alimony, counsel fees and expenses, custody and equitable distribution; WHEREAS, Nadine A. Bailey is represented by Joanne Harrison Clough, Esquire, and Lawrence J. Bailey is represented by Judith A. Calkin, Esquire and each party has had the opportunity and in fact has reviewed this Agreement in its entirety with his or her respective counsel prior to executing the same; and WHEREAS, the parties intend this Agreement to be a full and complete Postnuptial Agreement, providing for the absolute and final settlement of all their respective marital and property rights and all claims for spouse support, alimony pendente lite, alimony, counsel fees and expenses, and equitable distribution of marital property. NOW, THEREFORE, for and in consideration of the mutual benefits to be derived by the parties and intending to be legally bound hereby, the parties hereby covenant and agree as follows: 1. PERSONAL PROPERTY: HUSBAND warrants and represents to WIFE, and WIFE warrants and represents to HUSBAND, that they have effected a fair and equitable division of all marital property of the parties, and that any and all marital property, except as expressly provided herein, presently in possession of WIFE shall be the property of WIFE, and that any and all marital property, except as expressly provided herein, presently in possession of HUSBAND shall be the property solely of HUSBAND. (A) WIFE shall have the sole right, title and interest to the following personal property: 1. 1993 Ford Taurus Station Wagon: HUSBAND shall transfer any and all interest he has in said vehicle to WIFE. WIFE shall assume sole responsibility for any insurance or other expenses associated with this vehicle and shall indemnify HUSBAND and hold him harmless on any such obligation. (B) HUSBAND shall have the sole right, title and interest to the following personal property: 1. GMC Jimmy Truck: WIFE waives any right, title, claim or interest whatsoever she may have to said vehicle. HUSBAND shall assume sole responsibility for any insurance or other expenses associated with 3 this vehicle and shall indemnify WIFE and hold him harmless on any such obligation. 2. RBAL PROPBRTY: HUSBAND and WIFE agree that in consideration of the other promises and property distribution provisions set forth in this Agreement, HUSBAND shall transfer to WIFE any and all right, title and interest he has whatsoever in the marital residence located at 6402 Cannon Drive, Mechanicsburg, Cumberland County, Pennsylvania, 17055 in consideration of the following: a. WIFE shall assume sole responsibility for and indemnify and hold HUSBAND harmless on the first mortgage balance due and owing on the marital residence. b. WIFE further agrees to refinance the current mortgage on the marital residence on or before November 21, 1997, thereby fully releasing and further discharging HUSBAND from any liability thereon. c. WIFE further agrees to assume and/or be solely responsible for and indemnify and hold HUSBAND harmless on two thirds of the remaining balance of the home equity loan currently placed as a lien against the marital residence. HUSBAND agrees to pay one third of the balance of the home equity loan on said residence on or before November 21, 1997, the date on which WIFE has scheduled a real estate closing to refinance the first mortgage on the marital residence. The parties further agree that WIFE shall be solely responsible for any real estate taxes or other expenses associated 4 with the marital residence and agrees to indemnify HUSBAND and hold him harmless on any such debt or obligation from the date of execution of this Agreement. HUSBAND shall sign the deed transferring his interest in said property to WIFE contemporaneously with the execution of this agreement. 3. COLLEGE SUPPORT: HUSBAND and WIFE agree that the monies currently deposited in BELCO Credit Union account no. 177230 are to be used for the college education expenses of the parties daughter Jessica. HUSBAND and WIFE further agree that HUSBAND shall not be responsible for any additional college expenses or education costs of the parties' daughter. 