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JUDGMENT NOTE
010170270520 LS
A"" I 1~)-/70))
. _MI~II.'JIl88~\I!l9C1tRII",Ie.
(plaoe)
,Pennsylvania, DECEMBER 3. 1996
(date)
$ 763.20
,
(amount)
FOR VALUE RECEIVED, Ilwe promise 10 pay to the order of
ERIE INSURANCE GROUP
the sum of. .SEV"NHUNDRED SIXTY-THREE AND 20/100 *......*..*.............. dollars,
said sum to be payable as
follows: - .FJF-'!'Y_-^N~_-9()/1J2()__*..**_....***"**....*****..****..**** dollars, ($ 50,00 )
on the ..__..6J.h ___ day of ..
,JANUARY
1997 and
.fIFTLAND. ()()/!oo *.*.******-*****",********.*****u***,,*******,,* dollars, ($ 50.00)
on the .--___.~J:J!.__h_._._____. day of each and every
.M-9_NTH
thereafter until the
BAl,_ANCE IS__.. ____mUm. I
___J'_AID_.IUULL ._ 19 _____,
UPON FAILURE to make any payments as herein agrefld, tI)ls note shall, at the option of
Its holder, become Immediately due and payable, without demand or notice.
AND FURTHER, Ilwe 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 release 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.
X
- - ------ ---
~ICI~F~~ ~OUN;Z)
- #<cM)v /.
RICHARD MOUNTZ
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.
.. (L.S.)
11,1-, ~-
. -;&~~____ (L.S.)
Further, I do hereby acknowledge that the damages Incurred In the accident of
___JUN"_...9__.___ _ , 19 _9_~_ for which this note Is given resulted Irom my negligence
and fault, and I do hereby acknowledge and waive my right to any hearing or trial on that
Issue.
DRillER DATE OF BIRTH X _..J.:. f -. '- L. .
It _n_ (L.S.)
SEl.ENA /'IOUNJZ . _'~
'l.n{C;r.fDd. /2.$.:-- ..._..._ '... ..... So)
RICHARD MOUNTZ /
DRIVER OPERATOR NUMBER 1!. .::l~_'I(. "'..'.0__
OWNER DATE OF BIRTH X ,) -:,. , J
OWNER OPERATOR NUMBERX ,);J. In,) III
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