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HomeMy WebLinkAbout01-06129 .: DEe , 3200'~ 209 State Street 717.232.6300 Harrisburg, Pennsylvania 17101 Fax 717.232.6467 www.srklaw.com ~---<O December 122001 The Honorable Edward E. Guido Cumberland County Courthouse One Courthouse Square Carlisle, PA 17013-3387 INRE: Krista Coombs, Individually and as Parent and Natural Guardian of Kayla Coombs, a Minor Dear Judge Guido: I am writing to update you on the status of the proposed minor settlement. The Supreme Court decided Lititz Mutual Ins. Co. v. Steele on November 30,2001 holding that the Lititz Mutual Insurance policy language which contained "a pollution exclusion" did not exclude coverage for claims involving lead paint. The Defendant in this case is insured by One Beacon Insurance, a successor of CNA. Following the decision, I requested from the Defendant insurer their specific policy language. The insurer forwarded the policy to our attention. The policy, in this case, has a specific lead paint exclusion and a lead paint rider. I am enclosing a copy of the policy and rider. (See attached as Exhibit "A"). I incorrectly stated in the Petition that there is an issue of coverage. Upon review of the policy, there is clearly $50,000 in liability coverage for claims involving lead paint exposure. This was not previously disclosed, in fact, based on my conversations with the prior adjuster, there was a clear indication that they were defending this case on a reservation of rights relying on a pollution exclusion. There was no mention of a lead paint rider. The Petition requesting the approval of the settlement alleges that the pollution exclusion was in the policy. The Petition was served upon the insurance carrier weeks before the hearing. I have also enclosed for your review a copy of the assets search regarding Kerry Saintz. (See attached Exhibit "B"). Mr. Saintz is divorced and owns real estate individually with a value of $890,850.000. There are mortgages in the amount of $581,500.00. The mortgages have obviously been paid down, but even assuming maximum mortgages, he owns real estate valued in excess of $300,000.00. He also owns seven vehicles only one of which is encumbered by a loan. "~-.",,~, '~"', - , -~I--' .,.-., ,T "~ ~~"~,~ The Honorable Edward E. Guido December 12, 2001 Page Two There are still issues of liability and damages involved in this case. I would ask that you continue to hold the Petition in abeyance so that we may reevaluate the value of this case. We will amend the Petition if the client decides, after further review, that she still wants to proceed forward and settle the claim or the Petition may be withdrawn and we may proceed forward with litigation. Very truly yours, SCHMIDT, RONCA & KRAMER, P.C. / / I {./1 / r.'. -'- J ,>~___ . t. ..Gerard C. Kramer Attorney at Law / GCKj det Enclosures cc: Krista Coombs Victoria S. Price, Esquire I"'~~-~ I" -~ ~ - "~.= " ~",,,,,,,~-l'FIT~'i' Silver :?~.ume .Uocument: J~V ! Lomm \.Jen .Llao .t'orm~ ! \.--uwurywlue I V:J/V1.I71 1..L"VUUCt . ; .... us'"" .I. V.I. ~ _. ..'....'......",.....",. ..'.........'. '.."'" ,~I!rn"I:ll1Tim1,.l.IoI""(oIII-_._..,...,..,IJIIIlI.'.._ .' :"' '. . """,lj." -'tlll!!lll_ ww~~D1l.W1miml COMMERCIAL GENERAL LIABILITY CG 21 55 03 97 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. TOTAL POLLUTION EXCLUSION WITH A HOSTILE FIRE EXCEPTION This endorsement modifies insurance provided under the following: COMMERC1AL GENERAL LIABILITY COVERAGE PART Exclusion f. under Paragraph 2., Exclusions of Coverage A - Bodily Injury And Property Damage Liability (Section I - coverages) is replaced by the following: This insurance does not apply to: f. pollution ....top (1) "Bodily injury" or "property damage" which would not have occurred in whole or part but for the' actual, alleged or threatened discharge, dispersal, seepage, migration, release or escape of pollutants at any time. This exclusion does not apply to "bodily injury" or "property damage" arising out of heat, smoke or fumes from a ,hostile fire unless that hostile fire occurred or originated: (a) At any premises, site or location which is or was at any time used by or for any insured or others for the handling, storage, disposal, processing or treatment of waste; or (b) At any premises, site or location on which any insured or any contractors or subcontractors working directly or indirectly on any insured's behalf are performing operations to test for, monitor, clean up, remove, contain, treat, detoxify, neutralize or in any way respond to, or assess the effects of, pollutants. As used in this exclusion, a hostile fire means one which becomes uncontrollable or breaks out from where it was intended to be. (2) Any loss, cost or expense arising out of any: (a) Request, demand or order that any insured or others test for, monitor, clean up, remove, contain, treat, detoxify or neutralize, or in any way respond to, or assess the effects of pollutants; or (b) Claim or suit by or on behalf of a governmental authority for damages because of testing for, monitoring, cleaning up, removing, containing, treating, detoxifying or neutralizing, or in any way responding to, or assessing the effects of pollutants. Pollutants means any solid, liquid, gaseous, or thermal irritant or contaminant including smoke, vapor, soot, fumes, acid, alkalis, chemicals and waste. Waste includes material to be recycled, reconditioned or reclaimed. .../spserver.exe?Cmd=Query&Form=CLFMNUMB.SER&manual=ARTISANS+PROGRAM+ 11117/00 '.....'....'. '-'L'..L' L~U'-' .LJVV\..Ull~J.U' ..U.."--' I \,.;Vllll.ll uvH Llao rurtris 1 \....OlinrrywlOe ! Uj/U 1/'I/ I Forms Page 2 01'2 " .top CG 21 55 03 97 Copyright, Insurance Services Office, Inc., 1996 Page 1 of 1 . Add/Edit Notes Add Personal Note --".....-.----.-".--...---- ~ top..- - Document information Newer/Older versions Newer version of this document ---____.n..____.~__.____._.._._.._._.__._"__.___n._...__".__m__..____.._ .......,."_ ........___.. -.top -.----------.---------.-_______...__._..___.._._....__.__._n__.___ This page was created: 11/17/0012:07:02 PM ...lspserver.exe?Cmd=Query&Form=CLFMNUMB.SER&manual=ARTISANS+PROGRAM+ 11/17/00 ~it~~'mi!i~ ;111.~ ".~ ~- ,,-< -.\ ~- r::-.'~E-f:l'" CG 04 31 0998 YEAR 2000 COMPUTER.RELATED AND OTHER ELECTRONIC PROBLEMS - LIMITED COVERAGE OPTIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULES SCHEDULE A - COVERAGES TO BE PROVIDED (SUBJECT TO THE DESCRIPTION IN SCHEDULE B) Check anyone or more of the following: []I Bodliy Injury D Property Damage D Personal and Advertising Injury SCHEDULE B - DESCRIPTION OF LOCATION, OPERATIONS, PRODUCTS OR SERVICES TO BE COVERED (TO WHICH SCHEDULE A APPLIES) 1gescrlptlon of location(s) operation(s), product(s) or service(s) All iocations, operations, products or services to which this policy applies. SCHEDULE C - PREMIUM ...&~ Premium $ WAIVED The following exciusion is added to Paragraph 2., Exclusions of Section I - Coverage A - Bodily Injury And Property Damage Liability and Paragraph 2., Exclusions of Section I - Coverage B - Personal And Advertising Injury Liability, 2. Exclusions This insurance does not apply to "bodiiy injury", "property damage" or "personai injury" and "advertis- ing injury" (or "personal and advertising injury" if defined as such in your poiicy) arising directly or indirectlY out of: a. Any actual or alleged failure, malfunction or inad- equacy of: (1) Any of the following, whether belonging to any insured or to others: (a) Computer hardware, including microprocessors: (b) Computer application software, (c) Computer operating systems and related software: (d) Com puter networks: (e) Microprocessors (computer chips) not part of any computer system, or (f) Any other computerized or electronic eqUipment or components: or (2) Any other products, and any services, data or functions that directly or indirectly use or rely upon, in any manner, any of the items listed in Paragraph 2.a.(1) of this endorse- ment due to the inabiiity to.correctiy recognize, process, distinguish, interpret or accept the year 2000 and beyond. b. Any advice, consultation, design, evaluation, inspection, instaliation, maintenance, repair, re- placement or supervision provided or done by you or for you to determine, rectify or test for, any potential or actual prOblems described in Para- graph 2.a. of this endorsement. This exclusion does not apply to the types of injury or damage indicated in Schedule A - Coverages To Be Provided of this endorsement arising out of any opera- tions, products or services, or any operations or ser. vices at or from any specific location, described in Schedule B - Description Of Location, Operations, Products Or Services To Be Covered of this endorse- ment. ld Cli Eo rJ. CI Eo c,; rs Cl tI. to; ... ~ rs Eo ld: Ill: Eo tf. POLICY NUMBER, FPLQ79395 6 SERVICE OFFICE COPY :-;J!,<~_ ~ I1'!If .'1-' ,. l' '1 Silver Plume Document: ISO I Comm Gen Liab Forms I Countrywide I ...1971 Latest I Form Page 1 of 1 _..' . ..... .....11.. .... '.. :J1'I!r.lilI:l!'l1'l:'iTollr'lol'I..lolil .. - " --", . 'till... .... .' , ; i I" 11II!!Ift_'_ ...:.... w.w Comm Gen Liab Forms ~~l!m'iml1ZiIiim COMMERCIAL GENERAL LIABILITY CG 00 54 03 97 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. AMENDMENT OF POLLUTION EXCLUSION- EXCEPTION FOR BUILDING HEATING EQUIPMENT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART OWNERS AND CONTRACTORS PROTECTIVE LIABILITY COVERAGE' PART Subparagraph (1) (a) of the pollution exclusion under Paragraph 2., Exclusions of Bodily Injury And Property Damage Liability Coverage (Section I - Coverages) is replaced by the following: This insurance does not apply to: POLLUTION (1) "Bodily injury" or "property damage" ar~s~ng out of the actual, alleged or threatened discharge, dispersal, seepage, migration, release or escape of pollutants: (a) At or from any premises, site or location which is or was at any time owned or occupied by, or rented or loaned to, any insured. However, Subparagraph (a) does not apply to "bodily injury" if sustained within a building and caused by smoke, fumes, vapor or soot from equipment used to heat that building. ...top CG 00 54 03 97 Copyright, Insurance Services Office, Inc., 1996 Page 1 of 1 :.i-toP'-'----....---..'~-..,.-.-~---,."'.-~-.---.~'~.,,-.---.-----."...."'-.,--.--~~.-...,...--...".-~-..--,,.......",,-----",.,....- Add/Edit Notes Add Personal Note ':..:t;:;p,,-''''-''''-''--~''---''--'''''''''---'----''-''---''-'''-''-....-.---.."...---"-------,,.,--.---.,--,,- This page was created: 11/17/00 12:08:40 PM ...lspserver.exe?Cmd=Query&Form=CLFMNUMB.SER&manual=ARTISANS+PROGRAM+ 11/17/00 \f'}~\\'" .' "'~'I , , ~-~ ,- '-"-,r.'- '()" 13:_'8 <::~c.E No:(()'J cl/2c J ID : CGU [SQUJ Camp Hi II,Pa FAX:717 730 375~ PAGE 2 i I i i I G14011 0895\ EXCLUSION - LEAD CONTAMINATION - PENNSYLVANIA I This endorsement modifi.8S the insurence provided under the follOWing. I ; ,. I BUSINESSOWNERS LIABILITYCOVERAIlEFORM i COMMERCIAL l'lENERAL LIABI'LITY COVERAGE PART : Llal>lnly Coverage is hereby amended 1:0 exclude 'occurrenees" at any insured premises which result in: a. "Bodily Injur}'" arising out of the ingestion, inhalation, or absorption of lead in any form; b. "Property Damage" arising from any form of lead; c. "Personal Injury" ariSing from any form of lead; d. "Advertising Injury" arising from any form of leed; e. "Medlcaj Payments" arising from any form of lead; f' Any loss, cost or expense arising OUt of any reques~ demand or order that any insured or others test for, mon~or, cleen up, remove, contain, treat, detoxify or neutralize, or in any way respond 1:0, or assess the effscts Of lead, or g. Any loss, cost or expense arising out of any claim or suit by or on behalf of a governmental authority for damages because of testing for, monitoring, Cleaning up, removing, contlllning, treating. detoxifying or neutralizing; or In any way reSpOnding to, or assessing the effects of lead. ,;r~',~ ~,~, "'1- ,p- ~, ~ _.__"l 11' lllit.'" III ' ' <'."^, . ,~ ",.' __' _... \,IV ,J.v".LQ IJ,)'Ivf.:JV \..::>HUJ \....amP H t 1 ! l!Ja \ I \ " 71~ -,':<0 3754 l-AX: I - PAGE 3 LiabtUty G14012 089 ADDITIONAL COVERAGE-LEAD CONTAMINA ION LIABILITY-PENNSYLVANIA This endorsement modifies the insurance provided under the following: BUSINESSOWNERS L1ABILI1Y C;OVERAGE FORM COMMERCIAL GENERAllIABILI1Y COVEFlAGE PART A. The following COVERAGE Is added, LEAD CONTAMINATION 1. Insurlne Agreement. a. We will paythosesumsthatlheinsured becomes legally obligated to pay as damages because of "bodily injuIY" arising out of the ingestion. Inhala. tion or absorption of lead in any form. We have the right end duty to'defend any .suit" seeking these damages. We may ilt our discretion Inves. tigate any '=urtence" and settle any claim or "suit" that mey,resuit. But: (1) The amount we pay" for damages is limited as described in Item 8. LIMITS OF IN. SURANCE below, and (2) Our right and duty end when we have used up the applitllble limit of insurance in the payment of jUdgments, settlements or defense costs incurred by Us. No other obligation or liability to pay sums or perform acts or services is tovered under this policy. b. This insurance applies to 'bo(Iily Injury" only if: (1) The "bodily injury" is caused by an 'occur- rence' that takes place in the "coverage teYl'itory"; and B. (2) The "bo(Iily injul)I' occurs during the policy period. 2. Exclllllo05. This insurance does not epply to, a. "Sodlly injul)''' expected or intended trom tM stendpOlnt of the insured. b. "Sodily injury" lor which the Insured is obligated to pay damages by rellson of the assumption of liability in II contrllct or agreement. ,c. Any obligation of the insured under a workers' compensation, disabill~ benefits or unemploy- ment compensation law or any similar law. d. 'Bodily injUry" to: ^' ,r--"7'- (t) An employee of the insured arising out 01 and In the course of employment by the Insured: or (2) The spOuse, child, parent, brother or sister of that employee as a consequence of (1) above. nis exclusion applies, (U Whether the insured may be liable as an employer or In any other c'itpaclty. and (2) To any obllll~on. to. share damages with or repay someone else who must Pl\y damages [ be,::ause of the iniuf)'. . Any loss. cost or expense arising out of any. (1) Request, deman'a Or order that eny insured or others tesUor, monltOl', clean up, ra01we, contain, treat, detoxify or neutralize. or in any way respond to, or assess the effects of lead, or (2) Claim or suit by 01 on behalf of a govwnmen- tal authority for damages because of testing fOr, monitoring. Cleaning UP. removing, con. taining, treating, detoXilYing or neutralitine, or in any way respOnding to, 01 ~esslng the effects of lead. 01' INSURANCE. The follOWing provisions ere ha most we will pay for anyone "occurrence" tor dlly injury' reeulting from the ingestion, inhale- t on, or absorption of lead in any form under the erage provided by this endorsement is $60,000. his limit Is reduced by the legal costs nee_al}' to fend you. legal ,osts are defined as attorney's fees, penses fOr investigation and court costs. 2. most we will pay for all "o<;currences" during the Hey periOd for "bodily injury" resulting from the i gestiO", Inh.Jation. or absorption of lead in any form u de, the cpverage provided by this endorsement is $ 0,000. ' . .,' 4,~ '~TiT'1 . ~. . ,~ - -, ~." - r-' lJ'Il'~E'J1'''' THE EMPLOYERS FIRE INSURANCE COMPANY A Stock Company, Boston, Massachusetts 02108-3100 KERRY R. SAINTZ 731 HARRISBURG PIKE DILLSBURG, PA 17019-1602 ~I TRANSACTION; RENEWAL ' ,::l! . REX NUMBE.R: 8D4DWQ Yt. . tEl , ~ ~,.. /" 6J (A f":). }L ~mJ2 ~. U I:l:l 'OJ ~ )b '..-7 ()(} .5$./ /b . f./j l2; 6YJ C/l-ed..L ) .J.--f-I",.~ --= 1-1 i COMMON POLICY DECLARATIONS MANED INSURED and MAILING ADDRESS: BusiNESS: APARTMENTS FORM OF BUSINESS: INDIVIDUAL POLICY PERIOD: From 12/18/99 to 12/18/00 at 12:01 A.M. Standard Time at your mailing address. OCCUPANCY ADDRESS t) 1-1 t!) fz1 = E-t tIl 01 01 APARTMENTS 02 01 THREE FAMILY DHELLING 203-205-207 KULBERRY LANE MECHANICSBURG,PA 17019-1602 112-114"116 THIRD STREET LEMOYNE, PA 17043-0000 . r:r: E-t t) fz1 t:1t tIl t) 1-1 t!) fz1 The COMPLETE POLICY consists of: (1) this declarations and (2) all other declarations, forms and endorsements for which symbol numbers = are listed in this declarations. E-t tIl COVERAGE PARTS and SUPPLEMENTS PREMIUM PROPERTY fORM COVERAGES - SECTION I $1,591 LIABILITY FORM COVERAGES - SECTION II UMBRELLA LIABILITY COVERAGES - SECTION III BOILER AND MACHINERY FORM COVERAGES - SECTION IV $174 TOTAL PREMIUM $1,765 THIS POLICY IS SUBJECT TOINSTALLMATIC MONTHLY BILLING NAME and ADDRESS OF AGENT: COUNTERSIGNED BY; (Authorized Representative) (Date) G28100 112-93) Page 01 of 02 SERVICE OFFICE COPY OFFICE! HARRISRURC:: .." ~ ......__ ,..157110"10'1 .................. ',"\, ,.~.,,'^...., - -,. - ." . . ,7'1 ~- J' I , ~ - 1-1 _T r'.'~E'"'''' COMMON POLlCYDECLAIlATIONS ~~ ",-- ~ -~ - .' , ~~. -~"..-""O-4-N''""]'tfIT'it''''-'' --~~;iJil"_-"lr7'~lJ.1111 i ~'=-'~!~r'.ttl ~, r _r""'<~~F~~~ " THE EMPLOYERS FIRE INSURANCE COMPANY A Stock Company, Boston, Massachusetts 02108-3100 The following is a listing of the declarations, forms and endorsements which form your complete polley: INTERLINE FORMS, IL00171185 COMMON POLICY CONDITIONS GI07790588 EXECUTION Of OFFICER'S SIGNATURES G121510796 CONCEPT ONE COVRG AMENDMENT ENDORSEMENT. IL00030498 CALCULATION OF PREMIUM IL09100181 PENNSYLVANIA NOTICE IL02460996 PENN. CHANGES - CANCELLATION AND NONRENEWAl IL00210498 NUCLEAR ENE~GY LIAULITY'EXCL. ENDT IL09350898 EXCL OF CERTAIN COMPUTER-RELATED LoSSES G141330996 POLICyHOLDER NOTICE - EMPLOV~ENT RELATED PRACTICES G281001293 CONCEPT ONE Cl)MMON POLICY DE.CLARATIO'NS G281020493 CONCEPT ONE CO~MON POLICY DEC/FORMS/ENDTS PROPERTY FORM COVERAGES, CP01860486 CPOOlO0695 CPI0300695 CP00901185 G121560597 G141960597 CMOOOI0695 CMOO;ZS0695 CM00610695 G140630796 G282011193 CHANGES - POLLUTANTS BUILDING AND PERSONAL PROP. COVRG FORM CAUSES OF LOSS - SPECIAL FORM COMMERCIAL PROPERTY CO.NDITIONS BUSINESS INCOME COVERAGECAND EXTRA EXPENSE) BUSINESS INCOME CHANGES (NO WAITING PERIOD) COMMERCIAL INLAND.MAItINE CONDITIONS SIGNS COVEM$E FORM VALUABLE PAP'ERS AND RECORDS COVERAGE FORM EXTENDER COVERAGE ENDlfRlSEMENT CONCEPT ONE PROPERTY FORM COVERAGE DEC SECTION I LIABILITY FORM COVERAGES, CGOOOI0196 COMMERCIAL GENERAL LIABILITY FORM GI09550391 ABSlfLUTE. ASBESTOS EXCLUSION CG21471093 EMPLOYMENT - RELATED PRACTICES EXCLUSION CG00550397 AMENDMENT OF OTHER INSURANCE CaNilITIONS CG00540397 POLLUTIO.N EXCL. -AMENDMENT - EXCP FOR BLDG HEATING G140110895 PENN - EXCLUSION LEAD CONTAMINATION G140120895 ADDL COVERAGE -PENN. LEAD CONTAMINATION G121880492 EXCLUSION - NON-OWNED AUTO CG21550397 TOTAL POLLUTION EXCL WITH HOSTILE FIRE CG0431 0998 YR2000 LIMITED LIABILITY COVRG CG21340187 EXCLUSION - DESIGNATED WORK G282041193 CONCEPT ONE LIABILITY FORM COVERAGES DEC SEC II 6282051193 CONCEPT ONE LIABILITY FORM COV CLASS SCHEDULE ISO COPYRIGHT, INSURANCE SERVICES OFFICE, INC., 1984,1985,1986,1987,1988.1989, 1990,1991,1992,1993,1994,1995,1996,1997,1998,1999 COPYRIGHT, CGU INSURANCE COMPANY 1999 G28102 (04.93) OFFICE, HARRISBURG Page 02 of 02 SERVICE OFFICE COPY \... 1~~~~J\i~i~I"IlM,!fiffl;'S!~?l'Ml~@~~Jj,~l~~,~(';i.v\;l~H'~"~"'i'_>;(nV",t:v"''''''-'-'-~r"_",,,,-:,o''~-''~'W~!l~Ji\~lf.illl:~tll~nf,jI.