4. SPOUSAL SUPPORT AND ALIMONY: HUSBAND and WIFE agree that HUSBAND shall continue to pay to WIFE the sum of $ 650.00 per month in spousal support to WIFE until entry of a final decree in divorce. HUSBAND and WIFE further agree that HUSBAND shall continue to pay said sum of $ 650.00 per month to WIFE as alimony from the date of entry of the final decree in divorce until December 31, 2001. HUSBAND further agrees he shall then pay to WIFE the sum of $500.00 per month alimony until such time as he retires permanently from any employment. The alimony obligations set forth in this Agreement shall end in the event of: a. the death of either party; or b. upon cohabitation of WIFE; or c. upon remarriage of WIFE. 5 The parties specifically acknowledge that the amount and duration of said alimony is non-modifiable except in the event that HUSBAND experiences, through no fault of his own, an involuntary decrease of 20% of annual gross income from any and all sources. Said 20 % decrease in earnings of HUSBAND shall be determined as against HUSBAND'S total gross income for the 1996 tax year. HUSBAND and WIFE must provide each other in writing of his or her exact residence, address and telephone number, and must advise each other of any changes thereof within ten (10) days. 5. BELL ATLANTIC SAVINGS PLAN: The parties acknowledge that HUSBAND has a savings plan with Bell Atlantic and the marital portion of said savings plan is the dollar amount that was in said plan on March 1, 1997, the separation date of the parties. HUSBAND and WIFE further agree that the marital portion of said savings plan shall be divided equally between the parties in the form of a rollover of one half of said amount from HUSBAND's account to an account to be established by WIFE in her name in a financial institution of her selection via a Qualified Domestic Relations Order. 6. PENSIONS: The parties acknowledge that HUSBAND has acquired a pension with Bell Atlantic during the course of the parties marriage. HUSBAND and WIFE further agree to equally divide the marital portion of said pension acquired from the date of marriage of May 25, 1974 to the date of separation of March 1, 1997. The parties agree that WIFE shall receive her share of the marital portion of said pension when it goes in to pay status. The 6 parties further agree to cooperate in the preparation, execution and implementation of a Qualified Domestic Relations Order which will direct Bell Atlantic to equally divide the marital portion of said pension and pay WIFE's share of said pension directly to WIFE. HUSBAND shall name WIFE as the irrevocable beneficiary of one half the value of any death benefit that has accrued on said pension from the date of marriage to the date of the parties final separation. HUSBAND and WIFE further acknowledge that HUSBAND is waiving any right, title, interest or claim he may have what so ever in any pension or retirement plan of WIFE. Parties specifically acknowledge that WIFE has six (6) years in a pension with Camp Hill High School District but is not vested in said program. HUSBAND further agrees to waive any claim to his wife's minimal value 401K with Obermayer or any other pensions or pension rights, vested or unvested, WIFE may have whatsoever. 7. COUNSEL PEES. COSTS AND EXPENSES: HUSBAND and WIFE agree to each be responsible for any counsel fees, costs or other expenses he or she has incurred in the divorce process. HUSBAND shall not pay any of the counsel fees, costs or expenses of WIFE. 8. DEBTS AND INDEMNIPICATION: HUSBAND and WIFE represent and warrant to each other that except as provided herein, neither one has contracted or will in the future contract any debts, charges, or liabilities whatsoever for which the other party or their property to their estates shall or may be or become liable or responsible, will at all times keep each other free, harmless and 7 indemnified against and from any and all debts and liabilities heretofore or hereafter contracted or incurred by the other, except as expressly provided in this Agreement. 