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JUDGMENT NOTE
CLAIM NU~mER: 010170179551 DK
Mechanicswrg
(place)
,Pennsylvania, 3-18-96
(date)
, $ 2498.75
(amount)
1
FOR VALUE RECEIVED, IIwe promise to pay to the order of
ERIE INSURANCE GROUP
the sum of ThU TIl0USAND FOUR HUNDRED NINElY-EIGHr and 75/100----------- dollars,
, .' 1 , _ ' '.. said sum to be payable as
follows: TI~-FlVE and 00/100 -------------------------------- dollars, ($ 25.(0)
on the 3rd. day of APRIL 19 ~ and'
'ruFNTY-FTVF. Rnd 00/100 ------------------------------------- dullars, ($ 25.(0)
on the
3rd.
day of each and every ~XJtml
thereafter until the
BAlANCE
, . . PAID IN FUU.
.
w-,
on which date the entire balance of the principal then unpaid shall become due and payable.
UPON FAILURE to make any payments as herein agreed, this note shall, at the option of
Its holder, become Immediately due and payable, without demand or notice.
AND FURTHER, IIwe do hereby authorize and empower the Prothonotary or any attorney
of any Court of Record of Pennsylvania or elsewhere, to appear for and confess judgment
for the sum due and payable hereon, with or without declaration, with costs of suit, release
of errors, without stay of execution; and also waive the right of Inquisition on any real
estate that may be levied upon to collect this note; and do hereby voluntarily condemn
the same and authorize the Prothonotary to enter said voluntary condemnation upon any
Fieri Facias that may be Issued to collect said judgment; and further agree that said estate
may be sold on a Fieri Facias, and do hereby waive and re,lease all relief from any and
all appraisement, stay of execution, exemption or bankruptcy laws of this or any other
state now In force or hereafter to be passed,
xA~-u,u~:tl.U- +I. 7:: J: " ,5.)
Jilll~est u~
(L.S.)
This note Is given and executed without duress or coercion and with full and complete
understanding that upon failure to make payment as agreed, that my operating privileges
may be suspended.
Furth9ur I do hereby acknowledge that the damages Incurred In the accident of
AUG Sf 24 , 19 ~ for which this note Is given resulted from my negligence
and fault, and I do hereby acknowledge and waive my right to any hearing or trial on that
Issue.
)(DRIVERDATEOFBIRTH PoCII ,n 1- - xOi..u. \..l\iDl\t'-lJ..\.nrt:u~.)
~ Jill'West ~
)(DRIVER OPERATOR NUMBER ~ J... (rr~- lf72. (L.S.)
OWNER DATE OF BIRTH
OWNER OPERATOR NUMBER
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