~W,ilijJ;l'\q~~~~i~~f'; ~",,~^-, -. I-~--"-'" FILE NUMBER, CR308181 IWSCACQ 14'" T"~ C. ,~ ' C:'II'~E'fJ'''' PROPERTY FORM COVERAGES SECTION I DECLARATIONS POUCY PERIOD: From 12/18/99 '~ 12 . . . '"",," 0 . . FP~Q79395 6 11/04/99 L.....' i ~ = ~ 12 1-1 BUILDING NO. i THE EMPLOYERS FIRE IN$HRA'NCE COMPANY A Stock Company. Boston, Massachusetts 02108-3100 to 12/18/00 at 12:01 A.M. Standard Time at your mailing address. ~. '\ 1 BUILDINGS LIMIT OF INSURANCE: , VALUATION: COINSURANCE: DEDUCTIBLE: BUSINESS INCOME INCLUDING RENTAL . LIMIT OF INSURANCE, WAITING PERIOD : SIGNS LIMIT OF INSURANCE, DEDUCTIBLE: VALUABLE PAPERS & RECORDS LIMIT OF INSURANCE, DEDUCTI BL E : EXTENDER ENDORSEMENT COVRG . COVERAGE (S) (' +-;- G28201 (Ed. 11.93) OFFICE, HARRISBURG c.:~,~~, .,-, PREMISES NO. BUILDING NO. ~l 01 _ <If-. ~ ft"} $416,000 q~;d'.Q"'" REPLACEMENT COST 80Y. $250 ACTUAL LOSS SUSTAINED NO WAIT PERIOD APPLIES $10,000 $250 $10,000 $250 PREMISES NO. 02 $161,aDO REPLACEMENT 80Y. $250 01 'r.' Ilol (/1 (, COST ACTUAL LOSS SUSTAINED NO WAIT PERIOD APPLIES $10,000 $250 $10,000 $250 APPLIES AT LL LOCATIONS SERVICE OFFICE COpy ~ ~~ t.l 1-1 CI I1il = E-i tf.l p:: E-i t.l P1 ~ tIl t.l 1-1 CI r:rl Eo! Jet l:l: Eo U. Page 01 of 01 FILE NUMBE:R= CR308181 IWSCACQ ,] ..- ~ I r t:-i' r- l:'Il'~E'f1'" THE EMPLOYERS FIRE INSURANCE COMPANY A Stock Company, Boston, Massachusetts 02108-3100 LIAl1lLlrY FORM ~OVERAGES SECTION II DECLARATIONS ... .' '," ~ . FPL~79395 6 . . . ...11/04/9~ .. -" ~ ICl l:E POLICY PERIOD: From 12118/99 to 12118/00 at 12:01 A.M. Standard Time at your mailing address. PERSONAL AND ADVERTISING INJURY LIMIT; EACH OCCURRENCE LIMIT: FIRE DAMAGE LIMIT (Any One Fire): MEDICAL EXPENSE LIMIT (Any One Person) : LIMIT OF INSURANCE $2,000,000 $~,OOO,OOO $1,000,000 $1,000,000 $100,000 $5,000 ICl 12 l- E- Ill: ICl ::l COVERAGE GENERAL AGGREGATE LIMIT (except Products-Completed Operations) : PRODUCTS - COMPLETED OPERATIONS AGGREGATE LIMIT: . NDN DWNED AUTO EXCLUSION APPLIES to .. ~ 1'.1 ~ lei j:l ~ fJ j:l ~ t 1'.1 l:I tl t l- t Ii E II ~ E ~ G28204 (11.93) SERVICE OFFICE COpy Page 01 of 02 OFAC~ HARRISBURG ~1I1:' MIIU!:>.....". rD'll.,Ul'A' TLlC!:,..",..O :'~it~ ",~--~- .' , , ..,.. r) '~" "', ='.~- =~-'~.jjliir~~.- .~n'rii:r: -Tf~'-T II ~."' !Uf " -'IC"'~~-~"'~'~' l:'I1'~E'P'" THE EMPLOYERS FIRE INSURANCE COMPANY A Stock Company, ijolton, Massachusetts 021 08.31 00 . LlAB'ILITY FORM COVERAGES CLASSIFICATION SCHEDULE DESClllPTlON OF CLASSIFICATION CLASS CODE 65132 65101 PREMISESI PRODUCTS PREIUSES PREIIISES, RATE BASIS EXPOSURE AMOUNT ANNUAL FINAL RATE 1.555 38.661 P\~EMIUM CHARGED $136 $38 1. APARTIIENTS 2. DWELLING - 3 FAMILY PER 100 SQ.FT. PER DWELLING 8700 1 I DESCRIPTION OF COVERAGE l '- G282D5 (11.93) Page 02 of 02 SERVICE OFFICE COpy OFFICE, MARRISBURG FILE NUMBER, CR308181 IIlSCACQ ~.,.."...., " '~-'>i""~ ",~'5J?r._m__ _ P'I'llOili'4 'I'''~'-''<'';,-",''~'' 'R""i1!'1'O;':<J-F: 'If,F'Jf';jiP:'1'1~~m~~~~~~IIlll~'llll~~fftif,~filjlliWd'il1''iW-.!!-:-- "'-r,)JUMl!fil1~;-~~~I\'!!l.:, ".;~~-' ;-f,'''~_'_-_T_-''~'' I' Silver Plume Document: ISO I Comm Gen Liab Forms I Countrywide...l96I Forms-Forms Page I of20 _1!To!'I:lmi'i'I!I "l'Iolll 111'1'1 --fIlIIIj' __......;16.,.~ ~,Q,Jz^'^' r "''' : ,lli'*4$ ~ Comm Gen Liab Forms ~~ Forms.Form~3 COMMERCIAL GENERAL LIABILITY CG 00 01 01 96 COMMERCIAL GENERAL LIABILITY COVERAGE FORM Various provisions in this policy restrict coverage. Read the entire policy carefully to determine rights, duties and what is and is not covered. Throughout this policy the words "you" and "your" refer to the Named Insured shown in t~e Declarations, and any other person or organization qualifying as a Named Insured under this policy. The words lIwe", "USI! and Ilourll refer 'to the company providing this insurance. The word "insured" means any person or organization qualifying as such under WHO IS AN INSURED (SECTION II) . Other words and phrases that appear in quotation marks have special meaning. Refer to DEFINITIONS (SECTION V) . SECTION I - COVERAGES COVERAGE A. BODILY INJURY AND PROPERTY DAMAGE LIABILITY 1. Insuring Agreement a. We will pay those sums that the insured becomes legally obligated to pay as damages because of "bodily injury" or "property damage" to which this insurance applies. We will have the right and duty to defend the insured against any "suit" seeking those damages. However, we will have no duty to defend the insured against any "suit" seeking damages for "bodily injury" or "property damage" to which this insurance does not apply. We may, at our discretion, investigate any "occurrence" and settle any claim or "suitll that may result. But: ....top '(1) The amount we will pay for damages is limited as described in LIMITS OF INSURANCE (SECTION III); and (2) Our right and duty to defend end when we have used up the applicable limit of insurance in the payment of judgments or settlements under Coverages A or B or medical expenses under Coverage C. No other obligation or liability to pay sums or perform acts or services is covered unless explicitly provided for under SUPPLEMENTARY PAYMENTS - COVERAGES A AND B. b. This insurance applies to "bodily injury" and "property damage" only if: . , (1) The "bodily injury" or "property damage" is caused by an "occurrence" that takes place in the "coverage territory"; and (2) The "bodily injury" or "property damage" occurs during the policy period. c. Damages because of "bodily injury" include damages claimed by any person or organization for care, loss of services or death resulting at any time from the "bodily injury". ...Ispserver.exe?Cmd=Query&Form=CLFMNUMB.SER&mannal=ARTISANS+PROGRAM+ 11/17/00 'r:~-li!', - :,<:'>' -~ t'1 , , I ~-~" 1- , Silver Plume Document: ISO I Comm Gen Liab Forms I Countrywide.../96I Forms-Forms Page 2 of20 2. Exclusions This insurance does not apply to: a. ....top Expected or Intended Injury "Bodily injury' or "property damage" expected or intended from the standpoint of the insured. This exclusion does not apply to "bodily injury" resulting from the use of reasonable force to protect persons or property. b. Contractual Liability "Bodily injury" or "property damage" for which the insured is obligated to pay damages by reason of the assumption of liability in a contract or agreement. This exclusion does not apply to liability for damages: (1) That the insured would have in the absence of the contract or agreement; or (2) Assumed in a contract or agreement that is an "insured contract", provided the "bodily injury" or "property damage" occurs ~ subsequent to the execution of the contract or agreement. Solely for the purposes of liability assumed in an "insured contract", reasonable attorney fees and necessary litigation expenses incurred by or for a party other than an insured are deemed to be damages because of "bodily injury" or "property damage", provided: (a) Liability to such party for, or for the cost of, that party's defense has also been assumed in the same "insured contractU; and Page 1 of 13 ....top (b) Such attorney fees and litigation expenses are for defense of that party against a civil or alternative dispute resolution proceeding in which damages to which this insurance applies are alleged. c. Liquor Liability "Bodily injury" or "property damage" for which any insured may be held liable by reason of: (1) Causing or contributing to the intoxication of any person; (2) The furnishing of alcoholic beverages to a person under the legal drinking age or under the influence of alcohol; or (3) Any statute, ordinance or regulation relating to the sale, gift, distribution or use of alcoholic beverages. This exclusion applies only if you are in the business of manufacturing, distributing, selling, serving or furnishing alcoholic beverages. d. Workers Compensation and Similar Laws Any obligation of the insured under a workers compensation, disability benefits or unemployment compensation law or any similar law. e. Employer's Liability "Bodily injury" to: ....top (1) An "employee" of the insured arising out of and in the course of: .../spserver.exe?Cmd=Query&Form=CLFMNUMB.SER&manual=ARTISANS+PROGRAM+ 11/17/00 F~,~~, - 1_'" 'I, , ~~, ,. ',' Silver Plume Document: ISO I Comm Gen Liab Forms I Countrywide...I96I Forms-Forms Page 3 of20 (a) Employment by the insured; or (b) Performing duties related to the conduct of the insured's business; or (2) The spouse, child, parent, brother or sister of that "employee" as a consequence of paragraph (1) above. This exclusion applies: (1) Whether the insured may be liable as an employer or in any other capacity! and (2) To any obligation to share damages with or repay someone else who must pay damages because of the injury. This exclusion does not apply to liability assumed by the insured undef an 11 insured contract II . f. pollution ....top (I) "Bodily injury" or "property damage" an.slng out of the actual, alleged or threatened discharge, dispersal, seepage, migration, release or escape of pollutants: (a) At or from any premises, site or location which is or was at any time owned or occupied by, or rented or loaned to, any insured; (b) At or from any premises, site or location which is or was at any time used by or for any insured or others for the handling, storage, disposal, processing or treatment of waste; (c) Which are or were at any time transported, handled, stored, treated, disposed of, or processed as waste by or for any insured or any person or organization for whom you may be legally responsible; or (d) At or from any premises, site or location on which any insured or any contractors or subcontractors working directly or indirectly on any insured'S behalf are performing operations: (i) If the pollutants are brought on or to the" premises, site or location in connection with such operations by such insured, contractor or subcontractor; or (ii) If the operations are to test for, monitor, clean up, remove, contain, treat, detoxify or neutralize, or in any way respond to, or assess the effects of pollutants. Subparagraph (d) (i) does not apply to "bodily injury" or "property damage" arising out of the escape of fuels, lubricants or other operating fluids which are needed to perform the normal electrical, hydraulic or mechanical functions necessary for the operation of "mobile equipment" or its parts, if such fuels, lubricants or other operating fluids escape from a vehicle part designed to hold, store or receive them. This exception does not apply if the fuels, lubricants or other operating fluids are intentionally discharged, dispersed or released, or if such fuels, lubricants or other operating fluids are brought on or to the premises, site or location with the intent to be discharged, dispersed or :eleased as part of the operations being performed by such lnsured, contractor or subcontractor. ....top Page 2 of 13 ...!spserver.exe?Cmd=Query&Form=CLFMNUMB.SER&manual=ARTISANS+PROGRAM+ 11/17/00 j'j?!t.' -c. .,""-,_ ~, ,. I~" 1 fur Silver Plume Document: ISO I Comm Gen Liab Forms I Countrywide.../96I Forms-Forms Page 4 of20 subparagraphs (a) and (d) (i) do not apply to "bodily injury" or "property damage" arising out of heat, smoke or fumes from a hostile fire. As used in this exclusion, a hostile fire means one which becomes uncontrollable or breaks out from where it was intended to be. (2) Any loss, cost or expense arising out of any: (a) Request, demand or order that any insured or others test for, monitor, clean up, remove, contain, treat" detoxify or neutralize, or in any way respond to, or assess the effects of pollutants; or (b) Claim or suit by or on behalf of a governmental authority for damages because of testing for, monitoring, cleaning up, removing, containing, treating, detoxifying or neutralizing, or in any way responding to, or assessing the effects of pollutants. Pollutants means any solid, liquid, gaseous or thermal irritant or contaminant, including smoke, vapor, soot, fumes, acids, alkalis, chemicals and waste. Waste includes materials to be recycled, reconditioned or reclaimed. g. Aircraft, Auto or Watercraft Atop "Bodily injuryll or "property damage" arising out of the ownership, maintenance, use or entrus.tment to others of any aircraft, "auto" or watercraft owned or operated by or rented or loaned to any insured. Use includes operation and "loading or unloading". This exclusion does not apply to: (1) A watercraft while ashore on premises you own or rent; (2) A watercraft you do not own that is, (a) Less than 26 feet long; and (b) Not being used to carry persons or property for a charge; (3) Parking an "auto" on, or on the ways next to, premises you own or rent, provided the "auto" is not owned by or rented or loaned to you or the insured; (4) Liability assumed under any "insured contract" for the ownership, maintenance or use of aircraft or watercraft; or (5) "Bodily injury" or "property damage" arising out of the operation of any of the equipment listed in paragraph f. (2) or f. (3) of the definition of lImobile equipment". h. Mobile Equipment "Bodily injury" or Ilproperty damage" arising out of: A top (1) The transportation of "mobile equipment" by an "auto" owned or operated by or rented or loaned to any insured; or (2) The use of "mobile equipment" in, or while in practice for, or while being prepared for, any prearranged racing, speed, demolition, or stunting activity. i. War "Bodily injury" or "property damage" due to war, whether or not .../spserver.exe?Cmd=Query&Form=CLFMNUMB.SER&manual=ARTISANS+PROGRAM+ 11/17/00 ;s""~.,"",,,,,,~ ,_, " , .T ~ I ~. - .- r .~", :;' Silver Plume Document: ISO I Comm Gen Liab Forms I Countrywide.../96I Forms-Forms Page 5 of20 declared, or any act or condition incident to war. War includes civil war, insurrection, rebellion or revolution. This exclusion applies only to liability assumed under a contract or agreement. j. Damage to Property "Property damageU to: (1) Property you own, rent, or occupy; (2) Premises you sell, give away or abandon, if the "property damage" arises out of any part of those premises; (3) Property loaned to you; (4) Personal property in the care, custody or control of the insured; (5) That particular part of real property on which you or any contractors or subcontractors working directly or indirectly on your behalf are performing operations, if the "property damage" arises out of those operations; or .....top (6) That particular part of any property that must be restored, repaired or replaced because "your work" was i.ncorrectly performed on it. Paragraph (2) of this exclusion does not apply if the premises are "your work" and were never occupied, rented or held for rental by you. )?age 3 of 13 Paragraphs (3), (4),. (5) and (6) of this exclusion do not apply to liability assumed under a sidetrack agreement. Paragraph (6) of this exclusion does not apply to "property damage" included in the "products-completed operations hazard". k. Damage to Your Product "Property damage" to "your product" arising out of it or any part of it. l. Damage to Your Work "Property damage" to lIyour work" arl.Slng out of it or any part of it and included in the "products-completed operations hazard". This exclusion does not apply if the damaged work or the work out of which the damage arises was performed on your behalf by a subcontractor. .....top m. Damage to Impaired Property or Property Not Physically Injured "Property damage" to "impaired property" or property that has not been physically injured, arising out of: (1) A defect, deficiency, inadequacy or dangerous condition in "your productll or lIyour workll: or (2) A delay or failure by you or anyone acting an your behalf to perform a contract or agreement in accordance with its terms. This exclusion does not apply to the loss of use of other property arising out of sudden and accidental physical injury to "your product" or "your workll after it has been put to its intended use. n. Recall of Products, Work or Impaired Property .../spserver.exe?Cmd=Query&Form=CLFMNUMB.SER&manual=ARTISANS+PROGRAM+ 11/17/00 t~~:D~,. '. ", . ., ',- Silver Plume Document: ISO I Comm Gen Liab Forms I Countrywide.../96I Forms-Forms Page 6 of20 Damages claimed for any loss, cost or expense incurred by you or others for the loss of use, withdrawal, recall, inspection I repair! replacement, adjustment, removal or disposal of: (1) "Your product"; (2) "Your workll; or atop (3) "Impaired property"; if such product, work, or property is withdrawn or recalled from the market or from use by any person or organization because of a known or suspected defect, deficiency, inadequacy or dangerous condition in it. Exclusions c. through n. do not apply to damage by fire to premises while rented to you or temporarily occupied by you with permission of the owner. A separate limit of insurance applies to this coverage as described in LIMITS OF INSURANCE (Section III) . ,COVERAGE B. PERSONAL AND ADVERTISING INJURY LIABILITY 1. Insuring Agreement a. We will pay those sums that the insured becomes legally obligated to pay as damages because of "personal injuryll or "advertising injury" to which this insurance applies. We will have the right and duty to defend the insured against any "suit" seeking those damages. However, we will have no duty to defend the insured against any "suit" seeking damages for "personal injury" or "advertising injury" to which this insurance does not apply. We may, at our discretion, investigate any lIoccurrence" or offense and settle any claim or "suit" that may result. But: (1) The amount we will pay for damages is limited as described in LIMITS OF INSURANCE (SECTION III); and (2) Our right and duty to defend end when we have. used up the applicable limit of insurance in the payment of judgments or settlements under Coverages A or B or medical expenses under Coverage C. NO other obligation or liability to pay sums or perform acts or services is covered unless explicitly provided for under SUPPLEMENTARY PAYMENTS - COVERAGES A AND B. atop b. This insurance applies to: (1) "Personal injury" caused by an offense ar~slng out of your business, excluding advertising, publishing,.broadcasting or telecasting done by or for you; . (2) "Advertising injury" caused by an offense committed in the course of advertising your goods, products or services; but only if the offense was committed in the "coverage territory" during the policy period. 