9. INCOMB TAX FILINGS: The parties agree the parties shall file a joint tax return for the 1997 tax year. The parties further agree that each will sign any and all documents necessary to finalize this Divorce action promptly after execution of this Agreement, and further agree that this Divorce Action shall be finalized and a Divorce Decree shall be obtained on or immediately after January 1, 1998. The parties mutually agree to select an Accountant to prepare the 1997 Federal, State and Local tax returns and that each party shall meet separately with said Accountant to prepare and sign said return. HUSBAND further agrees that he shall pay any and all Federal, State and Local taxes that may be due for the 1997 joint tax filing and that WIFE shall receive 100% of any Federal, State or Local tax refund for the 1997 tax year.In the event of any future federal, state or local tax audit, HUSBAND and WIFE agree to cooperate in any audit process and further agree that in the event any taxes, interest and/or penalties are due for any year the parties filed a joint return, WIFE shall be responsible for any such tax, interest or penalty associated with any income earned by her, and that HUSBAND shall be solely responsible for any tax, penalty or interest associated with any income earned by him. Each party agrees to indemnify the other party and hold him or her harmless on any such obligation. 8 10. AFTER ACOUIRED PERSONAL PROPERTY: Each of the parties shall hereafter own and enjoy , independently of any claims or rights of the other party, all items of personal property, tangible or intangible, hereafter acquired by the other party, with full power to dispose of the same as fully and effectively, in all respects and for all purposes, as though he or she were unmarried. 11. WAIVER OF ALIMONY PENDENTE LITE: HUSBAND and WIFE agree that WIFE waives any and all right or claim to alimony pendent lite in consideration of other promises set forth in this Agreement. 12. TIME OF THE ESSENCE: HUSBAND and WIFE acknowledge that WIFE has a real estate settlement scheduled for November 21, 1997 and that time is of the essence for the completion of any and all obligations of HUSBAND and WIFE that must be completed Drior to the real estate settlement including but not limited to HUSBAND tendering the monies to pay off his one third of the home equity loan obligation at or before the time of WIFE's real estate settlement. 13. MUTUAL RELEASE: Subject to the provisions of this Agreement, each party has released, discharged and, by this Agreement, does for himself or herself, and his or her heirs, legal representatives, executors, administrators and assigns, release and discharge the other of and form all cause of actions, claims, rights or demands whatsoever, in law or equity, which either of the parties ever had, now have, or can have at any time against the other, specifically including rights or claims to spouse support, alimony, alimony pendente lite, counsel fees and expenses, and 9 equitable distribution of marital property, except for any cause of action for divorce from the bonds of matrimony and any cause of action for breach of any provisions of this Agreement. The parties hereto expressly relinquish and waive any and all rights that they may have now or in the future to claim and/or obtain spouse support, alimony pendente lite, alimony, counsel fees and expenses or equitable distribution of property. 14. ESTATE RELEASE: Except as herein otherwise provided, each party may dispose of his or her property in any way, and each party hereby waives and relinquishes any and all rights he or she may now have or hereafter acquire, under the present or future laws of any jurisdiction, to share in the property or the estate of the other as a result of the marital relationship, including without limitation, dower, courtesy, statutory allowance, widow's allowance, right to take property under equitable distribution, right to take in intestacy, right to take against the will of the other, and right to act as administrator or executor of the other's estate, and each will, at the request of the other, execute, acknowledge, and deliver nay and all instruments which may be necessary or advisable to carry into effect this mutual waiver and relinquishment of all such interest, rights and claims. 15. SEPARATION: It shall be lawful for each party at all times hereafter to live separate and apart from the other party at such place or places as he or she may from time to time choose or determine fit. 10 16. NO INTERFERENCE: Each party shall be free from interference, authority and control, direct and indirect, by the other as fully as if he or she were single and unmarried. Neither shall molest the other, compel or endeavor to compel, the other to cohabit or dwell with him or her, or to interfere with friendShips, society or acquaintances with either of the parties hereto may choose or have from this day forward. 