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BTANPAAP Claim Form 1-!2~8u .--., - , -. ,-.- -,- -.... ~-- ,..... ." -... .- ',', rRIi!r: AMOUNT $ LJ ClWCMAOIIEYOIlDEli'..___r_n'.__,____. I' I .__._________....1!.!2~_nJl!ll1!lb,\'!~.ACK!IDWlEE.l!!'J~~MEIIt rOil r~ll!.~lAIM. .. MOlml IlAV VHAI1 __~~~. _ ~) ~ I_.cir~ - 10. I t[j-19TzJ ClAIMAll 'BS,ONATliWi TOOAV'S (JATO , . .d~__0J1L_~ CLAIM (liNT~11 SIO~ATfmfi " i'" " " ,. ,," I' I' " " " " ji " 1\' i! H " ," Ii I'" " " i! ",.1 " " " .. " i' " " " " , ..... .... t , ~ . l:r~ If; " , I'!, (."! " (") l!v; ..~) ,tf: 'i \1.1.\, 1..1 ,," 1>' " 'n', ;;r.; I.Jt~ " I!i' n~ 1',");':1 (1\'1 t ~:;1 :,;/"j'j " ( :d: 1'-/ "J,q I, \!}, (1'1 I"" 1110,1.. ~, ~l , (...~ en I. 'h, I l;:;J u:~, , , r..) , ,j, " 1J. ,) r;;1 (.) " " f ~ '\ "1' " 'I, I;' , " ,- j! " I, " " " " I;, " " Ii , " jd( '1 ,. ,- I, " ij, " , " " .",; r: " I "I '.. I -I' ., , .( , , , , '. , ',I " ",' , liLl , I,L ') ') , ., (,1 ,. " " ;! f" i,I' "" " ,I; Ii " , /I ,. " ,. " " " I" "' . ,. " I' " ;I' " , ,;"1 " ,.' !lLq >, " " j, "i ,j !. " " I' I; /' " ,," " " " i " ,. ,1111\1 . H. 'ili;) i' v IN TIII~ q)IJ1~T OF COMMON PI.rWI OF C\JM1Hlg\.AN)) CtllJNTY, Pl\NNl'lYI.vANIA ()lVII, ACTIoN" I.A W NO, 9R - 3ROO CIVil, IN CUl'lTOPY MICIIAlII, .1, Mlfll\gAK, . 111111111\11' 1)1~111~A CIA Y MIZl'iMI\, 1)\)1911\llIn\ C()tJI\1'()ltllICfol . ANP NOW, IhlR ~J dllY pl',ll1n\mf)', 20()1, IlpOI1 oonsldomllol1 01' Ihp IIIhl91wd C\lsl(1(I)' COl1olllnllol1 I\pporl, Iho 1'ollowll1l:\ Ipl11porlll')' ollHlml)' onlol' Is Pl11erpd1 .. 1. 2, . Tho Flllhor, Mlol1!JOI .1, Mlzernll, 1I1\(\lho Mo\hor, Pobrn all)' Mlzorllk, shllll OHio)' slwNd 1011111 o\ls\OlI)' 01' JOhl1 MlohllOI Mlzol'llk, \101'11 floplombor 3, 19R4\ Klmborl)' Chorl Mlzol'nk, b01'l1 ,hmo 1;1, 19Rfilllnd Dnnlpllp Bllz~l\l\l\h Mlzornk, bol'll April 13, 19R1l, , Tho. Mothor shllll \1I\VO ph)'slolll ollSlod)' of Iho minor ohlldron Oil IIllO\'l1l1tll11:\ wookonds s\1I1'11111:\ ,IIII1\UIl')' 12'11 l1'onl Frldny 11001' sohool 01' who II tho Molhol'ls oIT of wOI'~ \111\11 MOlldll)' 11101'l11ng \vhon Iho Molhor shllll dllllvor Iho ohlldron 10 80hool, AcIdltlonllll)', Molhor shnll hllve ph)'slonl o\lslod)' of tho I11lno\' ohlldron Oil two wookdll)' oV!.'.lIll1l:\s pOl' wook' 1'1'0111 wholl Iho ehlldl'on nl'O oil' Il'om sol\ool \Il1tll IIPpl'O>lh11l1loly 7130 P,I11, Tho two wook dn)' OV0I1I11I:\S shnll bo nn'nl1l:\od \lolwcol1 tho plll'llos, 3, FlIlhor sh\11I hnvo ph)'slonl OI\sIOlI)' or tho I11lnol' ohlldrol1 whol1lho ohll(\rol1ll1'O 1101111 tho o\lslody of the Mothol',' . . " 4, Mother'8 periods of clIstod)' nre cOl1dltlol1ed .