2. Exclusions This insurance does not apply to: a. "Personal injuryll or "advertising injuryll: (1) Arising out of oral or written publication of material, if done by or at the direction of the insured with knowledge of its falsity; Page 4 of 13 .../spserver.exe?Cmd=Query&Form=CLFMNUMB.SER&manual=ARTISANS+PROGRAM+ 11/17/00 ':r'~~,. ~ ~I 1 ,~_ ' , I Silver Plume Document: ISO I Comm Gen Liab Forms I Countrywide.../961 Forms-Forms Page 7 of20 ....top (2) Arising out of oral or written publication of material whose first publication took place before the beginning of the policy period; (3) Arising out of the willful violation of a penal statute or ordinance committed by or with the consent of the insured; (4) For which the insured has assumed liability in a contract or agreement. This exclusion does not apply to liability for damages that the insured would have in the absence of the contract or agreement; or (5) Arising out of the actual, alleged or threatened discharge, dispersal, seepage, migration, release or escape of pollutants at any time. b. "Advertising injuryll arising out of: (1) Breach of contract, other than misappropriation of advertising ideas under an implied contract; (2) The failure of goods, products or services to conform with advertised quality or performance; (3) The wrong description of the price of goods, products or services; or (4) An offense committed by an insured whose business is advertising, broadcasting, publishing or telecasting. c. Any loss, cost or expense arising out of any: (1) Request, demand or order that any insured or others test for, monitor, clean up, remove, contain, treat, detoxify or neutralize, or in any way respond to, or assess the -effects of pollutants; or (2) Claim or suit by or on behalf of a governmental authority for damages because of testing for, monitoring, cleaning up, removing, containing, treating, detoxifying or neutralizing, or in any way responding to, or assessing the effects of pollutants. ....t~llutants means any solid, liquid, gaseous or thermal irritant or contaminant, including smoke, vapor, soot, fumes, acids, alkalis, chemicals and waste. Waste includes materials to be recycled, reconditioned or reclaimed. COVERAGE C. MEDICAL PAYMENTS 1. Insuring Agreement a. We will pay medical expenses as described below for "bodily injury" caused by an accident: (1) On premises you own or rent; (2) On ways next to premises you omlor rent; or (3) Because of your operations; provided that: (1) The accident takes place in the "coverage territory" and during the policy period; (2) The expenses are incurred and reported to us within one year of the date of the accident; and ...Ispserver.exe?Cmd=Query&Form=CLFMNUMB.SER&manual=ARTISANS+PROGRAM+ 11/17/00 L *~ Silver Plume Document: ISO I Comm Gen Liab Forms I Countrywide.../96j Forms-Forms Page 8 of20 (3) The injured person submits to examination, at our expense, by physicians of our choice as often as we reasonably require. b. We will make these payments regardless of fault. These payments will not exceed the applicable limit of insurance. We will pay reasonable expenses for: . top (1) First aid administered at the time of an accident; (2) Necessary medical, surgical, x-ray and dental services, including prosthetic devices; ~and (3) Necessary ambulance, hospital, professional nursing and funeral services. 2. Exclusions We will not pay expenses for "bodily injury": a. To any insured. b. To a person hired to do work for or on behalf of any insured or a tenant of any insured. c. To a person injured on that part of premises you oWn or rent that the person normally occupies. d. To a person, whether or not an "employee" of any insured, if benefits for the "bodily injury" are payable or must be provided under a workers compensation or di~ability benefits law or a similar law. e. To a person injured while taking part in athletics. f. Included within the "products-completed operations hazard". g. Excluded under Coverage A. . top h. Due to war, whether or not declared, or any act or condition incident to war. War includes civil war, insurrection, rebellion or revolution. Page 5 of 13 SUPPLEMENTARY PAYMENTS COVERAGES A AND B We will pay, with respect to any claim we investigate or settle, or any llsuitll against an insured we defend: 1. All expenses we incur. 2. Up to $250 for cost of bail bonds required because of accidents or traffic law violations arising out of the use of any vehicle to which the Bodily Injury Liability Coverage applies. We do not have to furnish these bonds. 3. The cost of bonds to release attachments, but only for bond amounts within the applicable limit of insurance. We do not have to Turnish these bonds. 4. All reasonable expenses incurred by the insured at our request to assist us in the investigation or defense of the claim or "suitll, including actual loss of earnings up to $250 a day because of time off from work. S. All costs taxed against the insured in the "suit". 6. Prejudgment interest awarded against the insured on that part of the judgment we pay. If we make an offer to pay the applicable limit of insurance, we will not pay any prejudgment interest based on that period ...Ispserver.exe?Cmd=Query&Fonn=CLFMNUMB.SER&manual=ARTISANS+PROGRAM+ 11/17/00 Wp_ I"'~~""" """"'"''l'"IT-~ {{ Silver Plume Document: ISO I Comm Gen Liab Forms I Countrywide.../96[ Forms-Forms Page 9 of20 of time after the offer. ~~ . 7. All interest on the full amount of any Judgment that accrues after entry of the judgment and before we have paid, offered to pay, or deposited in court the part of the judgment that is within the applicable limit of insurance. These payments will not reduce the limits of insurance. If We defend an insured against a "suit" and an indemnitee of the insured is also named as a party to the "suit", we will defend that indemnitee if all of the following conditions are met: a. The "suit" against the indemnitee seeks damages for which the insured has assumed the liability of the indemnitee in a contract or agreement that is an "insured contractU; b. This insurance applies to such liability assumed by the insured; c. The obligation to defend, or the cost of the defense of, that indemnitee, has also been assumed by the insured in the same lIinsu.red contract" ; d. The allegations in the "suit" and the information we know about the "occurrence" are such that no conflict appears to exist between the interests of the insured and the interests of the indemnitee; e. The indemnitee and the insured ask us to conduct and control the defense of that indemnitee against such lIsuitll and agree that we can assign the same counsel tO,defend the insured and the indemnitee; and f. The indemnitee: ~top (1) Agrees in writing to: (a) Cooperate with us in the investigation, settlement or defense of the I1suitll; (b) Immediately send us copies of any demands, notices, summonses or legal papers received in connection with the "suit"; (c) Notify any other insurer whose coverage is available to the indemnitee; and (d) Cooperate with us with respect to coordinating other applicable insurance available to the indemnitee; and (2) Provides us with written authorization to: (a) Obtain records and other information related to the "suit"; and ' (b) Conduct and control the defense of the indemnitee in such "suit" . So long as the above conditions are met, attorneys fees incurred by us in the defense of that indemnitee, necessary litigation expenses 'incurred by us a~d necessary litigation expenses incurred by the indemnitee at our request w~ll be paid as Supplementary Payments. Notwithstanding the provisions of paragraph 2.b. (2) of COVERAGE A - BODILY INJURY AND PROPERTY DAMAGE ' LIABILITY (Section I - coverages), such payments will not be deemed to be damages for "bodily injury" and "property damage" and will not reduce the limits of insurance. ~top Our obligation to defend an insured's indemnitee and to pay for attorneys fees and necessary litigation expenses as Supplementary Payments ends when: a. We have used up the applicable limit of insurance in the payment of .../spserver.exe?Cmd=Query&Form=CLFMNUMB.SER&manual=ARTISANS+PROGRAM+ 11/17/00 ';_"iJiJ!i"r;_I!:f1 I: I' .1'2j rw~_,", Silver Plume Document: ISO I Comm Gen Liab Forms I Countrywide.../96j Forms-Forms Page 10 of20 judgments or settlements; or b. The conditions set forth above, or the terms of the agreement described in paragraph f, above, are no longer met. Page 6 of 13 SECTION II - WHO IS AN INSURED 1. If you are designated in the Declarations as: a. An individual, you and your spouse are insureds, but only with respect to the conduct of a business of which you are the sole owner. b. A partnership or joint venture, you are an insured. Your members, your partners, and their spouses are also insureds, but only with respect to the conduct of your business. c. A limited liability company, you are an insured. Your members are also insureds, but only with respect to the conduct of your business. Your managers are insureds, but only with respect to their duties as your managers. d. An organization other than a partnership, joint venture or limited liability company, you are an insured. Your nexecutive officersll and directors are insureds, but only with respect to their duties as your officers or directors. Your stockholders are also insureds, but only with respect to their liability as stockholders. ....top 2. Each of the following is also. an insured: a. Your "employees", other than either your "executive officers II (if you are an organization other than a partnership, joint venture or limited liability company) or your managers (if you are a limited liability company), but only for acts within the scope of their employment by you or while performing duties related to the conduct of your business. However, none of these "employees" is an insured for: (1) IIBodily injuryll or "personal injury": (a) To you, to your partners or members (if you are a partnership or joint venture), to your members (if you are a limited liability company), or to a co-"employee" while that cO-"employee" is either in the course of his or her employment or performing duties related to the conduct of your business; (b) To the spouse, child, parent, brother or sister of that co-"employee" as a consequence of paragraph (1) (a) above; (c) For Which there is any obligation to share damages with or repay someone else who must pay damages because of the injury described in paragraphs (1) (a) or (b) above; or (d) Arising out of his or her providing or failing to provide professional health care services. ....top (2) "Property damage" to property: (a) Owned, occupied or used by, (b) Rented to, in the care, custody or control of, or over which physical control is being exercised for any purpose by you, any of your "employees", any partner or member (if you are a partnership or joint venture), or any member (if you are a limited liability company) . b. Any person (other than your "employee"), or any organization while .../spserver.exe?Cmd=Query&Form=CLFMNUMB.SER&manual=ARTISANS+PROGRAM+ 11/17/00 =.-' i' . . Silver Plume Document: ISO \ Comm Gen Liab Forms I Countrywide.../96\ FOlms-Forms Page 11 of 20 acting as your real estate manager. c. Any person or organization having proper temporary custody of your property if you die, but only: (1) With respect to liability arising out of the maintenance or use of that property; and (2) Until your legal representative has been appointed. d. Your legal representative if you die, but only with respect to duties aa such. That representative will have all your rights and duties under this Coverage Part. 3. with respect to "mobile equipment" registered in your name under any moto~ vehicle registration law, any person is an insured while driving such equipment along a pUblic highway with your permission. Any other person or organization responsible for the conduct of such person is also an insured, but only with respect to liability arising out of the operati~n of the equipment, and only if no other insurance of any kind is available to that person or organization for this liability. However.. no person or organization is an insured with~respect to: ....top a. "Bodily injury" to a cO-"employee' of the person driving the equipment; or b. "Property damage" to property owned by, rented to, in the charge of or occupied by you or the employer of any person who is an insured under this provision. 4. Any organization you newly acquire or form, other than a partnership, joint venture or limited liability company, and over which you maintain ownership or majority interest, will qualify as a Named Insured if there is no other similar insurance available to that organization. However: a. Coverage under this provision is afforded only until the 90th day after you acquire or form the organization or the end of the policy period, whichever is earlier; Page 7 of 13 b. Coverage A does not apply to "bodily injury" or "property damage" that occurred before you acquired or formed the organization: and c. Coverage B does not apply to "personal injury" or "advertising injury'" arising out of an offense committed before you acquired or formed the organization. No person or organization is an insured with respect to the conduct of any current or past partnership, joint venture or limited liability company that is not shown as a Named Insured in the Declarations. ....top SECTION III - LIMITS OF INSURANCE 1. The Limits of Insurance shown in the Declarations and the rules below fix the most we will pay regardless of the number of: a. Insureds; b. .Claims made or "suitsll brought; or c. Persons or organizations making claims or bringing "suits", 2. The General Aggregate Limit is the most we will pay for the. sum of: a. Medical expenses under Coverage C; .../spserver.exe?Cmd=Query&Form=CLFMNUMB.SER&manual=ARTISANS+PROGRAM+ 11/17/00 .,); Silver Plume Document: ISO I Comm Gen Liab Forms I Countrywide.../96I Forms-Forms Page 12 of20 b. Damages under Coverage A, except damages because of "bodily injury" or "property damage" included in the "products-completed operations hazardll; and c. Damages under Coverage B. 3. The Products-Completed operations Aggregate Limit is the most we will pay under Coverage A for damages because of "bodily injury" and "property damage" included in the "products-completed operations hazard". 4. Subject to 2. above, the Personal and Advertising Injury Limit is the most we will pay under Coverage B for the sum of all damages because of all "personal injury" and all "advertising injury" sustained by anyone person or organization. ~~ . 5. Subject to 2. or 3. above, whichever appl~es, the Each Occurrence Limit is the most we will pay for the sum of: a. Damages under Coverage A; and b. Medical expenses under Coverage C because of all "bodily injury;' and "property damage" arising out of any one lIoccurrence". 6. Subject to 5. above, the Fire Damage Limit is the most we will pay under Coverage A for damages because of IIproperty damage" to premises, while rented to you or temporarily occupied by you with permission of the owner, arising out of anyone fire. 7. Subject to 5. above, the Medical Expense Limit is the most we will pay under Coverage C for all medical expenses because of "bodily injury" sustained by anyone person. The Limits of Insurance of this Coverage Part apply separately to each consecutive annual period and to any remaining period of less than 12 months, starting with the beginning of the policy period shown in the Declarations, unless the policy period is extended after issuance for an additional period of less than 12 months. In that case, the additional period will be deemed part of the last preceding period for purposes of determining the Limits of Insurance. SECTION IV - COMMERCIAL GENERAL LIABILITY CONDITIONS 1. Bankruptcy ~top Bankruptcy Or insolvency of the insured or of the insured's estate will not relieve us of our obligations under this Coverage Part. 2. Duties In The Event Of Occurrence, Offense, Claim Or Suit a. You must see to it that we are notified as soon as practicable of an "occurrence" or an offense which may result in a claim. To the extent possible, notice should include: (l) How, when and where the "occurrence" or offense took place; (2) The names and addresses of any injured persons and witnesses; and (3) The nature and location of any injury or damage arising out of the lloccuI:'rence" or offense. b. If a claim is made or 11 suit II is brought against any insured, you must: .(1) Immediately record the specifics of the claim or "suit" and the date received; and (2) Notify us as soon as practicable. .../spserver.exe?Cmd'=Query&Form=CLFMNUMB.SER&manual=ARTISANS+PROGRAM+ 11/17/00 il'%'- ,-'i~ "lJU, , ' " Silver Plume Document: ISO I Comm Gen Liab Forms I Countrywide.../96I Forms-Forms Page 13 of20 You must see to it that we receive written notice of the claim or lIsuit" as soon as practicable. Page 8 of 13 c. You and any other involved insured must: ...top (1) Immediately send us copies of any demands, notices, summonses or legal papers received in connection with the claim or "suitllj (2) Authorize us to obtain records and other information; (3) Cooperate with us in the investigation or settlement of the claim or defenae against the "suitllj and (4) Assist us, upon our request, in the enforcement of any right against any person or organization which may be liable to the 1nsured hecause of injury or damage to which this insurance may also apply. d. No insured will, except at that insured's own cost, voluntarily make a payment, aSSUme any obligation, or incur any expe~se, other than for first aid, without our consent. 3. Legal Action Against Us No person or organization has a right under this Coverage Part: a. To join us as a party or otherwise bring us into a "suitU asking for damages from an insured; or b. To sue us on this Coverage Part unless all of its terms have been fully complied with. A person or organization may sue us to recover on an agreed settlement or on a final judgment against an insured obtained after an actual trial; but we will not be liable for damages that are not payable under the terms of this Coverage Part or that are in excess of the applicable limit of insurance. An agreed settlement means a settlement and release of liability signed by us, the insured and the claimant or the claimant's legal representative. ...top 4. Other Insurance If other valid and collectible insurance is available to the insured for a loss we cover under Coverages A or B of this Coverage Part, our obligations are limited as follows: a. Primary Insurance This insurance is primary except when b. below applies. If this insurance is primary, our obligations are not affected unless any of the other insurance is also primary. Then, we will share with all that other insurance by the method described in c. below. b. Excess Insurance This insurance is excess over any of the other insurance, whether primary, excess, contingent or on any other basis: (1) That is Fire, Extended Coverage, Builder's Risk, Installation Risk or similar coverage for lIyour work"; (2) That is Fire insurance for premises rented to you or temporarily occupied by you with permission of the owner; or .../spserver.exe?Cmd=Query&Form=CLFMNUMB.SER&manual=ARTISANS+PROGRAM+ 11/17/00 I, ",'-." " Silver Plume Document: ISO I Comm Gen Liab Forms I Countrywide.../96I Forms-Forms Page 14 of20 (3) If the loss arises out of the maintenance or use of aircraft, "autos" or watercraft to the extent not subject to Exclusion g. of Coverage A (Section I) . When this insurance is excess, we will have no duty under Coverages A or B to defend the insured against any "suit" if any other insurer has a duty to defend the insured against that "suit". If no other insurer defends, we will undertake to do so, but we will be entitled to the insured's rights against all those other insurers. .....top When this insurance is excess over other insurance, we will pay only our share of the amount of the loss, if any, that exceeds the sum of: (1) The total amount that all such other insurance would pay for the loss in the absence of this insurance; and (2) The total of all deductible and self-insured amounts under all that other insurance. We will share the remaining loss, if any, with any other insurance that is not described in this Excess Insurance provision and was not bought specifically to apply in excess of the Limits of Insurance shown in the Declarations of this Coverage Part. c. Method of Sharing If all of the other insurance permits contribution by equal shares, we will follow this method also. Under this approach each insurer contributes equal amounts until it has paid its applicable limit of insurance or none of the l?sS remains, whichever comes first. If any of the other insurance does not permit contribution by equal shares, we will contribute by limits. Under this method, each insurer's share is based on the ratio of its applicable limit of . insurance to the total applicable limits of insurance of all insurers. Page 9 of 13 5. Premium Audit .....top a. We will compute all premiums for this Coverage Part in accordance with our rules and rates. b. Premium shown in this Coverage Part as advance premium is a deposit premium only. At the close of each audit period we will compute the earned premium for that period. Audit premiums are due and payable on notice to the first Named Insured. If the sum of the advance and audit premiums paid for the policy period is greater than the earned premium, we will return the excess to the first ~amed Insured. C. The first Named Insured must keep records of the information we need for premium computation, and send us copies at such times as we may request. 