17. DOCUMENTS: Each party shall, at the request of the other, execute, acknowledge and deliver to the other party any documents which may be reasonably necessary to give full force and effect to this Agreement. 18. AGREEMENT AND SUBSEOUENT DIVORCE: It is specifically understood and agreed by and between the parties hereto and each of the said parties does hereby warrant and represent to the other, that each shall sign consents to no fault divorce and Waivers of Notice to Enter Final Divorce Decree contemporaneously with the execution of this agreement or in a timely fashion after the statutory ninety day waiting periOd has expired and that each will sign any other documents necessary to obtain a final decree in divorce from the court. It is further agreed that counsel for WIFE shall petition the Court for entry of a Final Divorce Decree after January 1, 1998. 19. ABSOLUTE AND FINAL SETTLEMENT: The provisions of this Agreement are intended to consider, determine and distribute all of the assets of the parties hereto as part of the terms of this Postnuptial Agreement. This Agreement is intended by the parties 11 hereto to be a valid Postnuptial Agreement, providing for the absolute and final settlement of their respective property rights and all obligations of spouse support. This Agreement is not intended to be a mere separation agreement. This Agreement contains the entire understanding of the parties and there are no representations, warranties, covenants or promises other than those expressly set forth in this Agreement. 20. VOLUNTARY EXECUTION AND FAIRNESS OF AGREEMENT: Each party acknowledges that this Agreement has been entered into of his or her own violation, with full knowledge of the facts and full information as to the legal rights, liabilities and the assets of the other, and that each believes this Agreement to be reasonable under the circumstances and not the result of any duress or undue influence. 21. MODIFICATION AND WAIVER: A modification or waiver of any of the provisions of this Agreement shall be effective only if made in writing and executed with the same formality as this Agreement. The failure of either party to insist upon strict performance of any of the provisions of this Agreement shall not be construed as a waiver of any subsequent default of the same or similar nature. 22. SITUS: This Agreement shall be construed and governed in accordance with the laws of the Commonwealth of Pennsylvania. 23. ENTRY AS PART OF DECREE: It is the intention of the parties that this Agreement shall survive any action for divorce which may be instituted or prosecuted by either party and no order, 12 judgment or decree of divorce (temporary, interlocutory, final or permanent) shall affect or modify the financial terms of this Agreement. This Agreement shall be incorporated with, but not merge with any such jUdgment or decree of final divorce. 24. BREACH: If either party breaches any provision of this Agreement, the other party shall have the right, at his or her election, to sue for damages for such breach, or seek such other remedies or relief as may be available to him or her, and the party breaching this contract should be responsible for payment of any and all reasonable attorney's fees, legal costs and expenses incurred by the other in enforcing their rights under this Agreement. 25. BINDING EFFECT: Each of the parties hereto intends to be legally bound hereby, and this Agreement shall be binding upon their heirs, personal representatives and assigns of the respective parties hereto. IN WITNESS WHEREOF, the parties have hereunto set their hands and seals the day and year first above written, each adopting the seal following his or her signature as his or her own. WITNESSES: .....j'-:~ (' ~adt;J ;'f. A1~ y- Na~ine A. Bailey ( // 13 : LAWRENCI'; J. BM1.EY, : IN THE COURT OF COHHON PLEAS Plaint iff : . CUMBERLAND COUNTY. PENNSYLVANIA . . . VS. : CIVIL DIVISION : : NO. 97-613 CIVIL TERM NADINE A. BAI1.EY. : PRAECIPE TO TRANSMIT RECORD To the Prothonotery: Tranlmit the record, together with the tollowing intormation to the court tor entry of a divorce decree: 1. Ground for divorce: irretrievable breakdown under 5330l(c) ~G~~l) ot the Divorce Code. (Strike out inapplicable section). 