\IpOIl Molhol' hnvll1B n sopnrnt'c rosldonoc whOI'll tho ohlldl'ol1 hnvo ov01111ght noool11111odnlloll8, Tho PlIl'llos ahl1H 11100\ IIl:\nln with tho C\lslody COl1olllnlol' tor n sooond COl1olllllllol1 fOl1lbrnlloo 011 Fl'ldn)', Fohrunr)' 9, 2001 lit 9130 11,\11, 5, ,'I 13YTIIHCOURT,./) / I' 'I / . ! / (//, ' jJl{~L (J L~ ~ Q 1M 11'0' RKs . co: MlII'OU8 ^.. MoKull:\ht,IIl, Esqull'o Thlll11I1S.l, WllIIlIIl1S, Esqulro . .' "4 I I I' fI ,I ,. " ,. " .," 'I, " " " " , \ .\ , 1\1; \ " ,'j , ., I , C\.l;i;,t f' \-1 , 1;'1 { , \-:,; .\. " ( \, ~ / / .:' " !I' " ,j,' d "I- ,,"'" "I, Ii "!'"I '" " ,." " ',I " ,I' " ,/4 I' 'I' 'I " I, ,,"I " " " ,. q " ,. ,. ,. '\/. ",. I" " " I " I'" ,. "" " d,l; Mlf~IIi\1~l, ,I, MIZ'Cn'\I~, 1'111111111'1' I IN TllIC CUfJHT C)If CUMMoN I'I,lcMl CW . I I ('~III\'''lICnl<l\NU CUfJN'l'Y, 1'ICNNSYIN/\NII\ I I CIVil, I\CTloN - 1,1\ W. I I OH-~HfIfI c""" TI~HM I I IN IHVOIWI1~ v, UICnHI\ GI\ Y MIZlmi\l<, Ullfllllllnlll NO'I'IC'C '1'0 'l'lm I>IW'CN'lANT , ' (('yon wlHh to dOilY 1II1Y o('tho HllltomolltH Hot Ihrlh IlllhlH lIfl1dIlVil, YOII IIl\1Hllilo II 001111101'- IIfflllllvil wilhllllwollty (20) dnYH 1If101' thlH nf'll<lnvil hllH heoll Horved Oil yon or Iho HlntOIlWlltH will 110 IIdl\liltod, I' " . " I. Tho pnrtloR to IhlH ncllon HOpnntlu(1 Olllll' IIhOll1 Ootohol' ~ I, 2000, nlld hllvo oOlltllluod 10 livo HOpnl'nto nlld IIpnrt tor II pOl'lod oj' nt 10llHt two YOllrH, Tho mlllTlnlJo iH IrrotrloVllhly hrokoll, 2, ~, I IIllclorHtnllcl thllt 1111uy IOHo r1lJhlH uOllool'l1llllJ nlhnollY, dlvlHloll 01' proporty, IIIWYOI"H IboH or OXpOnHOH If' I do llol ollll1n thom holhro II dlvUI'oo IH lJrllnlud, I vorlf'y Ihllt tho HtlltolnontH muclo In thlH IIf'11dllvlt 111'0 tI'lIo IIncl uorrool, Ilindol'Hlllncl Ihlll 1\\IHo Hlllt0ll10ntH hOl'ol1l 111'0 mnclo Hllh.lool 10 Iho ponllilloHof' I'R I'll, C,S, of' "00" 1'01lltlnlJ 10 unHWOrn fulHlflollllon to 1Il1thorltloH, . ,^ \-.. 1>111111 ,'nno _&, 2Ufl3 ~// ~~~M~',4 __ . ~~-ftM~ .. "Inlntlff .. " I,," , , , , \j I , , , ~ , , , I , I , , , , , , ,. , , , ., 1',1 I (1" , , , , ) I e~ , " ,. " I' " ;'j, , " (\ ," " , ,1< " " " ,( -iI' ";,.(," , ' , " '.i'i j' " " " " " " 'H " " " 'i, '1 , i II " ",.; Ii ,I " , ' 'f j '" i: iI tI " " ,I' "" " ,,'- " " " Ijl ,I' )' ,; " " 'f; ,," " " , " Ii' "