6. Representations By accepting this policy, you agree: a. The statements in the Declarations are accurate and complete; b. Those statements are based upon representations you made to us; and c. We have issued this policy in reliance upon your representations. 7. Separation Of Insureds Except with respect to the Limits of Insurance, and any rights or duties .../spserver.exe?Cmd=Query&Form=CLFMNUMB.SER&manual=ARTISANS+PROGRAM+ 11/17/00 f~- .:~",. ., ~. 1"'1 .. ,-...~ ''!J~ Silver Plume Document: ISO [ Comm Gen Liab Forms I Countrywide.../96[ Forms-Forms Page 15 of20 specifically assigned in this Coverage Part to the first Named Insured, this insurance applies: ....top a. As if each Named Insured were the only Named Insured; and b. Separately to each insured against whom claim is made or "suitll is brought. B. Transfer Of Rights Of Recovery Against Others To Us If the insured has rights to recover all or part of any payment we have made under this Coverage Part, those rights are transferred to us. The insured must do nothing after loss to impair them. At our request, the insured will bring "suit" or transfer those rights to us and help us enforce them. 9. When We Do Not Renew If we decide not to renew this Coverage Part, we will mail or deliver to the fir~t Named Insured shown in the Declarations written notice of the nonrenewal not less than 30 days before the expiration date. If notice is mailed, proof of mailing will be sufficient proof of notice. ~ SECTION V - DEFINITIONS 1. "Advertising injury" means injury arising out of one or more of the following offenses: a. Oral or written publication of material that slanders or libels a person or organization or disparages a person's or organization1s goods, products or services; .....top b. Oral or written publication of material that violates a person's right of privacy; c. Misappropriation of advertising ideas or style of doing business; or d. Infringement of copyright, title or slogan. 2. "Auto" means a land motor vehicle, trailer or semitrailer designed for travel on public roads, including any attached machinery or equipment. But Ilauto" does not include "mobile eguipmentll. 3. "Bodily injury" means bodily injury, sickness or disease sustained by a person, including death resulting from any of these at any time. 4. "Coverage territoryll means: a. The United States of America (including its territories and possessions), Puerto Rico and Canada; . b. International waters or airspace, provided the injury or damage does not occur in the course of travel or transportation to or from any place not included in a. above; or c. All parts of the world if: (1) The injury or damage arises out of: (a) Goods or products made or sold by you in the territory described in a. above; or .....top Page 10 of 13 (b) The activities of a person whose home is in the territory described in a. above, but is away for a short time on your .../spserver.exe?Cmd=Query&Form=CLFMNUMB.SER&manual=ARTISANS+PROGRAM+ 11/17/00 '}~.'. -",,"' . 'I~! ~w Silver Plume Document: ISO I Comm Gen Liab Forms I Countrywide.../96 I Forms-Forms Page 16 of20 business; and (2) The insured's responsibility to pay damages is determined in a I1suitll on the merits, in the territory described in a. above or in a settlement we agree to. 5. "Employee" includes a "leased worker I . lIEmployee" does not include a lItemporary worker". 6. "Executive officer" means a person holding any of the officer positions created by your charter, constitution, by-law~ or any other similar governing document. 7. "Impaired property" means tangible property, other than "your product" or "your work"l that cannot be used or is less useful because: a. It incorpolCates "your product" or "your work" that is known or thought to be defective, deficient, inadequate or dangerous; or b. You nave failed to fulfill the terms of a contract or agreement; if such propelCty can be restored to use by: a. The repair, replacement. adjustment or removal of ."your product" or lIyour worku; or ....top b. Your fulfilling the terms of the contract or agreement. 8. "Insured contract" means: a. A contract for a lease of premises. However, that portion of the contract for a lease of premises that indemnifies any person or organization for damage by fire to premises while rented to you or temporarily occupied by you with permission of the owner is not an "insured contract"; b. A sidetraCk agreement; c. Any easement or license agreement, except in connection with construction or demolition operations on or within 50 feet of a railroad; d. An obligation, as required by ordinance, to indemnify a municipality, except in connection with work for a municipality; e. An elevator maintenance agreement; ....top f. That part of any other contract or agreement pertaining to your business (including an indemnification of a municipality in connection with work performed for a municipality) under which you assume the tort liability of another party to pay for "bodily injury" or "property damage" to a third person or organization. Tort liability means a liability that would be imposed by law in the absence of any contract Or agreement. Paragraph f. does not include that part of any contract or agreement: (1) That indemnifies a railroad for "bodily injury" or "property damage" arising out of construction or demolition operations I within 50 feet of any railroad property and affecting any railroad bridge or trestle, tracks, road-beds, tunnel, underpass or crossing; (2) That indemnifies an architect, engineer or surveyor for injury or damage arising out of: (a) Preparing, approving, or failing to prepare or approve maps, shop drawings I opinions I reports, surveys, field ordersl ';~ ~-~ .../spserver.exe?Cmd'=Query&Form=CLFMNUMB.SER&manua1=ARTISANS+PROGRAM+ 11/17/00 '-'-1= ,'" s"'tt ,~~~ Silver Plume Document: ISO I Comm Gen Liab Forms I Countrywide.../96I Forms-Forms Page 17 of20 change orders or drawings and specifications: or (b) Giving directions or instructions, or failing to give them, if that is the primary cause of the injury or damage; or (3) under which the insuredf if an architect, engineer or surveyorf assumes liability for an injury or damage arising out of the insured's rendering or failure to render professional services, including those listed in (2) above and supervisory, inspection, architectural or engineering activities. 9. "Leased worker" means a person leased to you by a labor leasing firm under an agreement between you and the labor leasing firm, to perform duties related to the conduct of your business. "Leased worker" does not include a "temporary workerll. 10. "Loading or unloading" means the handling of property: a. After it is moved from the place where it is accepted for movement int't> or onto an aircraft, watercraft or "autoll; ,....top Page 11 of 13 b, While it is in or on an aircraft, watercraft or lIautoll; or c, While it is being moved from an aircraft I watercraft or "autoll to the place where it is finally delivered; but "loading or unloading" does not include the movement of property by means of a mechanical device,' other than a hand truck, that is not attached to the aircraft, watercraft or "auto". 11. "Mobile equipment" means any of the following types of land vehicles, including any attached machinery or equipment: a. Bulldozers, farm machinery, forklifts and other vehicles designed for use principally off public roads; b. Vehicles maintained for use solely on or next to premises you own or rent; e. Vehicles that travel on crawler treads; d. Vehicles, whether self-propelled or not, maintained primarily to provide mobility to permanently mounted: (I) Power cranesl shovels I loaders I diggers or drills; or (2) Road construction or resurfacing equipment such as graders, scrapers or rollers; ....top e. Vehicles not described in a., b., c. or d. above that are not self-propelled and are maintained primarily to provide mobility to permanently attached equipment of the following types: (1) Air compressors, pumps and generators, including spraying, welding, building cleaning, geophysical exploration, lighting and well servicing equipment; or (2) Cherry pickers and similar devices used to raise or lower workers; f. Vehicles not described in a., b., c. or d. above maintained primarily for purposes other than the transportation of persons or cargo. However, self-propelled vehicles with the following types of permanently attached equipment are not 'mobile equipment" but will be .../spserver.exe?Cmd=Query&Form=CLFMNUMB.SER&manual=ARTISANS+PROGRAM+ 11/17/00 T "~ - I' :\'~"~' -,- , Silver Plume Document: ISO I Comm Gen Liab Forms I Countrywide.../96I Forms-Forms Page 18 of20 considered "autos': (1) Equipment designed primarily for: {a} Snow removal; (b) Road maintenance, but not construction or resurfacing; or (c) Street cleaning; (2) Cherry pickers and similar devices mounted on automobile or truck chassis and used to raise or lower workers; and (3) Air compressors, pumps and generators, including spraying, welding, building cleaning, geophysical exploration, lighting and well servicing equipment. ....top . . 1 d" d 12. llOccurrence" means an accldentl lnc U lUg cont1uuoUS or repeate exposure to substantially the same general harmful conditions. 113. llpersonal injuryll means injury, other than IIbodily injurY"1 arising..out of one or more of the following offens~s: a. False arrest, detention or imprisonment; b. Malicious prosecution; c. The wrongful eviction from, wrongful entry into, or invasion of the right of private occupancy of a room, dwelling or premises that a person occupies by or on behalf of its owner, landlord or lessor; d. Oral or written publication of material that slanders or libels a person or organization or disparages a person's or organization's goods, products or services; or e. Oral or written publication of material that violates a person's right of privacy. 14. "Products-completed operations hazard": a. Includes all "bodily injury" and "property damage" occurring away from premises you own or rent and arising out of "your product" or lIyour work" except: (1) Products that are still in your physical possession; or (2) Work that has not yet been completed or abandoned. However, "your work" will be deemed completed at the earliest of the following times: ....top (a) When all of the work called for in your' contract has been completed. (b) When all of the work to be done at the job site has been completed if your contract calls for work at more than one job site. (c) When that part of the work done at a job site has been put to its intended use by any person or organization other than another contractor or subcontractor working on the same project. Work that may need service I maintenance, correction, repair or replacement, but which is otherwise complete, will be treated as completed. Page 12 of 13 .../spserver.exe?Cmd=Query&Form=CLFMNUMB.SER&manua1=ARTISANS+PROGRAM+ .11/17/00 -1:t"I"", " , ~.' . !' 11 . if~~ <-,,<~ Silver Plume Document: ISO \ Comm Gen Liab Forms I Countrywide.../96\ Forms-Forms Page 19 of20 b. Does not include Ilbodily injuryll or "property damagel1 arising out of: (1) The transportation of property, unless the injury or damage arises out of a condition in or on a vehicle not owned or operated by you, and that condition was created by the "loading or unloading" of that vehicle by any insured; (2) The existence of tools, uninstalled equipment or abandoned or unused materials; or (3) Products or operations for which the classification, listed in the Declarations or in a policy schedule, states that products- completed operations are subject to the General Aggregate Limit. ....top 15. nproperty damage" means: a. Physical injury to tangible property, including all resulting loss of use of that property. All such loss of use shall be deemed to occur at ~he time of the physical injury that caused it; or b. Loss of use of tangible. property that is not physically injured. All such loss of use shall be deemed to occur at the time of the Iloccurrencell that caused it. i6. "Suit" means a civil proceeding in which damages because of "bodily injury", "property damage"l "personal injuryll or lIadvertising injury I to which this insurance applies are alleged. "Suit II includes: a. An arbitration proceeding in which such damages are claimed and to which the insured must submit or does submit with our consent; or b. Any other alternative dispute resolution proceeding in which such damages are claimed and to which the insured submits with our consent. 17. "Temporary worker" means a person who is furnished to you to substitute for a permanent "employee" on leave or to meet seasonal or short-term workload conditions. 18. IIYour product" means: a. Any goods or products, other than ,real property, manufactured, sold, handled, distributed or disposed of by: ....top (1) You; {2} Others trading under your name; or (3) A person or organization whose business or assets you have acquired; and b. Containers (other than vehicles), materials, parts or equipment furnished in connection with such goods or products. nYour product" includes: a. Warranties or representations made at any time with respect to the fitness, quality, durability, performance or use of "your product"; and b. The providing of or failure to provide warnings or instructions. "Your product" does not include vending machines or other property rented to or located for the use of others but not sold. 19. IlYour work" means; ...Ispserver.exe?Cmd=Query&Form=CLFMNUMB.SER&manua1=ARTISANS+PROGRAM+ 11/17/00 r'!~!!JW'L,TI_.~ _' " ~I '"' H ~,., " Silver Plume Document: ISO I Comm Gen Liab Forms I Countrywide...I96\ Forms-Forms Page 20 of20 a. Work or operations performed by you or on your behalf; and b. Materials, parts or equipment furnished in connection with such work or operations. , l1Your work" includes: ....top a. warranties or representations made at any time, with respect to the fitness, quality, durability, performance or use of "your work"; and b. The providing of or failure to provide warnings or instructions. CG 00 01 01 96 Page 13 of 13 copyright, Insurance Services Office, Inc., 1994 ,-...----..--.......------.."....-..-.........---------..-.--.---...-----.---- ....top Add/Edit Notes Add Personal Note ,....top Document information Newer/Older versions Newer version of this document Older version of this document ....top This page was created: 11/17/0012:06:40 PM .../spserver.exe?Cmd=Query&Form=CLFMNUMB.SER&manua1=ARTISANS+PROGRAM+ 11/17/00 -:'*"'--., D~& P.O. Box 60515 Harrisburg, PA 17106-0515 (717) 599-5505 (800) 443-0824 Fax (717) 599-5507 December 6, 2001 Mr. Gerard C. Kramer, Esq. Schmidt, Ronca & Kramer P.C. 209 State St. Harris~rg, PA 17101 Re: Krista Coombs, Individually and as Parent and Natural Guardian of Kayla Coombs, a Minor Dear Gerry: This report summarizes Information Network Associates, Inc.'s ("INN') efforts to date to establish the financial assets and liabilities of the above-captioned individual, pursuant to your request dated November 26, 2001. On Monday November 26, 2001, INA conducted a database search to establish Mr. Kerry R. Saintz' address history to identify those jurisdictions to be searched for possible assets. The result of this search is the following address history for a Kerry R. Saintz having a date of birth of December, 1956 and a social security number of 182-40-8943: Address Date Reported 1) 731 Harrisburg Pike Dillsburg, PA 17019 11/01 2) 205 Mulberry Dr. Apt. #C Mechanicsburg, PA 17050 09/01 3) 1005 Silver Lake Rd. Lewisberry, PA 17339 10/99 4) 114 S. Third St. Lemoyne, PA 17043 Not Reported . ~;"'~__ 0 7"7"- " -~, T-'~, .1 -~ " . [tf~ Mr. Gerard C. Kramer, Esq. December 6, 2001 Page 2 On Wednesday November 28, 2001, the indices at the Cumberland County Courthouse in Carlisle, PA were reviewed for the name Kerry R. Saintz, with the results as indicated below for the period January 1, 1990 to November 26, 2001: INDEX SEARCHED RESULTS Secured Transactions (UCC's) Criminal Convictions Civil Suits Judgments Federal Tax Liens State Tax Liens Tax Assessment Office Property Ownership Mortgages Divorce Proceedings See Attached No Record No Record No Record No Record No Record See Attached See Attached See Attached No Record Also on Wednesday November 28, 2001, the indices at the York County Courthouse in York, PA were reviewed for the above- referenced name with the results as indicated below for the period January 1, 1990 to November 9, 2001: INDEX SEARCHED RESULTS Secured Transactions (UCC's) Criminal Convictions Civil Suits Judgments Federal Tax Liens State Tax Liens Tax Assessment Office Property Ownership Mortgages Divorce Proceedings See Attached No Record See Attached No Record No Record No Record No Record No Record No Record See Attached !'~iijWL)It!'L, f"-""1" - ~I ": "r j.', . ",r. '-~~"r ~ ~ tt'~ ~~, ~ '"~_. ~.-- ~-~~.,~ 0 ,-""" "I Mr. Gerard C. Kramer, Esq. December 6, 2001 Page 3 On Monday November 26, 2001, the indices at the United States District Court for the Middle District of Pennsylvania were reviewed for the name Kerry R. Saintz with the results as follows: INDEX SEARCHED RESULTS Bankruptcy Petitions Cj,.vil Actions Criminal Actions No Record No Record No Record On Tuesday November 27, 2001, INA conducted a search of motor vehicle ownership in Pennsylvania for Kerry R. Saintz d/b/a Saint z Plumbing & Electric. The result of this search is seven (7) vehicles that are currently registered to Kerry R. Saintz. Of these vehicles, only one is encumbered by a lien held by New Cumberland FCU, and all are registered to Kerry R. Saintz indi vidually or Saintz Plumbing and Electric. Copies of the related abstract motor vehicle ownership reports are attached herewith to this report for your information and review. On Monday November 26, 2001, INA conducted a financing statement search at the Commonwealth of Pennsylvania, Corporation Bureau, in Harrisburg, PA. The result of this search, as of November 7, 2001, is one (1) financing statement that is currently in effect. You will note that this is the same financing statement that is on file at the Cumberland County Prothonotary's office as noted above. The information contained in this report and the. attached documents is self-explanatory; however, if you have any questions, or if additional investigation is required, please call me. Thank you for using INA to help fulfill your information and investigative requirements. Very truly yours, Information Network Associates, Inc. By ~~~ Daniel . Ryan, CPA, CFA DPR:wl Attachments ;"'- ~>~,-,~' , ''''-c, ' , ,-,"1 I. - ,~ - ,~ ;~ PARTIES DEBTOR name (Last name first if Individual) and mailing address: SAINTZ, KERRY R. 203, 205 ANO 207 MULBERRY ORIVE MECHANICSBURG, PA 17055 DEBTOR name (last name first illndivldUal)and rnalllngaddress: DEBTOR name (last name firsllllndlvidual) and mailing address: 1b SECURED PA~TY(les) name(s) (last name first If Individual) and address for security Interest informallon: PNC BANK, NATIONAL ASSOCIATION 4242 CARLISLE PIKE CAMP Hill, PA 17001-8874 2 ASSIGNEE(S) OF SECURED PARTY name(s) (last name first if individual) and address for sec:urity Interest information: 2a SPECIAL Types OF PARTIES (Check If appliCable): O The terms -Debtor- and .Secured Party- mean-Lessee- and ~essor", resp~ctively. \ o o The terms -Debtor" and -Secured Party- mean .Conslgnee- and -Cool;lgnor-, respectivelY. Debtor is a TransmltlingUtlllty SECURED PARTY SIGNATURE(S) THIS STATEMENT IS FILED WITH ONL YTHE SECURED PARTY'S SIGNATURE tl>perfect a security Interest In collateral (check applicable box(es))-- a.o b.O ACaUIRED AFTER A CHANGE OF NAME, IDENTITY OR CORPORATE STRUCTURE of the Debtor. as to which the flllng has lapsed. c. already subject to a security Interest In ANOTHER COUNTY In Pennsylvania o o d. already SUbject toa security interest In ANOTHER JURISDICTlON-- o o "0 cJ'L/ 1, Jr. 0 STANDARD FORM - FORM UCC-1 (7-89) &. Approved by the Secretary 01 the Commonwealth of Pennsylvania '~.