2. Date and manner of service of the complaint: Personal Service Attorney Joanne Il. Clough 2/11/97 3. Complete either paragraph (al or (bl. (al Data of execution of the affidavit of consent required by 53301(01 of the Divorce Code: by plaintiff 2/2/98 by defendant 1/26/98 (b) (1) Date of execution of the affidavit required by S3301(dl of the Divorce Code: : (2) Date of filing and service of the plaintiff's affid~vit upon the ~~spondent: 4. Related claims pending: NONE 5. Complete either (a) or (b). (~) Date and manner of service of the notice of intention to file praecipe to transmit record, a copy of which is attaChed: N/A Waiver of Not.ice in S330l(c) Divorce w~s (b) Date plaintiff's filed with the Prothonotary: Date defendant's filed with the Prothonotary: ? /1./QA Waiver of Notice in 53301(c) Divorce was 2/3/98 ~~~~ tomey for (Plaintiff)(Defendant) JudIth A. Calkin ~- CI (l' i ". ~ .- lI!( .. ()- N . . h~ I c" w., .', C'l .J ~-' ) l::. I .',J e'l .' r ,. L~ -.j I , '- - <..> r- c,"'l U .J ~~; ~ - ......... .0 ~ ~ --- o~~ ~ .. ~ . r- ~ 1,)0 ~~,~ ~ ~ ~~ o-l!>l P-Ul ~~ 0 .... ~ z E .... ... ;;;a ~ 8 0 0," fJ {:)~ ~~ 't:l ~d~ o c:l ~'O <: <.. ~~ r;;~ U :>- 0 0""" '<"';! l:l ~u 1XlP- ~~ u..... <~nl~ . ~g 8~ .., ~..... ~ ~(. !: .,; o' z" .. U ~ .. - !~ ~ '""'"" <...~ . ~ l:l Cl ~" .. ::J :a ,;:. -. ::! HU ~ < ::: counseling prior to a Divorce Decree being handed down by the t .. r Court, WHEREFORE, the plaintiff prays your Honorable Court to enter a Decree in Divorce from the bonds of matrimony, Respectfully submitted: '\ I '7'1 \---ttIML / {~LL -Judith A, c:1kin, Esquire Attorney for Plaintiff 2201 North Second Street Harrisburg, PA 17110 (717) 238-2312 ~ .= ~ <... ..:J ~ r M ~- ':> ..1)< \.. :: C) x: :.:;?; T u.. -~ f-- ::~ ;::J [ .... _"1' ;,,'4 J(fi l'.' en :,h ~. w r:: "'- r;:!O- ~. IA- f- a 0 a' E~~ 8-'<,~ g = ~~!: ~ ~ ~ 8 ~~ ..cl .. ~ -a E' ~~~r- o~'" - .... U 0& , , , 'C> 'C;. n .0 0 f ..... ." -., ::l ""O(i' ITI ~I- :!J rOir ;" CO '~~ ~:-:.- 2:1, (J)~ . ..,.. ., .....;... '.) r;'. '"0 J'j." -;," ~ .:j~ "." .', t ~ :5 >:..;: .-i -, '.. <. ~ =2 .... ~ LAWRENCE J, BAILEY, Plaintiff IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA vs, NO. 97-613 Civil NADINE A, BAILEY, Defendant CIVIl, ACTION-DIVORCE AFFIDAVIT OF CONSENT 1, A Complaint in Divorce under Section 3301(c) of the Divorce Code was filed on February 6, 1997, 2, The l11clrriage of Plaintiff and D,,!(endant is irretrievably broken and ninety (90) days have elapsed from the date of the filing of this Complaint, 3, I consent to the entry of a Final Decree in Divorce after service of notice of intention to request entry of the decree, 1 understand that false statements herein ar.e made subject to the penalties of 18 Pa,C,S, Section 4904, relating to unsworn falsification to authorities, DATE :;2./,], I~ ~ 11 cost of the survivor annuity. The Alternate Payee instead shall receive the following percentage of the Qualified Joint and Survivor Annuity benefit available under the Plan's Qualified Joint and Survivor Annuity provisions: Number of months participation in the Plan while married Number of months participation in the plan (up to benefit commencement date) PART G-FORM OF BENEFIT AT COMHENCBMBNT If the Alternate Payee's assigned benefit is to be paid over the life of the Alternate Payee, then the benefit will be distributed in the form of an actuarially equivalent life annuity paid over the Alternate payee's own lifetime. It will be the responsibility of the Alternate Payee to advise Bell Atlantic as to the date on which payment of benefits are to commence. If the assigned benefit is to be paid over the life of the participant and the Order requires a Qualified Joint and Survivor Annuity benefit, then the only available form of benefits to both the Participant and Alternate payee is for the Participant to receive his/her benefit in a Qualified Joint and Survivor Annuity, The Alternate payee will be considered a partial or total survivor Annuitant, as specified in part F, PART H-COMMENCEMENT OF BENEFITS If the assigned benefit is to be paid over the life of the Alternate Payee, subject to the provisions of Part I (Understandings & Conditions), the Alternate Payee may elect commencement of his/her assigned benefit at the earliest date at which the participant may commence benefits, but no later than when the Participant commences receipt of benefits, If the assigned benefit is to paid over the