~,~7'1_Hrr " -"7- when the COLLATERAL WAS MOVED to thlscounty. wt,en the DEBTOR'S RESIDENCE OR PLACE OF BUSINESS WA.S MOVED to this county, wt,en the COLLATERAL WAS MOVE D to Pennsylvania. wt,en the DEBTOR'S RESIDENCE OR PLACE OF BUSINESS W A.S MOVE D to Pennsylvania. which Is PROCEEDS of the collateral described In block 9, In which a security Interest was prevIously perfected (also describe proceeds In block 9, If purchased wilh cash proceeds and not adequalelY described on the origInal ffnanclng statement). SECURED PARTY SIGNATURE(S): (required only If box(es) Is checked above): <, I' FINANCING STATEMENT UNIFORM COMMERCIAL CODE FORM UCC-1 FILING NO. (stamped by filing officer): DATE, TIME, FILING OFFICE (stamped by filing off-lcer) ./"Lt.. 9 6, 1/.5" f LA c.-C- T~ 1a .n ""/' <"7\ 0.0 0 -1f11, .. 5 ". j V C" co -n 5 This FINANCING STATEMENT Is presented for flllng pursuant to the-Y[l~~r.m corrifi\erclal ~de, and Is to be flied wIth the (check applicable box): rA r; >:., --i:\ -_~ .:--" ~...-.' 1 D secretary of the CommonWealth. ~~~:, ~_. ~ .,-~ j~? ,.- .,;C) [!J Prothonotary of Cumberland county :~..... :~~: : : .+ \ o real estate Records of ~~1Y. ~D -:~f~ 6 NUMBER OF ADDITIONAL SHEETS (If any): OPTIONAL SPECIAL IDENTIFICATION (Max. to characters): COLLATERAL "--I ~. .::;) .- ';:. ~J 7 -. , 3 Identify collateral by Item and/or type: 1tr All Inventory, Chattel Paper, Accounts, Equipment and General Intangibles; together with the lollowing specifically described property; Instrumenls and Documents; whether any 01 the loregoing is owned now or acquired later; all accessions, additions, replacements, and substitutions relating to any 01 the loregoing; all records 01 any kind relating to any 01 the foregoing; all proceeds relating to any of the foregoing (including insurance, general inlangibles aryd J2!~ accounls proceedst. klot;'A:t~(I q-,( Otto' (J:i(rj '-'> Co/\:'~~i.') W."ilt 1-k_/~,"'4- 6vrtJ\;~:J" .,,rOt.'H~ (M,.-,il'l #l! pt.,.t.~ ~'w~ qs .;,..~. ;j,Os, "",<I JO, 1'1.../6"',) lh~! [!] (check only If desIred) Products of the collateral are alsocovered.M\ c/.c1/)ft-f~, fA. 9 IDENTIFY RELATED REAL ESTATE, if applicable. The collateral Is, or Includes (check appropriate box(es))-- a. D CROPS growing or to be grown on -- b. D goods which are to become FIXTURE on-- c. D MINERALS or fhe/lke (Including 011 and gas)as extracted on~- d. 0 ACCOUNTSRESUL TING FROM THE SALE OF MINERALS or the like (including oll'and gas) at the wellhead or mlnehead on-- the following real estate: STREET ADDRESS: DESCRIBE AT: Book lor of (check one) D Deeds D Morlgages,atPage(s)_. County. Uniform Parcel Identifier D Describe on Additional Sheet NAME OF RECORD OWNER (requIred only If no Debtor has an Interest of record~ ,. DEBTOR SIGNATURE(S) ......,.- ~ 'KE;,~a ~ . 1b 11 RETURN RECEIPT TO: 4 PNC BANK, NATIONAL ASSOCIATION 630 DRESHER ROAD, SUITE 200 HORSHAM, PA 19044 " ,fr.;. ;- fa......-{ -r.l, e '7'i?1--l FILING OFFICE ORIGINAL / NOTE - This page will not be relurned by Ihe Department of Slate. ---- .n'.f~ z 0 H '" E-< Ul H '" '" '" H ;;: '" Ul '" ~ '" U '" '- E-< '" Ul " Ul Z '" '" '" SO " E-< >< '" '" 0 Ul '" " SO H H '" '" '" >< t5 " '" SO H Ul E-< '" '" '" > >< '" '" H H H is '" '" H '" D S; '" '" I'< :>: " '" 0 I'< <>: " '" ~ oo D '" '" rl 0 0 :>: N M rl N Ul N '" '" 0 0 '" rl 0 '" 0 00 '" H C- H '" rl \0 D N 00 " I'< '" '" Z '" <>: '" '" H D '" I u <>: '" Ul Ul Ul H '" :i! '" '" '" ~ D '" '" I'< '" '" Z >< Ul Z ~ '" '" H .. SO '" '" '" '" :>: '" rl H 0 0 Z OJ OJ oo H ;;: >< ;;: >< H '" c- D ~ '" '" '" '" '" '" '" '" OJ OJ OJ OJ D '" '" '" '" Ul " " " " I'< I'< I'< E-< Z Z Z Z H H H H <>: <>: <>: <>: Ul Ul Ul Ul " '" " OJ " OJ " OJ ,.. Z ;;: :l ;;: Z E-< ~ ~ E-< " :<i " Z H I'< I'< I'< H I'< D '" Ul '" Ul '" Ul '" Ul 0 OJ OJ OJ '" U !i] " '" <>: '" <>: '" <>: '" S '" :>: '" :>: '" D D D U U U U 0 '" rl "' 00 Z '" c- '" c- oo 0 rl 0 H , , , , OJ "' '" c- OO U '" '" rl oo ~ N "' ~ "' 0 0 N 0 , , , , rl oo '" '" N N N 0 , , , , N '" N 0 rl rl ~ ~ \~~'f~~ >'1'. -","-,,"-. 'i'~-" " -I- r I ~ ~ ~, ~," 8"11". -. " Focetwin Screen Print for public, from "CAM~Login" 1l/28/01)'f:02:58 PM {" 1 "~' CUMBERLAND COUNTY ASSESSMENT OFFICE DISTRICT: 12 - LEMDYNE TOWNSHIP SO: CONTROL # 12000420 9 PARCEL: 12-21-0265-286. SPEC ID: LOT: Tback: Short Name LAST NAME FIRST NAME C/O NAME ADDRESs1 ADDRESs2 POST OFFICE STATE & ZIP SAINTZ, KERRY R SAINTZ KERRY R 731 HARRISBURG PIKE DILLSBURG PA 17019 I PROPERTY TYPE: RA SALES DEED BK/PG.....00116-00766 DATE OF SALE...12/23/1994 SELLING PRICE: 65000 103 307 .08 J CURRENT VALUES Assessed Fair I FMV - 146150 L - C&G- B- approved? -> - T- Market 13610 132540 146150 Situs: 114 THIRD prop Oeser; p. : LAND USE TYPE: NEIGHBORHOOD: DEEDED ACRES: STREET Screen 1 Number -switch Down Arrow -Next Enter Selection> screens, X -Exit, J -Jump Mode, Entry, Up Arrow -Previous Entry, Record: F -Forms, I ? -screens, 30168 -Image B -Browse ';1"", -~~' .~,,' .,~,." ._=."_"",~,. ~o'''~-''',' _ < c ~ -'~I -.",- ~. / ,..,....j ~ 7'3"7; -~~,i,5tf/ ., T<\><. \iu-.u..j. / ? - ;;J. J - 0," (p ,,- -;/~G, This Indenture, Made the ) .-, December 21st day of in tbe year of one thousand nine hundred and ninety f9Jlr(1994). -!j Between GEORGE A. ZEIDERS, by his Power of Attorney Mary N. Zeiders and MARY N. ZEIDERS, husband q.nd wife ,i (hereinafter ealled the Grantors). of the one part, and KERRY R. SAINTZ, a married man (llcreiallfter called the Grantee), of the other part, Witnesseth That the said Grantors for and in consideration of the sum of Sixty Five Thousand and 00/100 Dollars {$65,OOO.OO} lawful money of the United States of America, uOJo them well and truly paid by the said Grantee, at or before the sealing and delivery hereof. the receipt whereof is hereby acknowledged, granted, bargained and sold, released and confirmed, and by these presents do grant, bargain and sell, release and confirm unto the said Grantee, as sole owne(. his heirs and assigns, ALL 1'HOSE CERTAIN TRACTS of land t wi tb the erected, situate, lying and being in the Borough Cumberland and Commonwealth of Pennsylvania, limited and described as follows, to wit: improvements thereon of Lemoyne, county of more fully bounded, .~. TRACT NO.1: BEGINNING at a point on the easterly side of Third Street, said point being referenced 61 feet southwardly from Bosler Avenue; THENCE North 50 degrees 00 minutes East, a distance of 40 feet to a point; ~HENCE South 40 degrees 00 minutes East, a distance of 83 feet to a point on the Northern line of Apple Alley; THENCE along same, south 50 degrees 00 minutes West, a distance of 40 feet to a point on the easterly side of Third Street; thence along same, North 40 degrees 00 minutes WeSt, a distance of 83 feet to a point, the Place of BEGINNING. BEING known and numbered as 114-116 Third Street, Lemoyne, PA TRA~ NO.2: BEGtHNING at a point on the northern line of Apple Alley, said point being referenced eastwardly a distance of 40 feet from Third Street; THENCE North 40 degrees 00 minutes West, a distance of 21 feet to a, point; THBNCE North 50 degrees 00 minutes East, a distance of 2 feet to a point; THENCE south 40 degrees 00 minutes East, a distance of 21 feet to a point on the northern line of ~pp1e Alley; THENCE along same, south ~OOK 116 rAG[ 766 J I"~ ......". ~:-:_}-" -" - ,. ~ ...~,,.,.- ',,-, ,,-W'~" - , ~-, ~- ~".r,;" ".. ~ '" , '-- \..- ",",<,?,;"".~- " . - 50 degrees 00 minutes westl a distanoe of 2 f~~,to a point, the plaoe of BEGINNING. . -.. BEING the same premises which George A. Zeiders and Mary N. Zeiders, his wife, by their deed dated June 17, 1977 and recorded in the Office of the Recorder of Deeds in and for cumberland County, Pennsylvania, in Book 27-G, page 935, granted and conveyed unto George A. Zeiders and Mary N. Zeiders, his wife. Tog e th e r with nil and singular the buildings improvements. ways, streets, alleys, driveways, passages, waters, water-courses, rights,liberties, privileges. hereditaments and appurtenances. whnlsoevcr unto the hereby granted premises belonging, Of in anywise nppertainillg, and the reversions and remainders, rents, issucs, and profits thereof; and all the estate, right, title, interest, properly, claim ami demand whatsoevcr of the said grantors, as well at law as in equity, of, ill and to lhe same. To have and to hold the so!d lot or piece of ground described hereditaments and premises hereby granted, or mentioned and intended so to be, with lbe appurtenances, unto the said Grantee, his heirs and assigns, to and for the only proper use and behoof of the said Grantee, his heirs and 3Ssigns, forever. And the said Grantors, their heirs, executors and administrators do CQvemmt, promise and agree, to lInd with the soid Grantee, his heirs and assigns, by these presents, that the said Grantors and their heirs, all and singular the hereditaments and premises hereby granted or mentioned and intended s.o to be, with appurlemmccs, unto lhe said Grantee, his heirs and assigns, against the said Grantors and their heirs, and against all and every person and persons whosever lawfully claiming or to claim the same or any part t11creof, by, from or under or any of them, shall tlnd will SPECIALLY WARRANT and forever DEFEND. In Witness Whereof, the parties of lhe first part their hand and seal. Dated the day and year first above written. hcrculllo set Sealed and Delivered IN THE I'RESENCE OF US: f~(LI {SEAL) of Attorney ~7 71, 80 ;j~{SEAL} MARY N. EIDERS Secretary 8ijij~ 116 P^tf. 767 " ," ':-'~~~~I -~ - ""~~:" -" .}i ~,,," 'f-;~ -. "''"tn-' ,. l' ~_ Commonwealth of Pennsylvania County of &v,.,tdu~~ ss: ./: ';/ ~ . On this, the 21st day of December, 1994, before me, a Notary Public for the Commonwealth of Pennsylvania, County of Cumberland, the undersigned Officer, personally appeared MARY N. ZEIDERS individually and as Power of Attorney for George A. Zeiders known to me (satisfactorily proven) to be the person whose name is subscribed to the within instrument, and acknowledged that she executed the same for the purposes therein contained. I hereunto set my hand and official seal. The address of the above.named Grantee is:/oo~-~~~ /... /7.J3'l ~ d/'.I1f~h7'- Notary Public << '" a: ~~. L1.'LI..I1- c;l.I.I% u.JC:=< _I... 0 .....JoO a: CI::; :r.~3 U11l:::u= UJ <:) W OUal ~w_ a:.... ~ <> ,- """"'S;;;--J ~tu.~'6~iC ~-_"".~j,:'il:. o "Upl1~'I~ ~j; C? or .-l .-l e:: a:: . , "f Pennsylvania } . 0, \i1 Cumberland 55 . .1 In the offIce lor the recording of Deot:> ';1\"; '''''1'' l'Uj for\humborl~~d CountVT:e~... . ~'l 'UQok -U1P- Vol. _ Page.ti(lf.LJ 1"'llJ:.l:l mv hand and I of office ~;",JlL:hJ. PA thi da M N I eOOK it6 rAGf 768 ~"~ ___"1-' Pl ~~~9 "Q.~.Q. :.-0-....- @~~:g .~.CO_l..... < ~ - " -- ~~@t1 gggg "'/li/il131<1 !.-;.!"",..'. roo !'::;!-i~'=> = Ri~;':-" t3~=i~ ~ <.<:o-t ~ ~ = -. "' (~. ""~ ,..... tH:,l~ N ggg~~ """""""~, 9~ ~ ;g fl 'i1 ~. ~ f2 ,. " ~ ,...eo. &~ !';1":g ""'-" li&::t . ~~ ~ ~8 :=2- . '. ., ~. .- ~ ~ o ':l ~ ~ ~ a: t; 1-1 ;:, ~g ~ '" "J .. # '^ ,",-. ~, . ..J .J' J' .~~.~ ~ . ,"""'- 1JjfT" ;~,f,"l;;'~,~,~ ~I . --,'-" Facetwin Screen print for public, from "CAMA-.Login" 11/28/01.:\2:02:40 PM t" . CUMBERLAND COUNTY ASSESSMENT OFFICE DISTRICT: 19 - MECHANICSBURG 4TH WRD SD: short Name LAST NAME FIRST NAME C/o NAME ADDRESS1 ADDRESS2 POST OFFICE STATE & ZIP SAINTZ, KERRY R SAINTZ KERRY R 731 HARRISBURG PIKE DILLS BURG PA 17109 Situs: 203 MULBERRY DRIVE prop Descrip.: LAND USE TYPE: NEIGHBORHOOD: DEEDED ACRES: 211 19 .61 CONTROL # 19000421 6 PARCEL: 19-23-0569-071 SPEC ID: 'LOT: L-0054 + Tback: I PROPERTY TYPE: CA SALES DEED BK/PG.....00191-00383 DATE OF SALE. ..12/21/1998 SELLING PRICE: 400000 J CURRENT VALUES Assessed Fair I FMV - 414720 L- C&G- B- approved? -> T - Market 132860 281860 414720 Screen 1 Number -Switch Down Arrow -Next Enter selection> Screens, X -Exit, J -Jump Mode, Entry, Up Arrow -previous Entry, Record: 41657 F -Forms, I -Image ? -screens, B -Browse 1-1 -~, '71 - ,,- " ,"" i.f -. ,,-' '. :~." ,) \...- LAWOFF'CE!> MARLIN R. MCCALEB ''--..-' :~~!~"",'" ,,"'.- '-/ ~ 10':>- '<. ",f.:: .ax Parcel No,: 19-23-0569-071 ..: ,.- ",':":YL:,~;D (:OUtl !'- i".'; , l ~'" ~~ '96 DEe 21 RPl 8 5Y THIS DEED, MADE .HE ;Ji'-' day of December in the year of our I..ord One Thousand Nine Hundred Ninety-Eight (1998). between .HOMAS C. WElZEL and CHERI L. WElZEL, his wife. of the Borough of Mechanicsbur9, Cumberiend County. Pennsylvania, parties of the first part, hereinafter called the Grantors, AND KERRY R. SAINTZ, single man. of Dillsburg, York County, Pennsylvania. party of the second part, hereinafter called the Grantee, WITNESSElH, that in consideration of Four Hundred Thousand and No/100 ($400,000.00) Dollars, in hand paid, the receipt whereof is hereby acknowledged. the said Grantors do hereby grant and convey to the said Grantee, his heirs and assigns, ALL THAT CERTAIN tract of land situate In the Borough of Mechanicsburg, Cumberland County, Pennsylvania, more particularly bounded and described as follows, to wit: BEGINNING at a point on the western side of Mulberry Road (T-586) at the dividing line between Lots Nos. 56 and 57 on the Plan of Lots hereinafter mentioned; thence along said dividing line between Lots Nos. 56 and 57, South 89 degrees 43 minutes West, a distance of one hundred twenty-six and eighty-nine one-hundredths (126,69) feet to a point on the dividing line between Lots Nos. 56 and 46 as shown on said Plan; thence along the line dividing Lots Nos, 56, 55 and 54 from Lots Nos 4B, 47. 46 and 49. North 01 degree 10 minutes West, a distance of two hundred ten (210) feet to a point at the dividing line between Lots Nos. 54 and 53; thence along the dividing line between Lots Nos. 54 and 53. North 89 degrees 43 minutes East a distance of one hundred twenty-six and sixty-two one-hundredths (126.62) feet to a point on the western side of Mulberry Road (T-566) first mentioned above; thence along said western side of Mulberry Road (T-586), South 01 degree 14 minutes East. a distance of two hundred ten (210)/eet to a point on the same at the dividing line between Lots Nos, 56 and 57. at the point and Place of BEGINNING, .uu~ 1St IACf 383 c,~'r-II_ ~ ., I"" , 'W~"'r- :~"""o~"",~.=:' f_'," __.'"__~__", LAW OFFICEs MARliN R. McCALEB .~ . ~ ~'I-- .:0\- f e. BEING Lois Nos. 54, 55 and 56 on the Plan of Lots entitled ';Section 1, Valley Streams Estales" as recorded in the Office of the Recorder of Deeds in and for Cumberiand County, Pennsyivania. in Plan Book 13, Page 8. BEING Ihe same premises which Edward L. Wertz. et ai.. by their deed daled May 6. 1988, and recorded in the Office of the Recorder of Deeds of, Cumberiand County, Pennsylvania, in Deed Book "I", Volume 33, Page 406. granted and conveyed unto Thomas C. Wetzel and Cheri L. Wetzel, his wife, the Grantors herein. AND" the said Grantors hereby covenant and agree that they will warrant specially the property hereby conveyed. IN WITNESS WHEREOF, said Grantors have hereunto sel their hands and seals the day and year first above written. Signed. Sealed and Delivered in the Presence of (SEAL) (;;.J){,)J !t.~ ~ht?~ Cheri L. W tzei (SEAL) I do hereby certify that the precise residence and complete post office address of the within named Grantee is: 731 Harrisburg Pike, Dillsburg. PA 17019 bOO~ 1S1 rlGE 384 1-' ~ ,- .~~ \~ -, /) ...:.--J j; 1;!['Wl_:~ ._ _ ,. - r. - . ;i~ I '--- COMMONWEALTH OF PENNSYLVANIA) ;/: t .', SS. COUNTY OF CUMBERLAND) On this, the .J8.uJ. day of December, 1998, before me, ~ Notary Public in and for said State and County, the undersigned officer, personally appeared THOMAS C. WETZEL and CHERI L. WETZEL, his wife. known to me (or satisfactorily proven) to be the persons whose names are subscribed to the within instrument, and acknowledged that they executed the same for the purposes therein contained. IN WITNESS WHEREOF, I hereunto set my hand and official seal. /)n"N~~~~'~{SEAL) Notarial Seal Je&OnF. emB",No\a~ My~~,~ur::~'1IB11.2002 '. StM~ of Pp.nnsylvania } Ce'lnty of Cumberland 86 ~" ?fQrdat! in the office for the recording of Deeds .~~ . in.\lnd for{('MFberlan~unty.12rv2: !I ,u.~eookLf.l_.Vol._Page&" 11'1 nc!>S tl\,! haoo ~saal of oft 0 (\(1 C<:dlsle, P . 's .....at.L-day 191.L i;.'!i'999~8R{ffli?-i~~F?I 1!' ~ ""'->P'" ,'<t r, l:"""~2~~l;l iT. ~~.Q.,p... Si! -J $;:1> '=' ~ ~. P. 1><1""''''',."",,,,'::!:::=; j I ~ ~ ~ ~C,!l("'1o:...,~e::t>ol=.l~:>c;I:e:: Po - @ 5Sa;;~~rii==c''''''''=l~ ~ ....4--~Ul:!i:;.'" gg; _ ~~ ., ~ ti '1'I~ ~G ~ ~!;: ~ @' ~oi!. = : ~;J ~ M c:t"i ",.-., ~ M'O ~. " ~ ~ Q ~, '0 =0 ;;; .~ ;;<t I.AWoFFICES 'l--t- fij - ~ 0 MARLIN A. McCALE:B ~~ aDUK 1.91 r~ 2~ rAGE, 385 1;; ~ :;; s ;:, l!l ~,*' ill 0" . ., ~. .... -.... "l. C;l1-)..p.f'.... ~ ~~~.. NI"'~ 0 "'-..- ~8gU.-.-:=888 .- ~ ~ co '* ~~ gd$ ~~ g ~d:'J g id~ ~ ~ co :<; \ \. . '~.~, -, . < - " -<-- -, ... ,",,1""1 ". ~'i0:"","' "-. ~ -~"=". . Facetwin Screen Print for public, from "CAMA-Login" 11/28/0~A,2:02:24 PM , '. , CUMBERLAND COUNTY ASSESSMENT OFFICE CONTROL # 42005459 DISTRICT: 42 - UPPER ALLEN TOWNSHIP SO: 6 PARCEL: 42-28-2417-165. SPEC ID: 'LOT: II-0008 Tback: short Name SAINTZ, KERRY R I I PROPERTY TYPE: I LAST NAME SAINTZ : L1 FIRST NAME KERRY R C/O NAME SALES ADDRESSl 731 HARRISBURG PIKE OEED BK/PG.....00216-00261 AOORESS2 DATE OF SALE...02/16/2000 POST OFFICE DILLSBURG SELLING PRICE: 66000 STATE & ZIP PA 17019 situs: SOUTHVIEW DRIVE J CURRENT VALUES l prop Descrip.: MEADOWVIEW ESTATES Assessed Fai r Market LAND USE TYPE: 100 I FMV - 65000 L - 65000 NEIGHBORHOOD: 466 c&G - B - 0 DEEDED ACRES: .51 approved? -> - T - 65000 Screen 1 Enter Selection> Record: 89545 Number -Switch screens, x -Exit, J -Jump Mode, F -Forms, I -Image Down Arrow -Next EntrYJ up Arrow -previous Entry, ? -screens, B -Browse / 'i'rwm"'~"'~'T' ~ , ~~,' ""'1-" -,.1 . -~ ..~ '" , ... . \'--.- "-," 'ii:~yn ,ttl:~ -'J"~ ,~"'o. ~, .C' ., :/" .l1f'ac e..- ,/ \ Tax Parcel No. 42-28~2417-165 THIS DEED, MADE mE tO~ day of ~6t,,(~ thousand (2000) --. ~ I I the year two in BETWEEN CINDY L.. ARNOLD and MARK A. KNAUB, partnership, both of Mechanicsburg, county, Pennsylvania, <::> <::> ...., ~ '" Grantors~ a general Cumberland and KERRY R. SAINTZ, single person, of oillsburg, pennsylvania, ..... GranteEt::l en <::> WlINESSETH, that in consideration of Sixty-six ThousanCi and NO/loa Dollars ($66,000.00), in hand paid, the receipt w~ereof is hereby acknowledged, the said Grantors do hereby grant and convey to the said Grantee, his heirs and assigns: 1 ALL THAT CERTAIN piece or parcel of land situate in Upper Allen Township, Cumberland County, Pennsylvania, bounded and described as follows, to wit: BEGINNING at a point on the southern dedicated right-of-way line of south view Drive, said point being on the dividing line between Lots Nos. Band 9 on the hereinafter mentioned Plan of Lots; thence continuing along said dividing line South 47 degrees 27 minutes 21 seconds East, one hundred thirty-five and zero ooe- hundred~hs (135.00) feet to a point; thence South 42 degrees 32 minutes 39 seconds West, one hundred sixty-five and zero one- hundredths (165.00) feet to a point on the eastern dedicated right~of-way line of Kendall Drive; thence along same North 47 degrees 27 minutes 21 seconds west, one hundred twenty-seven and nine one-hundredths (127.09) feet to a point; thence continuing along same on a curve to the right, having a radius of twelve and zero one-hunpredths (12.00) feet, an arc length of twenty and seventy-one one-hundredths (20.71) feet to a point on the southern dedicated right-of-way line of South View Drive; thence BOOI. 216 1',ILi :;;61 '1 ,~ I .lIlIt~1 '" ~ n c: ",,,, tom::::! ",oQ ::0 g ~~ \: 0 ". ~ fJ:-; .....,0;"1 0.'1- s~;::: :'j IT! r~ -<0'" 'en'" "0 ,. /' ?:'".,~ .. . . ;"' '^.-"" ~, .,- "'.' .!;?, < .~ 't r ~" -, continuing along same on a curve to the left, having a radius of three hundred thirty-two and fourteen one-hundredths (332.14) feet, an arc length of fifty-one and twenty-seven on~-hundredths (51.27) feet to a point; thence continuing along same North 42 degrees 32 minutes 39 seconds East, one hundred and zero one- hundredths (100.00) feet to a point on the dividing line between Lots Nos. 8 and 9 on the hereinafter mentioned Plan of Lots, the place of BEGINNING. BEING Lot No.8, in section II - Phase IV, Final Subdivision Plan of Meadowview Estates, said Plan being recorded in the Cumberland county Recorder of Deeds Office in Plan Book 78, Page 147. BEING part of the same premises which John M. Knaub by deed dated June 24, 1996 and recorded June 26, 1996 in the Cumberland county Recorder of Deeds Office in Deed Book 141, Page 644, granted and conveyed unto Cindy L. Arnold and Mark A. Knaub, a general partnership, the Grantors herein. UNDER AND SUBJECT, NEVERTHELESS, to the Declaration of Restrictive Covenants dated May 25, 1999 and recorded on May 28, 1999 in the Cumberland County Recorder of Deeds office in Miscellaneous Book 614, Page 314. ALSO, UNDER AND SUBJECT, NEVERTHELESS, to a fifteen (15) fdot utility easement and other restrictions, set-backs and all notes appearing in Section II - Phase IV, Final Subdivision plan of Meadowview Estates, said Plan being recorded in the Cumberland county Recorder of Deeds Office in Plan Book 78, Page 147. --./. f ;;;'" ~.,,,;k g H.. iIi l>l", Ii1 ,-t-~'l> ~"., E;!--o:on:;;;Jrrl:;;;J ~*g.;J." r;: ~$' ... aou....;,u......"" ;:z;, I r.;.....<..'I<..'I~e::.>~F:l__ @.g~g~~;:C~~=lS iR :::~ a:!E=;;;i : ~;! -.:r iT; : => '" H ,-, = ~ "' i-i or ~ ~ ~ .. " ~ ::;. f!: it S ~ ~~ '" ':.l .. g ~= = ~~ H ~ :i !;; - :;~ 9 ~ iil "' !;5 :=;li- ~ l'3 ".~ :i1 = ~ .0 oj 8 ~ if ii BU6i 216 r.lI: 262 d ' .....~ u, ,., H "~ ~ ~~_3i__=~~~ = ~g~g88ggggg:g /'" . - -^~ Y'I '.T r . . \ '~-' ,'I", ANDtne said Grantors hereby covenant and agree that they will warrant specially the property hereby conveyed. IN WITNESS WHEREOF, said Grantors have hereunto set their hands and seals the day and year first above written. ~ ;Mt~l Signed, SoIl.led.nd Delivered In lhe freaence of I j r..nri;'j ~ () A " ."e,./ CINDY L. ARNOLD ~ ?J["j c. X MARK A. KNAUB '\ (SEAL) ~~~ (SEAL) COMMONWEALTH OF PENNSYLVANIA COUNTy OF CUMBERLAND 55. On this, the iOo.. day of !Zb/f.,{tl!2;/- ,.;;(){)(), befdre me, the undersigned officer, personally apVeared CINDY L. ARNOLD, known to me (or satisfactorily prQven) to be the person whose name is subscribed to the within instrument, and acknowledged that she executed the same for the purposes therein contaiQed. IN WITNESS WHEREOF, I hereunto set my hand and seal. Notarial Seal LIsa A. Killhbauglt, Nota:r. PublIc Shlremanltown Bom. CulJ"be end County My CommIssIon ExpIres Apr. 6', 2003 BOOX 216 "ALi 263 '- . >~~'IlI "..c,," ",_."1,."',' , ( "~'. COMMONWEALTH OF PENNSYLVANIA SS. COUNTY OF CUMBERLAND On this, the /rjI-,. day of rePuQ/l-,;. , 2000, before. the undersigned officer, personally a~peared MARK A. KNAUB, to me (or satisfactorily proven) to be the person whose n. subscribed to the within instrument, and acknowledged th~ executed the same for the purposes therein contained. ~ IN WITNESS WHEREOF, I seal. NolarJalSeal Lisa A. Kishbaugh, Notary Public Stllremanslown Boro. Cumberland COunty My CommissIon Expires Apr. 6, 2003 I do hereby certify that the precise residence and complete post office address of the within named grantee is 7,J1 Hf.,M'SO'V~G" /J*.r c)/<<JO" ':;,.P--r /?/~'1 rq:J. /..r- , 2000 At~ (;;/(A,v7FC COMMONWEALTH OF,PENNSYLVANIA SS. day Of~/?:J said County, in Deed Book COUNTY OF CUMBE~LAND RECORDED oh this in t~ Recorder's 0 fice sil.f C' ' Page G~ven under In date above written. I&, of the , 2000, and and the seal of the said office, the .,;t, -,.- rr"" J0.L- - , Recorder. BOU!. 216 I'M" 264. .." ""C "rl- - ~"^ ~r, ~! ~ -' "'" FacetWin Screen print for public, from "CAM~Login" 11/28/01 12:01:54 PM , CUMBERLAND COUNTY ASSESSMENT OFFICE CONTROL # 40000599 DISTRICT: 40 - SOUTH MIDDLETON TWP SD: 8 PARCEL: 40-09-0533-072. SPEC ID: LOT: L-0029 Short Name SAINTZ, KERRY R ' Tback: 40-09-0533-008. : II I LAST NAME : SAINTZ : PROPERTY TYPE: R FIRST NAME : KERRY R C/O NAME : SALES ADDRESs1 : 22 DERBYSHIRE DRIVE DEED BK/PG.....00248-03855 ADDRESs2 : DATE OF SALE...10/15/2001 POST OFFICE: CARLISLE SELLING PRICE: 270000 STATE & ZIP: PA 17013 Situs: 22 DERBYSHIRE DRIVE J CURRENT VALUES Market L Prop Descrip.: MAYAPPLE VILLAGE Assessed Fai r LAND USE TYPE: 101 I FMV - 264980 L - 44710 NEIGHBORHOOD: 844 C&G - B - 220270 DEEDED ..ACRES: .31 approved? -> T - 264980 screen 1 Enter selection> Record: 6'9185 Number -Switch Screens, x -Exit, J -Jump Mode, F -Forms, I -Image ~ Down Arrow -Next Entry, Up Arrow -previous Entry, ? -screens, B -Browse i--~_-__,,,,,__, ',""'~" ;~ - ~ ".' " 1-. :1i\w . .. ,1 ~u,~ ~l ~)")... Parcel No. 40-09-0533-072 SPECIAL WARRANTY DEED T.ItIS DEED, rrade the 12th day of October, 2001, BIrn4ImN Jerzy W. I<:w:ha=zyk and Aleksar.1d1:a B. I<:w:ha=zyk, husband and wife, of South Middleton Township, Cumberland County, Pennsylvania, Grantors, AND Keny R. Saintz, single person, of Dillsblrrg, York Count>:, ~ Pennsylvania, Grantee. Wl'DIESSETH, 'I11at in consideration of ThD HUndred. Seventy Thousand ($270,000.00) Dollars, in hand paid, the receipt whereof is hereby acknCMledged, the said grantors do hereby grant and =ey unto the said grantee, his heirs and assigns, 1\LL 'l'BM' CELmIpllot or parcel of land, together with the inproverrr:nts thereon erected, situate in South Middleton Township, Cumberland County, Pennsylvania, rrore particularly bounded and described as follows: BmINIiI1:NJ at an iron pin on the Westerly right-of-way line of Del:byshire Drive, a 50 foot wide right-of-way, which said point is !!Pre particularly located at the intersection of the Westerly right-of-way line of DeJ:byshire Drive and the dividing line between lDts Nos. 28 and 29 on the Plan of lots known as "Final Plan for Mayapple Village, Derbyshire lots 1-39", thence fran said iron pin North 72 degrees 30 minutes 19 seconds West, a distance of 158.40 feet to an iron pin on the property line of other lands n= or fonnerlyof Mayapple Village as shown on the aforesaid Plan of lots; thence fran said iron pin along the property line of other lands DCM or fonrerlyof Mayapple Village North 33 degrees 57 minutes 06 seconds East, a distance of 70.50 feet to an iron pin on the property line of other lands DCMor fonnerly of Mayapple Village and the dividing line between lots Nos. 29 and 30; thence fran said iron pin North 81 degrees 06 minutes 31 seconds East, a distance of 125.00 feet to an iron pin on the Westerly right-of-way line of Derl:Jyshire Drive and the dividing line between lots Nos. 29 and 30; thence frc:m said iron pin along a curve to the right having a radius of 300.00 feet, an arc distance of 126.91 feet along a chord bearing of South 05 degrees 22 minutes 31 seconds West, a chord length of 125.97 feet to the point and place of BEGINNIN3. BEING lot No. 29 containing 0.3110 acres on the Plan of lots known as "Final Plan for Mayapple Village, DeJ:bysh:i.re lots 1-39", prepared by Statler-Brehm, Engineering and Planning Cbnsultants dated Janua:ty 26, 1989, and recorded in the Office of the Recorder of Deeds of CunU:Jerland County, Pennsylvania in Plan Book 58, Page 68-A. o ,., 2'A8 c::~o55 ~.J'". ~ ..~~ h". - ,,,.. -'"'I-' I. <.^ ~ - ~~ I: I BEIN3 the same premises which George H. Hall, Jr. and Kimberly L. Hall, husband and wife, by their deed dated February 27, 199B and recorded on August 14, 1996 in CL1llU:Jerland Cbunty Deed Book 163, Page 554, granted and conveyed unto JerzyW. Kucharczyk andAIeksandra B. Kilcharczyk, the grantors herein . AND the said grantors will SPECIALLY WARR.!IN1' AND FOREVER. DEFiNO the p:rc:perty hereby conveyed. m WI'1'NESS WIlEREDF, said grantors have hereunto set their hands and seals, the day and year first above-written. Sealed and del'vered in the - of: ~oU( w. ~+. ~uf ~uut '/uduu . AI B. kui:lharo . Certificate of ResiQ~"e I hereby certify, that the precise residence of the grantee herein is as follows: 22 Derbyshire Drive Carlisle, PA 17013 DOOk 248 ",\, .3d56 :'\'!Cc '., -"~"--'- ,-_..,. -',1-' >" (,;~ CXI>HlNWEAIIIH OF PEalSYLV1\NIA CClIlNlY OF D~~ ~,J On this, the Jq.~daYOf October, 2001, before Ire, a notal:ypublic, the : ss. : undersigned officer, personally appeared Jerzy W. Kucharczyk and Aleksandra B. Kucharczyk, husband and wife, known to Ire (or satisfact=ily proven) to be the persons whose names are subs=ibed to the within instrument, and acknowledged that they executed the sarre f= the ptll1;XJSE! therein contained. IN Wl'lNESS WHERIlX>F, I have hereunto set my hand ~ seal. NOTNW. 8EAI, CtWlI..E8I. HNlOH. NaIety PIlbllc ~ PA. Olql/Ih Col.r1ty 00n~1"", . Feb. 26. 2005 Public ~.. ...~;~.,'" ~. "':$' .,.;;.rt;\:;~" 0.. ;JJ- ,.u':3.~~'.)~ V/~ ',~.~-". -:..,...-;:..t~~':"~'~ :VA~~ ;.21 ~.... .....;;...(~.,. ~\:_ '. :"3.~-~ ,..... ~ . '"'-'11" ].~ll. ' .~. .~- ,,-.. ,. :J~."!i ".0,7.~ -... ~,,:,~#~ ",,-.,~,.. '''''Cofi!' ,. . . ./*t/(J.' .~;,,:~;..~ ~.('!~ " -IL ,,;p,,~)I-.."~- . ~ "l~i ;:i --I ~'f ,..... ""'. ...... r- . : ,I (J"I ~ :."i ~'.! My Catmissian Ellpires: ~ 411 CJ' . C"-4' ::: ~.l g l;'; ~':~ :z: r.l r~~ -I r:1 (Tj -( 0 -..; 1 UJ. -0 >- I Certify this to b ICe recorded n umberland C ounty P A ~~r' ~ ~ -0 ::3 ...... N> Recorder of Deeds ~~99~gl<l~~Ff!~~ iii' l-I .. il ..."a.a.. _a... '=' i :? -1:ii....._! I ::c::>: I I .... ;;b cr ><' .. ..........~ 2525-= 1!1. ... ~~~*~ ~~;s~ ..... - :5 ... .... .. - .,. i "'g ~ ~ ~ a :;;<Q ...... !l!!"'" ~ : ~...... nl '" :f:: on 0= . "" .... .. .... ~ .. .. .... ; '=' i _. li'< . S; ,..., "'if. - .... , ,.:> ......'" " fj 248 PA~t;:'cl57 - :::;~ L" BOO~ '. liS _..... N l;l", 00 Ul C> .... - ...... ... !r ...... N tl~_5l__:::~~~ ::: - fir ';:1 ..... c.."oc...,OQOu.ooo.~C"" ~ OQOO<:;Oooooo 0- ~ ,~~"~~'" - '.' Jr,"~'!-.'- ',,__~,F~, , ,~ ~- ri~ 1 - ~ - ',"1 ~ '" '" N ro e- e- N 0 0 I I I "' 0-, "' '" '" "' H N "' "' ~ 0 0 0 I I , '" '" "' 0-, ;;: N N 0 I I I H N ~ 0 H '" '" " 0 ... ... ... U H H H '" '" '" U U U ~ '" '" .0: .0: '" '" '" 0 0 0 0 0 0 0 0 ~ "' 0 0 "' E-< '" 0 0 '" Z '" N 0 ro H "' <n- "' N "' t!J 0 <n- H ~ '" 0 "' 0 "' Ul '" e- " "' '" t!J "' N e- t!J .0: "' tl '" E-< '" 0 Z '" '" e- "' t!J 0 " 0 "' 0 N "' e- Z "' '" '" '" H " ~ E-< '" Ul :iJ [:: 0 t!J '" E-< " ro '" "' 0-, 0 "' '" 0-, 0-, 0 0 '" '" 0 0 0 "- "- "- Z '" '" N '" 0 N '" N N '" '" H e- ~ H "- "- "- H '" '" .0: N N N '" " '" " E-< t!J N H .-< '" '" '" Z '" .0: E-< H '" H '" '" '" Z u .0: "' '" H Ul Ul Ul ~ H t!J H '" '" ~ .0: '" '" '" E-< ~ "' Z >< Ul '" '" H '" '" '" Z '" '" H .. '" "' "' "' H 0 0 >< >< >< H '" e- " '" '" '" '" H '" Ul .0: '" '" '" .0: '" .0: t!J '" '" '" E-< '" E-< '" '" '" 0 Ul '" E-< 0 Z " " N E-< E-< E-< Z Z Z H H H .0: .0: .0: Ul Ul Ul Z >< '" ~ '" 0 U '" " E-< '" H :iJ " .0: "' '" '" E-< "' U '" t!J 0 '" '" >: 0 .0: u "' z ~ t!J H '" Ul ::l H '" H "' "' H " '" H U '" "' Z ~ " '" " " " Z "' ~ "' ~ "' >< .0: ;;: E-< E-< E-< H .0: .0: z '" E-< '" E-< '" E-< '" "' Ul '" Ul '" Ul 0 "' "' "' u >: .0: >: .0: >: .0: '" '" '" '" '" '" U U U "~1"7 "'I " . ~.~. "'-" .. ,,-' ., \..- ",,,.:,,,, 0',1, .J1di. ""1 .f-v 11""'1 n. ~-1-t ~ - J;u... ~ /3/($013 '"'' ' . (6~).~-9Jj .-:;'1 "-:;'ch,- ~"'..<{,-~ RaDEriT P. ZIEGlEH RECORDEf\ OF DEEDS CU/.lOERLldlD COUtlTY ~ PA " -, '9'1 DEe 23 A~ 1l.Y3 _~^bo'oeThl.Uoel'wllllolllil"lI)"... 1'l,.n"SA'HT1. . MORTGAGE THIS MORTGAGE rSecurity Instrwnenn is givcn 011 December 11, 1994, The mortgagor Is KERRY It. SA1NTZ ("Borrowez"). This Security Instrument is given to GEORGE A. ZEJl)ERS llnd MARY N. ZEIDERS. whose address is 698 QUl.lker Road, r..ewlsberry, Falrvlew TownshIp, York County, Pennsylvnnfa, ("Lender"). Borrower owes Lcnder the prlnclllal sum of SIXTY ONE THOUSAND FIVE HUNDRED DOLLARS ond 001100 (U.s. $61,500.(0). TIlls debt Is evidenced by Borrower's notc d.'Itoo the s.1mc d.,te as this Security Instrument ("Notc"', which provides for monthly payments, with the full 'debt, if not p<,id earlier, due and payable on January 01,1005. This Securily instnnnent l;C<:urcs to Lender: (a) thc repllymcnt of the debt cvidelleed by the NOle, with iilteresl. and all renewals, CJ!.lcnslons: and modiGeallons: of the Note; (b) the p<'ymcnt of all other sums. with Inlerest, advnnced under, paragraph 7 to protect tile sc<:urity of this Security lnsttwnent; and (c) tIle pcrronnauee of Borrower's covenants and agreements under this Security Instrwnenl and tile NDle. Por this purpose. Borrower docs hereby mortgagc, grallt and collvey to Lender the following described property located In CUMBERLAND County, Pennsylvania: See Exhibit "A" LF.GAL DESCRIPfION Altaclled hereto and made n part hcrl!Of which has the address or 112,114,116 TUIRD STREET, LEMOYNE, PENNSYLVANIA ("I'ropertyAddrcss"); TOGETHBR WITH alllhe improvcrnenls now or hcreafier ert(;loo Olllhe property, and al1 e3scmenls. appurtenances, and fixtures now Of hereafter 11 part of the property. All replacemcnts and lIddillons shall also be covered by this Security Instrument. All of the foregoing isrcferred to in Ihis Security Instrument nsthc nPropctly," BORROWER COVENANTS tfmt Borrower Is lawfully seised of tile eslate hereby conveyed and has the righlto mortgage, grant and convey we Propr;:rty and tI"'It the Property is uncnclUubered. cxcept for encumbrances of record. Borrower warrants and will defend scnetnlly tile title to the Property against all claims and demands, subject to any cnel1lllbranees of record. PENNSYLVANIA.Single Family-Fannie MaC/Freddie Mac UNifORM INSTRUMENT f>Jtgc J of6 'bllOK :U2A.t; PAct '575 f"(ll"m 3039 9190 Amendodv'~1 1nJllals:~~.. > --~ 'I - , -'. t9,~ ... 'i~_~f~~_ ._" ., '!1"-~_) ~',o, <~ ). _?-' I ASSIGNMENT OF NOTE AND MORTGAGE f C)ID-> I Q.... ...1 KNOW ALL MEN BY THESE PRESENTS, .ha'I, MARY N. ZEIDERS, ,(SSIGNOR, of Fairview Township, York County, Pennsylvania. being the surviving Mortgagee named in the Mortgage hereinafter mentioned, for and in consideration of the sum of One ($1.00) Dollar lawful money unto me in hand paid by Mary E. Flurie, Trustee of TIlE MARY N. ZEIDERS TRUST AGREEMENT dated May 13, 1998, do hereby grant, bargain, s.ell, assign, transfer and selover uoto THE MARY N. ZEIDERS TRUST AGREEMENT dated May 13, 1998, ASSIGNEE. ALL my right, title and interest in the Mortgage given and executed by KERRY R. SAINTZ, in the principal sum of Sixty One Thousand Five Hundred ($61,500.00) Dollars dated December 2 t, 1994, and recorded in the Office for the Recording of Deeds in and for Cumberland County, Pennsylvania. in Mortgage Book 1246, page' 575, and secured upon that certain tract of land which is located in the Borough ofLemoyne, Cumberland County, Pennsylvania, as set forth in Exhibit A, attached hereto and incorporated herein ALSO, the Note in the said Mortgage recited. and all Moneys, Principal and Interest, due and to grow due thereon, with the Warrant of Attorney to the said Note annexed, together with all Rights, Remedies and Incidents thereunto belonging. And all my Right, Title Interest, Property, Claim and Demand, in and to tile same: TO HAVE, HOLD, RECEIVE AND TAKE, All and singular the hereditaments and premises hereby granted and assigned, or mentioned and intended so to be, with the appurtenances, unto THE MARYN. ZEIDERS TRUST AGREEMENT dated May 13, 1998, to and for its ,.,nly proper use, benefit and behoof forever; subject, nevertheless, to the equity of redemption of said Kerry R. Saintz, the Mortgagor in the said Mortgage named, and his heirs and assigns therein. IN WITNESS WHEREOF, I have hereunto set my hand and seal this 13th day or May, 1998. Sealed and Delivered in the presence of us: , ;hr'1n~91( ~~ALJj MaryN.Ze' rs ~.llmrd ~ (I p~JJ.>mM-' ~!';j~dt,f!? "-- ft D - !~LJ:} 800~ 580 PAtE 166 ,0. ;""'1" ". J -, <0 0> "- ~ ", N '.::.' ::0 ,~l'. i :3 0 .-.. 6 ~~ ~i~ ;; N .:~:~ :', tn ;\ ., ,. ~~. 'iM.~T;~;>",I,!!i ., .--;' " Ct-'":_ ~- Lf' "1)' ~ri'o5 ~ RECORDATION REQUESTED BY: PNC BANK, NATIONAl ASSOCIATION 4242 CARLISLE PIKE CAMP HILL, PA 17001-8874 , . ..: ,.. ::i::C!.ER :..: ::..::;;~:-:. DF DEEDS ;;::~~;~\:~~L'~liD COUNTY- PA 'sa DEe 21 AI'I B 155' WHEN RECORDED MAJL TO: PNC BANK, NATIONAL ASSOCIATlott 630 DRESHER ROAD, SUITE :aoo ' HaRSHAM, PA 19044 . ~ SPACE ABOVE THIS LINE IS FOR RECORDER'S USE; ONLY OPEN - END MORTGAGE THIS MORTGAGE SECURES FUTURE ADVANCES THIS MORTGAGE IS DATED DECEMBER 18. 