live of the particip~nt, subject to the provisions of Part I (Understandings & Conditionsl, the Alternate payee's benef1t commencement will occur when the participant elects to commence receipt of benefits, Please Note: Regardless of whether the benefit is to be paid over the life of the Alternate payee or the life of the Participant, the benefit cannot be distributed until the 60 day waiting period has expired or until receipt of a properly completed and notarized Waiver of Appeal form, IMPORTJlJ'lT: It is the responsibility of the Alternate payee to contact the Bell Atlantic Benefit Office at least 60 days in advance of the date when he/she wishes to elect to commence receipt of his/her assigned benefit, ~ IT IS SO ORDERED THIS Participant ~,..~&~ Signature _ I2.nJ"~$-Lf'1J:.._.,_ Da~- Attorney for Participant !~< gnature , /l/'/dJ! 7 /ff'J' D~ / Print Name and Mailing Address MWUNCI: :T. -:BA-i ~ 7' 60 ? I A45s ~ J)t. ),II-r- J _.I-IJlJ;t, PA-. I? III 1t?- 5&.J-??f'7 Telephone number . 199" ,J, Alternate pa}'ee ~ 1111 ;, ~ ?/ j(~rLL.L:./.r Sig ature " ,,-~/~,"-,--2(PTd7~- Date~ ..,." Attorney for Alter ate Payee Date Print Name and Mailing Address ~'d(lr\ ;r\t. r-\, R.c. :\.~I __ \, Llr)~ C.CAi\rv')f". \Jr. __ \n."k~~..,b';)j P) II)-:JS;~- III - 'V lo~ '01] Telephone number <l -..0 ~ f-. 0) .' DO :;J "(;" '0 \'-1~ mi, :;) r- ,-- ,.", ...,,1'1 :;.; :~. '~rJ iJ:.~.; "'- ""6 -<- .:'] ~.:-l~ ; ~ ' . ~f ...;( \ - ' !(') ','-. t-. - : ;rn ;" ',' .. :--::, ~ :..n '" ::"1 ~ ", (11 ~ ~"' - ~ ::I- ~ '1 ~ 5== ~ ~~ >. .., 'ri o-lsl ~ 1'<<Il U ~ffi aJ <Il ~I'< ... Z 51 ~ o . .... '" ... ~~ ~... .., ClO S2 ~ .... s:: ~ ~~~ ~ 'ri l=l!l s:: .:: . III i ~~ ~"" ~8 u l=l g <Il s:: U!<Q~ ~ .... ~~ u~ ~ ~ ~~~ I ~ 8~ '" ...;1'< .... 'ril'</;l 'l> f.:l . .., Cf ~~;c.i E I U . < ~ ~~ .... ~ .... '" '" ~ o<~!5 :- ~ :J ~ ~ . ~u ~ J .... -. = .... ;! ~ Re~ations order, the Alternate Payee's assigned benefit will be processed for payment as soon as practical following the 60 day waiting period or upon receipt of a properly completed and notarized Waiver of Appeal form, SECTION (6) UNDERSTANDINGS AND CONDITIONS 1, Change of Plan sponsor-changes in plan sponsor, Plan Administrator or Plan Name shall not affect this Order, 2, Death of the Alternate payee-In the event of the Alternate payee's death prior to the distribution of the assigned benefit, the amount assigned will be paid out to her estate. 3, Name ana Address-The f'articipant and the AJ.ternate payee must advise the Plan Administrator of any changes in the mailing address(s) or legal names(s) as previously set forth in this Order, 4, Notice of Prior Order-By the submission of this Domestic Relations Order, the interested parties in this cause certify that they are not aware of any prior Orders which purport to dispose of the benefits described herein (except other proceedings in the same matter with respect to the same parties and of which the Plan Sponsor already is aware), Should a prior Order exist, it is the responsibility of the interested parties to advise the plan Administrator prior to the Plan Administrator's determination of the "qualified status" of this Order, 5, Qualified Domestic Relations Order-This Order is intended to fulfill the requirements of a Qualified Domestic Relations Order pursuant to Section 414(p) of the Internal Revenue Code, and as such, this Order is not intended to require the Bell Atlantic Savings and security plan to provide any increased payments over those otherwise due the participant under the Plan, 6, Tax Basis-The tax basis of the distribution to the Alternate f'ayee must be on a pro-rata basis pursuallt \.0 I:lterna.~ Revenue Code Section 72(m) (10), 7, Terms-The terms used in this Order shall have the same meaning as in the Bell Atlantic plan documents, 8, valuation-Accounts in the Bell Atlantic Savings & security plan are valued on a monthly basis, IT IS SO ORDERED THIS :l/!-' day of , 199 t ,1/ J, l 'i!-/(r9'i1 Date Alternate Payee , " ~/t j,.! 4 J}rtL I!t :1' Si nature 'l-.y(3 -fY Date .~ a.l~~ t Payee Attorney for Participant Attorney for Altern J>-/:l - f'P Date -~. Signa~ure ~l ' l "2-J\::1 , Date Print Name and Mailing Address Lawrence J. Bailey 5071 Bass Lake Drive Apt. T-1 Harrisburg, PA 17111 717-561-8787 Print Name and Mailing Address Nadine A, Bailey 10S F~wn Ridge North H'IrrishlJrg, [>1\ 17110 717-652-0901