1998. between KERRY R. SAINTZ1 whose address is 731 HARRISBURG PIKE, DILLSBURG, PA 17019 (referred to below as "Grantor"); and PNC BANK, NATIONAL ASSOCIATION, whose address Is 4242 CARLISLE PIKE, CAMP HILL, PA 17001-8874 (referred to below as "Lender"). ~ GRANT OF MORTGAGE. For valuable considerallon, Grantor grants, bargfllnll, seUs, conveys, assigns, transfers, releases, confirms and mor1gagas 10 Lender aU of Granlof's right, title, amf Interest In and to the foDowlng described real property, tog!!ther with all exlsllng or subsequenlly erected or afflxed I)ulldlngs, Improvements and illdurest an streets~ 1ar'lBS, alleys, passages, and ways: aD easements, rl\lhts of way, aD IIbBrlles, priVileges, lone'ments, hereditaments, and appurtenancas lhereuntO belonging or IlntwfSe made Ippurtenant henlatlar, and the revem'ons and remainders wllh re6peCt thereto; ell water, waler rights, walercoursas and ditch rights (Including stock In utiDlIes wllh ditch or Irrigation rights); and all olher rights, royalllea, and proHts relating 10 the real property, Including Wllhoulllmllallon all mlnerElls, cR, gas, geothermal and similar mailers, located in CUMBERLAND County, Commonwealth of PennsYlvania (the "Real Property"): SEE RIDER "A" ATTACHEO HERETO AND MADE A PART HEREOF The Real PropertY or Its address Is . commonly known as 203,205 AND 207 MULBERRY DRIVE, MECHANICSBURG eOROUGH, PA 17055, GrantOl presently asslgna 10 lender all-of Granlor's right, 1IIIe, and Inl&telt In and 10 all leases of lhe Proparty and all ~enls from the Property. In addition, Granlor grants to lendel' a Unllorm Commercial Code sacurUy Inlerest In the Personel Property and Rents. DEFINITIONS. The lollowlng wOlds shall have the 101loWlng meanings when usad In ihls Mortgage. Tarms no! olherwlss deftnsd In Ihls Mortgage shall have the meanings allrlbuled 10 SUCh terms In the Uniform Commercial Code. All refarences 10 dollar amounts shall maan amounts In lawful money of the Unlled Slatss of America. Granlor. The word "Grantor" means KERRY R. SAINTZ. The Granlot Is the morl9agor und&llhls Mortgage, Guarantor. The wOld "Guaranlor" means and Includes without IImltallon each and all of the guarantors, surell!!s, and accommodal1on parties In connecffonwflhlhelndebledness. Improvements. The word "Improvements" means and Includes wllhoulllmllaUon all existing and lulure lmprovemenb, buildings, s\J'Uclures, mOORe homes affixed on Ihe Real Property, faCllllles, addlllons, mplacemenls and olhetconslrucUon on lIle Real Property. Indebtedness. The word "lndebledness" means all principal and Interest payable under ItIs Nole and any amounts expended or advenced by Lendlll'10 discharge obligations 01 Granlor or expenses In<:urred by,lendsr 10 enforce obligatIons of Grantor'under lhls Morlgage, together with lnleresl on such amounls as pravfded In fhfs Mortgage. In addlllon 10 Ihe Nofa, the word "Indebfedness" Includes all obllgaffons, debls and IIabllltles, plus Inleresllherson, of Grantor 10 Lender, or anyonE! or !flore of them, as well as 811 claims by Lendlll' agalnsl Granlor, or.any one 0( more ollhem. Whelher now existing or hereaflar arising, whelher ralaled or unrelated to IhB purpose 01 the Note, whether voluntary or olherwlse, whether due or ,not due, absolute or contlngenl, Jlquldated or linllquli:lal8d and whether Grantor may be lIab!e Individually or lolnlly Wllh others, whether ol)lIgaled IS guarantor or olherwlse, and Whether recovery upon such IndebtednllSS may be or hereafter may become barred by any statute ollimllallons, and whether such Indebtedness may be or hereatter may become olherwlse unenloroeable. Lender. "The word 'Lender" means PNC BANK, NATIONAL ASSOCIATION,lts sucx:essors and assigns. The Lender Is the morlgagee under this Morigaga. Mortgage. The word "Morlgage- means Ihls Mortgage between Grantor and Lender, and Includes wilhoulllmllallon all assIgnments and securlly Inleresl provlslonsrelallng 10 lhe Personal Property and Renls. Note. The word, "Nole" means the promIssory nole or credit agreement daled December 18, 1998, In the original principal amount of $320,000.00 Irom Grantor to Lsnder, together With all renewala 01, exI$nslons 01, modlncations 01, reftnanclngs of,\consolldallons of, and substllullons lor the promlssorynole or agreement. Personal Property. "The words "Personal Property"_mean all equlpmen~ fixtures, and other arllcles of personal property now or hereafter owned by Granlor, an~ now or herealllll' attached or llfflxed 10 the Real Property: together wIIh all a~asslons, parts. and additions to, aD replacemenls of, J . and all SUbSIllLip~ lor, any of such property: and logether wllh all prooeeds-~ncIudlng wllhoutllmllallon all Insurance proceeds and refunds of .!: premIUms} frolJl!any Sale or other dfsposKlon of Iha f'loparty. Property. The \word "PIoperly" means collecllvely lhe Real Property and the Personal Property. Real Property. The WOlds "RiPl Property" mean lhe property.I~IeAlsls and rights dBSCribed above!n t.h~ "Gran! 01 Mor1gage" secUon. Relaled DOCUMents. The Words "Related Documents" meen end InclUde wllhoUl lIml1aUon all promIssory noles, credit agreemenls, loan ejju'llllmenls, envlronmenlal agreements, 'gU8fllnUes, securl!y agreements, mortgages, deeds of !rus!, and llII oUler Instruments, apresmenls and documents, whelher now or hereafter exlsHng, executed In connection wllh Ihe tndebledness~ .800K1507 fAGE .240 "~r '"'""""" ,~ '--.-. ~\:::...:' ',; :::1,;" r' '., '''-,.,' "~''-,''",i' - ., _.<._~ti-"""""" ,.. , lta f'f/&'{ RECORDATION REQUESTED BY: PNC BANK, NATIONAL ASSOCIATION 4242 CARUSLE PIKE CAMP HILL, PA 17001-8874 ':";" ::",,:;lr\ . Gi' IJEE'i)S ',I :.h\.:.~;U GOUNT~'~i'A WHEN RECORDED MAil TO: PNC BANK, NATIONAL. ASSOCIATION 630 DRESHER ROAD, SUITE 200 HORSHAM, PA 19044 '98 DEe 21 AI'I 8 55 SPACE ABOVE THIS UNE IS FOR RECORDER'S USE ONLY ASSIGNMENT OF RENTS THIS ASSIGNMENT OF RENTS IS DATED DECEMBER 18, 1998, between KERRY R. SAINTZ, wHose address Is 731 HARRISBURG PIKE, DILLSBURG, PA 17019 (referred to below as RGrantor"); and PNC BANK, NATIONAL ASSOCIATION, whose address is 4242 CARLISLE PIKE, CAMP HILL, PA 17001-8874 (referred to below as "Lender"). ASSIGNMENT. For valuable consideration, Grantor assigns, grants a continuing security Interest In, and conveys to Lender all of Grantor's right, tlUe, and Interest In and to the Rents from the following described Property located In CUMBERLAND County, Commonwealth of Pennsylvania: SEE RIDER "A" AlTACHED HERETO AND MADE A PART HEREOF The Real Property or Its address Is commonly known as 203,205 AND 207 MULBERRY DRIVE, MECHANICSBURG BOROUGH, PA 17055. DEFINITIONS. The rollowlng words shall hava the following meanIngs when used In thts Asslgnmenl. Tllfms not otherwise ttellned In IhIs Assignment shall have the meanings al1rlbUled to sUCh terms In Ihe Uniform Commercial Code. All relerences to dollar amounts shall mean amounts In lawlul money or the United Stales ofAmerlca. Asslgnmenl. The word ~Asslgnment~ means this Assignment of Rents belwlllln Grantor and Lender, and Includes wllhout IImllallol\ all assignments and securltylnleresl provislol\S relaUng to the Renls. Event of Oelaull. The words "Event of Oelaulr mean and include w1thoulllmllallon any of lhe Evenls of Default set forth below In Ihe see lion titied "Evenlsof Defaull.. Grantor. The word "Grantol' meanS KERRY R. SAlNTZ. Indebtedness. The word ~lndebtedness~ means all prIncIpal and lnlerest payable under the Note and any amounts expended or advanced by Lender 10 discharge obligations 01 Granlor or expenses Incurred by Lender 10 enforce obligallons of Grantor under lhls Assignment, together w1lh Inleresl on such amounts as provided In this Asslgnmenl. In addlUon to the Nole, Ihe word .lndebtedness~ Includes all_obllgallons, debts and lIablUlies. plus Inlaresllheteon, of Grantor 10 Lender, or any one or more ollh8m, as well as all clallTl$ by Lender against Grenier, or any one or mere of Ihem, whelher now axlsOng or hereafter arising, whether related er unrelated to the purpose of Ihe Note, whether volunlary or otherwise, whether due or nol due, absolute or contlngenl, liquidated or unllquldaled and whether Grantor may be liable Indlvldually or lolnlly wllh others, wheltler obligated as guarantor or otherwise, and whether rllCilV8ry upon such Indebtedness may be or hereafter may become barred by any statute of IImilallol'lS. and whelher such Indebtedness may be or hereatter may become otherwise unenforceable. L.ender. The word '1.ender" means PNC BANK, NATIONAL ASSOCIATION, Its successors and assIgns. Nole. The word ~Note" means the promissory nole or credll agreement dated December lB, 199B, In the original principal amount of $320,000.00 Irom Granlor 10 Lender. logelher wllh all renewals of, extensions 01, modlflcaUons of, reUnanclngs of, consolidallons of. and subslilullons for Ihepromlssorynot,e or agreement. Property. The word .Properly" means the ,eal property. and ell Improvements thereon, described above In the "Assignment" $OOllon. Real Property. The words "Real Property" mean the property, Interesls and rights described above In the "Property OeUfl1l10n~ sectlon. Related Ooc;uments. The words "Aelaled OQCuments~ mean and Include wllhout limitation ell promissory noles, cret;flt agreemenls. loan agreemenls. environmental agreements, guaranties, security agrllQmenls, mortgages, dllQds of trust, and alt other lnslruments, agreements and documents, whether now or hereafter exlsUng, elCeouted tn oonnectlon wllh I he Indebtedness. Rents. The word "Rents. means all rents, rllV9nlles, Income, Issues, proftls and proceeds from the Prcperty, whether due now or leter, InCIUdl1lg w1thoutlimllalton aU Rents from allleasllS described on any exhibit allached 10 Ihls Asslgnmenl. THIS ASSIGNMENT-IS'GIVEN TO SECURE (1) PAYMENT OF 'THE INDEBTEDNESS AND (2) PERFORMANCE OF ANY'AND All OBLIGATIONS OF GRANTOR UNDER THE NOTE, THIS ASStGNMENT,'AND THE RELATED DOCUMENTS. THIS A~~I~~ IS GJVEW Hlq ACCEPTED ON THE FOLLOWING TERMS: BOOK OttO 'PAGE .1.;"10 PAYMENT AND PERFORMANCE. Exceplas olherwlsa provided In this Assignment or any Related Document, Grantor shall pay to Lender all amounts secured by lhls Assignment as they become due, and shall slrlctly perform ell of Grantor's obligations under this Assignment. Unless and until Lender exercfses lis right to colJecllhe Renls as provided below and so long esthere Is no defeult under Ihls Assignment, Granlor may remain In possession and conlrol 01 end operate and manage the Properly and collect the Rents, provided thatlhe granting 01 the right 10 collect the Rents shall no! constilule Lender's consent 10 the use of cash collalerel In abanknlploy prOOQedlng. GRANTOR'S REPRESENTATIONS AND WARRANTIES WITH RESPECT TO THE RENTS. WJth r8Sp9l::t 10 lha Rem. Grantor fspresenls and ~~,'~I ,,~ , ) .,--/ .'. J '-..-/. W1$1jg !f1;<'~'iiIJ~~[l!l!!, ^','"~c' "_,>. _ _;"_0,, "_'_' " 12-18-1998 Loan No ASSIGNMENT OF RENTS (Continued) Page 2 warranls 10 lender that: OwnershIp. Grantor Is enl1lled \0 receive the Renls free and clear of all rights, loans,llens, encumbrances, and claIms except as disclosed to and accepted by lender In wrillng. RIghi 10 Assign. Grenlor has the lull rIght, power, and aulhorlty to enter Into Ihls Asslgnmenl and 10 assign and con~~'he Rents 10 Lender. No Prior AssIgnmenl. Granlor has not previously assigned or conveyed the Renls to any olher person by any Ins"umenl now In1orce. No Furlher Trllnsler. Granlor will nol sell. assIgn, encumber, or otherWIse dispose of any 01 Grantor's rlghl$ln lhe Rents except as provlc:led In this AgreGment. LENDER'S RIGHT TO COLLECT RENTS. Lendel' shall have the rlghl al any lime, and even though no defaull shall have occurred under this Asslgnmenl, 10 callecland receIve lhe Renls. For this purpose, Lender ts herebyll!ven and lIranled the IoI10wlnll rlghls,powars a ndsuthority: Notice 10 Tensnls. Lender may send naUces 10 any and aD lenants of the Properly advisIng Ihem of this '1Slgnment and dlrecllng all Rants 10 be paid dllecllyto Lend9f or Lender's agent. \ Enler the Properly, lender may enler upon and lake possessIon or the Property; demand, colle<:l and receive from IhG lenanls or from any olher persons lIablelherefar, all 01 the Aents; Inslltute and carryon aD legal proceedings necessary lor the prolectlon01 Ihe Properly,lncludlngsuch proceedings as may be necesSlll)' 10 recover possession 01 Ihe Property; coltecllhe Rents and remove any tenant or tenants or other persons lromlhaProparly. Maintain Ihe Property. Lender may enter upon Ihe Properly to maintain the Properly and keep IIle same In repalr; to pay the costs Ihereaf and of all services 01 all employees, Including Ihelr equipment, and of an conUnulng costs and expenses of maintaining lhe Properly In proper nlpalt and candlDon, and elso to pay all taxes, assessments and waler ullUtles, and Ihe premiums on fire and other" Insurance efIecled by Lender on IhG Property. Compliance wllh laws. Lender may do eny aru:l all things 10 execute and comply wllh the laws olltle Commonweallh 01 Pennsylvania and also all other laws, rules, orders, otdlnances and requlremenls ofall olhergovamme nlal agencies ellacllng the Properly. Lease the ProperlY. Lender may renl Of lease Ihe whole or any pari oltha Properly lor such term or terms and on SUCh candlUons as Lender may deem appropriate. . Employ Agenls. Lender may engage such agenl or agents as lender may deem appraprlata, either In Lend81's name or In Granlor's name, 10 renlandmanagetlutProperty,lncludlnglhecallecllonandappflcallonafRlInls. OIher Acls, Lender may do all such olher Ihlngs and acla with respect to Ihe Properly as Lender may deem appropriate and msy acl exclusively and solely In the place and slaad of Granlol"end to have all of lhe pOWOr9 01 Granlor for the pl,lrp0se8atatedabava7 No Requlremenllo Acl. Lender shall nol be required to do any of lhe foregoing acts or things, and lhe facllhatlender shall have performed one or more.of lhe foregoing acls or lhlngsshall not require lender 10 do any otherspeclllcaclorlhlng. . APPLICATION OF RENTS. All oasis and expenses Incurred by !.Bnc:ler In connecllon with the Property shall be lor Grantor's account and Lender msy pay such cosls and &Xpensas from the Renls. Lender, In Its sole dlscreUan,'shall determine Ihe BPpllcallon 01 any end all Rents received by II; however, any such Rents received by Lender which 818 not applied to,such costs and expenses Shall be applied to the Indebledness. All expenditures msde by Lender undllr thIs Asslgnment and nol reimbursed from the Rents shaD become a pari of !he Indebledness secure~ by Ihls Assignment, and shall be payable on demand, wilh inlerest althe Note rate from dale of expendllure unllf pald. FULL PERFORMANCE, If Grantor pays all 01 the lndebledness when dua and otherWI58 perlorms ell the obligations Impasad upon Grantor under this Assignment, Ihe Note, and lhe Related Documenls, Lender shall execute and deliver to Grantor a sullable saUBfllOllon of Ihls Assignment and suitable stalemenls olterininallon of sny IInancll1g slalement on me avldenclng Lender's security Interest In the Rents and Ihe Property. Any termination fee reqlllred by law shall be paid byGranlar,llpermllled by appllcable law. EXPENDITURES BY LENOER. If Granlar falls to comply wllh eny provision of Ihls AssIgnment, or 11 any IIOlIon or proceeding Is commenced that would malellallyalrecl Lendef5 Inleresls In the, Propefty, Lender on Gtantar'sbehallmay, bulshall nol be required lo, take any ecllon IhaI Lender deems approprlala. Any amaunl lhat Lender expends In so doing will bear Intemsl altha rale provided fOl in Ihe Nole from !he date Incurred or pafd by lenc:ler to tha dale of repaymenl by Granlor. All such expilnses, at Lender's opUon, will (a) be payable on demand, (b) be added 10 Ihe balance ollhe Ncte and be apportioned among and bel payable with any InS,lallmenl paymenls 10 become dua during either Q) the lerm of any sppllcable InsurallCQ policy or (D) lhe remaining term of the Nole, or (c) be treated' as a belloon payment whlch wlll be due and payable althe Note's maturlty. This Asslgnmenl also w1~ 5ecure payment of thsso amounts. The rllIhls provlded !of In thls paragraph shall be In addll1an to any olher rights or any remedlas 10 which Lender mey be entllled on aocounl of Ihe default. Any such acllon by Lender sl'lllll not be conslruad AS curing tha delaull so as 10 bar Lender from any remedy !hat It otherwise would have hed, DEF AUL T, Each 01 the following, althe opllon of lender, shall conslllute an evenl 01 default ("Even! of Defaull") under !hIs Assignment: Default on Indebledness- Failure 01 Grantor to make any peymenl when dua on Ihelndebledll9Ss, Compliance Defaul!. Failure of Granlor 10 comply wllh any other term, obligation, covenant 01 candlllon conlalned In this Assignment, Ihe Nale or In any of lha Related Documents. False Slalements, Any warranty, represonlallon or slalamenl made or furnished to Lendar by or on behalf cl Grenlor under this Assignment, the Note or the Relaled Documents is false or misleading In any malerial respect, either now or altha I1ma made orfumlshad. Delecllve Collaterallzallon. This Assignment or any of Ihe Relaled Documents ceases lo be in lull farce and effect (Including fallure of any collateral dacumenl$lo creale a valid and perfected security Interest or lien) at any lime and lor any reason. Olher Defaults. FaUllre of Grantor 10 comply wllh any term, obligallon, covenant, or condition contained In eny olhet egreement between Granier and Lender. Death or Insolvency. the death of Granier or the dissolution or lermlnatlon of Grantot's~~ncV~~gJ~~us~~,~e InsolVency of Grantor. the appolntmenl of a receiver fcr any pari 01 Grantor's property, any asslgnmenl for Ihe beneOl of credllors, any lype of creditor workout or the commellCQmanl ot any proceadlng under any bankrUptcy Of Insolvency laws by or agalnsl Granlar. Foreclosure, Forlellure, ele. Comfl\9noemenl of _lareclosllt9 cr fOrlel1ure pr~edlngs, whGther by Judicial proceeding, sell-help, repossession or any alher melljo!:l, by aflY creditor ol,Grantor or by IIny governmenlal agency: against anyofthe,Proparly. However,th_Is subsecllon shall not apply In Ihe evenl 01 a good fallh dlspule by,Grantor as 10 the vaJ!I;Ilty ones,sonllblene$s 01 the claim whia~ Is the basls of tholorecJOSlN8 or forefellura proceedIng, provided that Granlor gives Lender wril\en noHoe of such cJa1m and furnishes reserves cr a_surely bond forthe claim satlsfaclory to Lendar. Events AffecUng Guaranlcr. Any of the preceding events ocCUrs wllh respeclta any Gueranlor 01 any of the Indebtedness Of any Guarantor dies ';1 ,~, .', {: b);;~U ;;d;l!lrJi\II ~'~, "; . N,_'. " " 12-18-1998 Loan No ASSIGNMENT OF RENTS (Continued) Page 3 or becomes lncompelenl,orrevokes ordlsputesthevalldllyof,orllabnlly under ,anyGuaranly of the Indebtedness. _ '\ Adverse Change. A malerial adverse change OC1:urs In Grenlots financial condlllon, or Lender believes the prospect of paymenl or pertormanCG 01 the Indeblednessls Impaired. RIGHTS AND REMEDIES ON DEFAULT. Upon the OCCUITenC8 01 eny Evenl 01 DelauJl and at any Ume thereallSl, L,rrilQr may exercise anyone or more 01 lhelollowlng rlghls and remedies, In addlUon to any olher righls or remedies provided by law: {., Accelerate tndebtedness. Subject tit applicable law. Lender shall have lhe righl at lis option wlthoul nollCG to Granlor 10 c!eQlare the enllre Indebledness Immedlatelydue and payable. Colfeel Rents. LlInder shall have thll righI, wllhout nollca to Grenlor,lo lake possessIon of the Properly and eoll9c1 the Renls,lncludlng amounts pasldueand unpeld,and apply Ihe net proceeds, over and above Lender's costs, aga Insllhelndebledness.lnfurtheranceollhlsrlghl.Lendllt shall have all the rlghls provided lor In the Lender's Right to Collect SeelIon, above. If Ihe Rents are collecled by Lender, then Grantor IrreVocably deslgnales Lender as GraRlor's allOlnB)'--ln-facllo endorse Inslrumenls received In paym&nl thereolln llI:e name of Grantor and to negollalelhe same and collecllha proceeds. Payments by lenants or other users 10 Lender In response 10 Lender's demand Shall satisfy lhe obligations for which the payments are made. whelher or nol any proper grounds lor the demand existed. lender may exercise lis rlghls under Ihls subparagraph ellherln person, byagenl,orthrough llreoelver. Appoint Receiver. lender shaQ have Ihe righllo have a receiver appolnled 10 take possession of all or any part of the Properly, wllh IhB power to proleclandpreservetheProperly,tooperalelhePropEHtyprecedlngforeclosureorsale,andtooollecl Ihe Renls from Iha Properly and applylhe proceeds, over and above Ihe cost ollhe receivership, agalnsllhe Indebtedness. The receiver may serve wllhout bond II permllted by law. lender's rlghlto the appolnlmenl of a recelvar shall exlslwhatherornollheapPllllllll-value oflhe Property exceeds Ihe Jndebladnoss bya substanllal amounl. Employmenl by Lender shall nol disqualify a person from seJVlng as a receiver. Olher RemedIes. lander shall have all olher fights and remedies provided In this AssIgnmenl or Ihe Nole or by law. Waiver, Elecllon 01 Remedies. A waiver by any party 01 a breach of a provisIon ollhls Asslgnmenl shall nol conslltule a waiver of 01 prejudice lhe party's fighl$ otharwlse 10 demand strlcl compHance with Ihal provision or any oIher provision. EleaUon by Lender 10 pursue any remedy shall nol exclude plU$ull 01 any olher remedy, and an alecUon to make expendllures or lake ,ac110n 10 p9lform an obllgaUon 01 Granlor under this AssIgnmenl aller fallul"9 01 Grantor to perlorm shall not alleel Lender's righl to Oeclare a defaull and exercise lis remedl9$ under IhlsAsslgnmenL Atlorneys' Fees; Expenses. If Lender lnsmutes any sull or llC!lon to enforce any oIlhe !elms of Ihls Assignment, Lender shall be enntled 10 recover such sum as Ihecourt may adJudge reasonable asaRorneys'fees allrial and on llny appeal. Whelher 01 nol any courl IlQUon Is Involved. all reasonable expenses Incurred by Lenderlhal In Lender's cplnlon are necessary alanyUmelorlhBprolecllotlofnslnl9fBSlorlheen~mBnl 01 Us rlghls shall become a part ollhe Indebtedness payable on demand and shall bear Interesl from the dale QI expenditure untit repaid althe rale provIded 101 In the Note. Expenses covered by this paragraph Include, wilhoul Dmllallon, however subJacllo any IImlls under applicable law. Lender's attorneys' lees and,lender's IegaJ expenses whelheror not there Is a lawsull, Includ!ng attorneys' fees lor bankruplcyproceedlngs (Including efforls 10 modify or vacale any automatic slay orlnJunollonl. appeals and any anllclpaled'post-Judgmenl collecllon services. tha cost of searchlngrecords,oblalnlng IllIe reporls (lncludlng loreclosurereporls),surveyors'repo rts,and appraisal lees, and title Insurance, 10 the lllllenl permllted by applicable law. GrantOl also will pay any court cosls, In addlUon 10 all other sums provided by law. MISCELLANEOUS PROVISIONS. The following miscellaneous provisions are a part olthlsAsslgnmenl: Amendments. This Asslgnmenl, togethBt wilh any Related Oocumsnls, conslllules the entire underslandlng and agrqement of lhe parties as 10 Ihe mailers set forth in Ihls Assignment. No allerallon, of or amendmenllo this Asslgnmenl shall be effecllve unless given In writing and signed by the parlyOl parlles sought 10 be cnarged or bound by the alleraflon oramendmenL Applicable Law. This A",gnment has been delivered 10 Lender and accepted by Lender in Ihe Commonweallh of Pennsylvania. This Assignment shall be governed by and construed In accordance with the laws of Ihe Commonweallh of PennsylvanIa. No Modlffcallon. Granlor shall nol enter Inlo any agreemenl with the holder of any mortgage or olher security agreement which has priorily over this Asslgnmenl by which lhal agreemenlls modillGd. amended, extended, or renewed wllhoultho prlOl written consenl of LSndllf. Granlor shall nellherrequeslnoracceplanyfulureadvancasundaranysuchsecufilyagreement wilhoul the prior wrlllen coneent 01 Lender. Severablllly. II a court of compelenl JurisdlcUon llnds any provlslon 01 this Ass1gnmenl to be Invalid or unenforceable as 10 any person or clrcumslance, such finding shall nol render tnal provision lnvand or unenlolll eable as 10 any other persons orclrcumslances. Ilfeasibte,e!lysuch of lending provision shall be deemed 10 be modlned 10 be wRhln the IImfts 01 enforceability or validity; however. ilthe offending provision cannot be so modllied, II shall be stricken and all othet provisions ollhls Asslgnmentln all olher respects shall remain valid and enforceable. Successors and AssIgns. Subject 10 IhetlmltaUons slated In this Assfgnment on transfer of Granlor's Interest, this Asslgnmenl shall be binding upon and Inure 10 the benefil oIlhe parl19s,lh'elrllBlrs,pSflonalrepresenlallves,s uccessorsendasslgns. If ownership of lhe Propartybecomes vested In a parson other lhan Grantor, Lender, wilhoul notlceto Grantor, may deal wlIh Grantor's successors wllh reference 10 thls Assignment and lhe Indebledness by way of lorbearance or exlansloo wllhout releasing Granlor from the obllgallons of Ih!$ Asslgnmenl or lIabillly under the Indebtedness. Time la,of the Essence. TIme Is ollhe essence in the performance 01 this Asslgnmenl. WaIvers and Consents. Lender shall nol be deamed 10 have waived any rlghls under lhls Assignment (or under Ihe Relaled Documents) unless such waIver Is In writing and sIgned by lender. No delay or omission on Ihe pari of Lender In exercising any rlghl shall operale as a waiver of suchrlghtoranyolherfighl. A wa1ver by any party 01 a provlslon orlhls Asslgnmenl shall nolconslllUleawalveroforprejudloelhepart)"srlghl otherwlse 10 demand slrlcl compllanCG wllh thai provision or any olher provision. No prIor waiver by Lender. nor any course 01 dealing between Lender and Grenlor, shall constltute a waIver of any 01 Lender's rights 01 any !?I Granlor's obligations as 10 any lulure transactions. Whenever consenlbyLemlerlsrequlredlnlhlsAsslgnmenl,lhegranllngolsuchcol'lSllnlbyLenderlnanylnslanCGshallnotconsllluteconllnulngconsenlto subsequenlJnstances whera such consenl Isrequlred. ~::~~~R ACKNOWLEDGES HAVING READ ALL THE PROVISIONS OF THIS :ASSIGNMENT OF RENTS, AND GRANTOR AGREES TO ITS THIS ASSIGNMENT HAS SEEN SIGNED AND SEALED BY iHE UNDERSIGNED. GRANTOR: X~~""'"'4~\lI BOOK 598 rAGE 200 "" -, - J -'. Lv ~ !~J~[i~_,'o" 0 -!' "';r:~'~~'-""":,-",, ',1=-;,' ,. , o,~ ._ ,j Rider "A" - Assignment of Rents by Kerry R. Saintz to . '. PNC Bank, National Association dated December 18, 1998 I -, ALL those three lots of land and premises, situate, lying and being in the Borough of Mechanicsburg in the County of Cumberland and Cornxnonwealtlf of Pennsylvania, more particularly described as follows: BEGINNING at a point on the western side of Mulberry Road (T-586) at the dividing line between Lot Nos. 56 and 57 on the Plan of Lots hereinafter mentioned; thence along said dividing line between Lots Nos. 56 and 57, South 89 degrees 43 minutes West, a distance of one hundred twenty-six and eighty-nine one-hundredths (126.89) feet to a point on the dividing line between Lots Nos. 56 and 46 as shown on said Planj thence along the line dividing Lots Nos. 56, 55, and 54 from Lots Nos-, 46, 47, 48, and 49, North 01 degree" 10 minutes West, a distance of two hundred ten (210) feet to a point at the dividing line between Lots Nos. 54 and 53; thence along said dividing line between Lots Nos. 54 and 53, North 89 degrees 43 minutes East, a distance of one hundred twenty-six and sixty-two one-hundredths (126.62) feet to a point on the western side of Mulberry Road (T ~586) first mentioned above; thence along said western side of Mulberry Road (T-586), South 01 degree 14 minutes East, a distance of two hundred ten (210) feet to a point on the same at the dividing line between Lots Nos. 56 and 57, at the point and place of BEGINNING. I BEING Lots Nos. 54, 55, and 56 on the Plan of Lots entitled "Section 1, Valley Streams Estates" as recorded in the Office of the Recorder of Deed in and for Cumberland County, Pennsylvania, in Plan Book 13, Page 6. BEING the same premises which Thomas C. Wetzel and Cheri L. Wetzel, husband and wife, by their deed dated December 18, 1998 and intenqed to be recorded previous to this Assignment in the Cumberland County Recorder of Deeds Office, granted and conveyed unto Kerry R. Saintz, grantor herein. ~\;l\e of PennsVIVania} 86 County uf Cumberland t!!COf 'd in the Olf8;' for Ine recording of Deeds €h, n ndfor~ erland.COUn1Y~p \ Bookt.J.....LJ._Vol._Page witne '$ my hand and &;,1 of office a a(f CarHsle,PAthis~davof ~ vf~fl ~~ ,~-;" '\ '" ~Y.rl.:"..",-,......:..,~;;;? "\' -A':::~~:'-'. ., J BOOK 598 PAGE 202 I , ," > -~ - :~ ,0." \.~ ,,-.. ":"-' -"C,," t?,<~,"..,,~,"'_' ;. 12-18-1998 Loan No ASSIGNMENT OF RENTS (ConUnued) x Witness x Wllness CERTIFICATE OF RESIDENCE Page 4 /,. -'. I hereby certlfy,ll'Iallhe precise address of the mortgagee, PNC BANK, NATIONAL ASSOCIATION, herein Is as follows: 4242 CARLISLE PIKE, CAMP HILL, PA 17001-8874 ~",,::"~.. INDIVIDUAL ACKNOWLEDGMENT STATE OF n..UO:;I)'....d.a.J\A COUNTY OF \)A H {"\..h J ) ISS , Onthls.the~dayo' D~ft:MBj:Rt19.2!Lbe'Offlma . l~. e, ,the undersigned Nolary Public, personally appaared KERRY R, SAINTZ, known 10 ma tlor lisfaclorlly proven) 10 be Iha person whosa nam9 Is sUbSCtlbedlolhewllhlnlnslrumelll,andacllnowledgedlhatheorsheexeculed Ihe same' lhe purposes Iherelnconlalnod. In wllness whereOf,l hereunto set my hand and olUcla1 seal. Notarial Seal Jason F. Ernest, NolaIy Public Harrisburg, Dauphln Countv MyCommlsslorl ExpIres June 11, 2002 BOOK 598 PAGE 201 _>'C "., . ~.,. . "; ~..,..--.--.--. ~, ] 4'('31 iJ'~ ~I ~ f)' p:(.inr:f,T? ':::![.~Lr:R nE~,'J;- ~)[:. :;:l= ~r::EDS !; 'J I,! [J~' L\ ii"~ (:(1 '; 'JTY - p~ '01 OCT is Pr112 18 Prepared By: Jennie West. Merrill Lynch Credit Corporation 4802 Deer Lake Drive East Jacksonville, FL 32246 Return To: Merrill Lynch Credit Corporation 2001 8ishops Gate Blvd. Mount Laurel. NJ 08054 Parcel Nwnber: 40-09-0533-072 Loan #: 7075811179 [Space Above This Line For Recording Data] MORTGAGE DEFINITIONS Words used in multiple sections of this docwnent are defined below and other words are defined in Sections 3, 11, 13, 18, 20 and 21. Certain rules regarding the usage of words used in this document are also provided in Section 16. (Al "Security Imtrument" means this docwnent, which is dated October 12th, 2001 together with all Riders to this document. (Bl "Borrower" is Kerry R Saintz, AN UNMARRIED PERSOtf Borrower is the mortgagor under this Security Instrument. (el "Lender" is Merri 11 Lynch Credit Corporation Lenderis a Corporat i on PENNSYLVANIA - Single Family - Fannie Mae/Freddie Mac UNIFORM INSTRUMENT . -6(PA) 10008' " Page 1 of 16 form 3039 1/01 '''ffi".' H J!2f VMP MORTGAGE FORMS. j8oo1521-7291 BK I 7 35 F G 3 7 5 5 Original 'T~jLr~.w _ """_",C_" - ':""' ,~ '~II ., '-', ", , ;' organized and e)listing under the laws of Del awa re Lender's address is 4802 Deer Lake Dri ve East Jacksonvi 11 e, FL 32246 Lender is the mortgagee under this Security Instrument. (D) "Note" means the promissory note signed by Borrower and dated October 12th, 2001 The Note states that Borrower owes Lender Two Hundred Thousand Doll ars and Zero Cents Dollars (U.S. $ 200.000.00 ) plus interest. Borrower has promised to pay this debt in regnlar Periodic Payments and to pay the debt in-full not later than November 1st, 2016 (E) "Property" means the property that is described below under the heading "Transfer of Rights in the Property. " (F) "Loan" means the debt evidenced by the Note, plus imerest, any prepayment charges and late charges due under the Note, and all sums due under this Security Instrument, plus interest. (G) "Riders" means all Riders to this Security Instrument that are executed by Borrower. The following Riders are to be executed by Borrower [check box as applicable]; D Adjustable Rate Rider o Balloon Rider D VA Rider o Condominium Rider D Second Home Rider o Planned Unit Development Rider 0 1-4 Family Rider o Biweekly Payment Rider llU(other(s\ Ispecifvl. . ) Property ae~CrtptlOn (II) "Applicable Law" means all controlling applicable federal, state and local statutes, regulations, ordinances and administrative roles and orders (that have the effect of law) as well as all applicable final, non-appealable judicial opinions. (I) "Community Associatlnn Dues, Fees, and Assessments" means all dues, fees, assessments and other charges that are imposed on Borrower or the Property by a condominium association, homeowners association or similar organization. (J) "Electronic Funds Transfer" means any transfer of funds, other than a transaction originated hy check, draft, or similar paper instrument, which is initiated through an electronic teooinal, telephonic instrument, computer, or magnetic tape so as to otder, instruct. or authorize a {mancial institution to debit or credit an account. Such teoo includes, but is not limited to. point-of-sale transfers, automated teUer machine transactions, transfers initiated by telephone, wire transfers, and automated clearinghouse transfers. (K) "Escrow Items" means those items that are described in Section 3. (L) "MJsceIlaneous Proceeds" means any compensation, settlement, award of damages, or proceeds paid by any third party (other than insurance proceeds paid under the coverages described in Section 5) for; (i) damage to. or destruction of, the Property; (ii) condemnation or other taking of all or any part of the Property; (iii) conveyance in lieu of condeJDIiation; or (iv) misrepresentations of, or omissions as to, the value andIor condition of the Property. (M) "Mortgage Insurance" means insurance protecting Lender against the nonpayment of, or default on, the Loan. (N) "Periodic Payment" means the regularly scheduled amount due for (i) principal and interest under the Note, plus (ii) any amounts under Section 3 of this Security Instrument. [";;"["~ .-6(PAII00081 f) Page 2 of 16 form 3039 1/01 BK I 7 3 5 PG 3 7 5 6 Original !i,'~"7""'l ,f , . I'~'''' - -,;r~!,~'T>f,[~!~~'!!lIi'l'lj!l;,.t"..,"~ <'r-. :"I"''''''~'''' '1 ~""'~'~~~~!!!AA"f1!Iffl~rr"')""'";''''H-'''"~~I''''''''''''''' ",,,"~_~~ilW"'i'--' !,'}' PBl In The Court of Common Pleas of York County, Pennsylvania 2001/11/28 KERRY R SAINTZ VS JENNIFER P SAINTZ Case Number 1993 SU 04456 02D Case Type Divorce APPEARANCES BRUNT, CONSTANCE P D 001 SA~NTZ, JENNIFER P 703 YMCA DRIVE NEW CUMBERLAND PA 17339 CONNELLY, JOHN J JR POOl SAINTZ, KERRY R 1005 SILVER LAKE ROAD LEWISBERRY PA 17339 DOCKET ENTRIES 1993/10/18 COMPLAINT IN CIVIL ACTION - DIVORCE 1994/10/03 WITHDRAWAL AND ENTRY OF APPEARANCE WITHDRAW JOHN J CONNELLY ESQ & ADD DIANE G RADCLIFF ESQ FOR PLTF 1995/01/12 PLAINTIFF'S AFFIDAVIT UNDER SEC. 3301(D) 1995/02/01 ANSWER AND COUNTERCLAIM W/CERT OF SVC 1995/02/01 COUNTER-AFFIDAVIT UNDER SEC 3301(D) DEFTS W/CERT OF SVC 1995/04/03 CERTIFICATE OF SERVICE OF PLAINTIFFS AFFIDAVIT UNDER SECTION 3301(D) OF THE DIVORCE CODE 1996/03/01 ACCEPTANCE OF SERVICE OF COMPLAINT IN DIVORCE BY ATTY CONSTANCE P BRUNT ESQ ON 10/18/93 1996/04/12 WITHDRAWAL AND ENTRY OF APPEARANCE WITHDRAW DIANE G RADCLIFF ESQ & ENTER GARY L KELLEY ESQ FOR PLTF ;-:~"'i""-~''''''"' " "or I, , 115.00 0122 0332 0,00 0096 0358 0.00 0004 0181 0.00 0010 0199 0,00 0010 0200 0.00 0033 0099 0.00 0021 0030 0.00 0037 0573 - ~;",- PB1 In The Court of Common Pleas of York County, Pennsylvania 2001/11/28 KERRY R SAINTZ VS JENNIFER P SAINTZ Case Number 1993 SU 04456 02D Case Type Divorce DOCKET ENTRIES 1996/08/0~ ENTRY OF APPEARANCE JOHN J CONNELLY JR ESQ ON BEHALF OF PLTF KERRY R SAINTZ 1997/03/05 AFFIDAVIT OF CONSENT OF PLAINTIFF 1997/03/05 WAIVER OF NOTICE OF INTENTION TO REQUEST DCRE OF PLAINTIFF 1997/03/05 AFFIDAVIT OF CONSENT OF DEFENDANT 1997/03/05 WAIVER OF NOTICE OF INTENTION TO REQUEST DCRE OF DEFENDANT 1997/03/19 WITHDRAWAL OF DEFT/COUNTERCLAIM PLTFS CLAIM FOR EQ DIST APL COUNSEL FEES COSTS & EXPENSES & ALIMONY 1997/03/19 RECORD TRANSMITTED TO COURT FOR FINAl DECREE 1997/05/02 ACCEPTANCE OF SERVICE 1997/05/02 RECORD TRANSMITTED TO COURT FOR FINAl DECREE 1997/05/06 DIVORCE GRANTED **SPECIAL DECREE** UNDER SECTION 3301(C) BY THE CT MICHAEL J BRILLHART JUDGE 1997/05/06 NOTICE GIVEN RE: PA R. C. P. 236 c. ,""" "~ ",'n'.," ," , ,~ """1"':'1' 0082 0058 0024 0141 0024 0142 0024 0139 0024 0140 0029 0564 0029 0565 0049 0603 0050 0273 0050 0273 0000 0000 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 ,- "!~ me'" "" ~~ -:w_, - '''' ", PEl In The court of Common Pleas of York County, Pennsylvania 2001/11/28 KERRY R SAINTZ VS JENNIFER P SAINTZ DOCKET ENTRIES ** END o F ? .r~" CAS E '", '1--' ,~" Case Number 1993 SU 04456 02D Case Type Divorce P R I N T 0 U T ** (PROTR10) ~ . -~..."...., "q~~ ,.~... ".",,., ~~: ~ - ~ . " -~, ~~~. .....-'~~ "'1(~" ~:! >1' 'I'i.')! '. Wi irj (;,:j Wi ~1 "i! ;,'; ::"1 ."".~~ ~'-I- , " O~ "~, "-. ~~~'""1~"._-.- , ..-~'~"W"""""-"'-. .~ 1-^1 = ~ -.'I'!"~-~ "="''' ~~ T'~~I'_ " , ~" ^ ,~, "~",~-,",. """-~, --.~'-~'-"',""r""-':""" "",~~ ~,. ~^S11""" ",;"";';"~'c~~ool!'1'!1!ij~. "=,"~ 'I "'II!II! 1 ~ . '"'~'~"r _ _~~,'~~":W'Y'c,. - ~"'''''"- ~,,~~ ~ 'I "~, 'C','",- ~ _ il!I?~~:'- ["~WJllf~~IW'!;f~Il:~ -I " . "~~~~~ ~.~IIII! ,""","IA,. ." ~=, J_.,,,,~~' '''''';J~"", ~~ "", ~ - ~~,~ ~~!"",.,- . . fully i::.~on:ed as to his or her .legal rights and obligations. Eac:. par:'::.y acknowledges and accepts that this Agreement is, under the circumsta"ces, fair and equitable. and that it is being entered into freely and voluntarily after having received such ad.....ice and \.rith !-H.~ch Y:.nO\,:l~dge, and that execution of this Agreement is not the resulc of any duress or undue influence and that it is not the result of any collusion or improper or illegal a9re~ment or c\greements. In addition, each p'3.rty hereto acknow- ledges that he or she has been fully advised by his or her respective at~crney of the impact of the Penn3ylvania Divorce Code, whereby the Court has the right a:1d duty to determine nil marital right@ of the parties. incluuing divorce, alimony, alimony Dcnd~:'lte liJe, equitable distribution of all marital property owned or possessed jointly or individudlly by either party, counsel fees and costs of litigation, and, fully knowing the same and oeing fully advised of his or her rights ther"und"r. each party h~~eto still desires to execute this Agreement, acknowledging that th" terms and condition. set forth her"in are fair. just and equitable to each of the parties. .nd waive. hi. and her respective right to have the Court of Common Plea. of York County or any oth"r court of comp"tent jurisdiction make ^ny detenr.ination or order affElcting the rl'!Bpt!ctivl! parties' rightiP to a divorce, alimony, ulimony Q~n.~ liu, ~quit.1blp. distribution of all marital proparty, counsel fees and coats of litigati0n. 3 J .,~ C::(.O'I ,; >+ Il ill.} tLll,.. ',"1' '"-~"1;"~'J'U:]~ < , ~=w' .e _ '" - ~..v,,~~ . 1";f';'Vl!~""..,""~, ......-'-""1-' ".,..., " ._ ~ ~",,,~'~'m,' - -r,- 'C'_f+T''lrrt-,];,I<;101 ~~ - ~'''?-. I--"~- - ~~I"'~,"m',",,",,"' fI ~ ,.0-,,-.-,.1.. , , - . ~-'" ' J~ 1-" -"'~"i,"HI!l!l~_, l- ~ I'. .- - ~.c '"-,",~'l'~~_'~ 'I ,. .~ , . _~~ T-''''-' "'t!~ ""~,' , ",- I -T ~~ !l:!f!i'!W- " -';"'I'~""'il'!I"~.~"",1<!' ,--, - .._ 'liTPf'T " '<'"le;W""'f,,\~.,_ ""1"" ~"""" .~~..,,"~-'- " 1'Tf'W"\"'~;!~~~~i!! I I ~""..,..,.."...... ~~ - ~ ~. "~~. 'I" - "-'il',-M"""~''''',,",,*~f'~ -* ,~~,.~~_) I"!'~ .""~~~'r "'~~~ ~ ~"<;~., ~~~""" '--'''''''-'"-'''''''''''~.'''~''''''~'~~ I -,,~ <">'!.__.....'!',..,..._-"'1"Ifii\1~I!I!~__.. , ~~~,l"~-;'~'" ~. , 2 'mW__~, ~~ _ ~~.", p - 1 ~ ,.. ~~" ~_,,~!nl'l[!lI ....... , I I I , I 1 I I I I I i I I I I I I ~. I I I I i , I I I , I t , I ! ~ I I ! i I I " , I i I "-"',,,,,,,,,- I, W>"""'",- PB1 In The Court of Common Pleas of York County, Pennsylvania 2001/11/28 KERRY R SAINTZ VS JENNIFER SAINTZ Case Number 1993 SU 01064 03 Case Type Custody APPEARANCES BRUNT, CONSTANCE P D 001 NO~LE-SAINTZ, JENNIFER 703 YMCA DRIVE NEW CUMBERLAND PA 17339 BRUNT, CONSTANCE P D 002 RINKER, JENNIFER YMCA DRIVE NEW CUMBERLAND PA 17339 CONNELLY, JOHN J JR POOl SAINTZ, KERRY R 1005 SILVER LAKE ROAD LEWISBERRY PA 17339 DOCKET ENTRIES 1993/03/10 COMPLAINT IN CUSTODY ACTION 1993/03/10 DIRECTIVE APPOINTING CUSTODY CONCILIATOR STEVEN M CARR ESQ ASSIGNED TO CONDUCT A CONFERENCE ON MARCH 23 1993 AT 10:00 1993/05/04 ORDER OF COURT MATTER DISMISSED W/OUT PREJUDICE VIDE BY CT J BLACKWELL 1993/05/04 NOTICE GIVEN RE: PA R. C. P. 236 1993/05/04 REPORT OF CONCILIATOR STEVEN CARR ESQ 1993/11/24 ORDER RE: CUSTODY BY CT PENNY L BLACKWELL JUDGE 1993/11/24 NOTICE GIVEN RE: PA R. C. P. 236 55.00 0028 0015 100.00 0028 0015 0.00 0049 0395 0.00 0000 0000 0.00 0049 0109 0.00 0137 0859 0.00 0000 0000 , PB1 In The Court of Common pleas of York County, Pennsylvania 2001/11/28 KERRY R SAINTZ VS JENNIFER SAINTZ Case Number 1993 SU 01064 03 Case Type Custody DOCKET ENTRIES 1993/11/24 CONSENT TO ENTRY OF COURT ORDER 1993/11/24 CONCILIATION CONFERENCE MEMORANDUM 1994/06/06 PETITION FOR MODIFICATION OF CUSTODY ORDER 1994/06/06 DIRECTIVE APPOINTING CUSTODY CONCILIATOR STEVEN M CARR ESQ ASSIGNED TO CONDUCT A PRE HRG CONF 6/21/94 AT 11 AM/DIST CT ADMNR 1994/06/24 REPORT OF CONCILIATOR FILED BY STEVEN M CARR ESQ 1994/06/30 ORDER FOR MEDIATION BY THE CT: PENNY L BLACKWELL JUDGE (BOTH PARTIES TO ATTEND ORIENTATION MEDIATION) 1994/06/30 NOTICE GIVEN RE: PA R. C. P. 236 1994/06/30 ORDER RE: CUSTODY BY THE CT: PENNY L BLACKWELL JUDGE 1994/06/30 NOTICE GIVEN RE: PA R. C. P. 236 1994/08/05 WITHDRAWAl AND ENTRY OF APPEARANCE WITHDRAW OF MARIA P COGNETTI ESQ & ENTRY OF CONSTANCE P BRUNT ESQ ON BEHALF OF DEFT 1994/10/03 WITHDRAWAl AND ENTRY OF APPEARANCE WITHDRAW JOHN J CONNELLY JR ESQ & ADD DIANE G RADCLIFF ESQ FOR PLTF ;\~'(l\;~~ . """..'- 1-<' 'I" r ~,~ - - 0137 0848 0137 0847 0055 0050 0055 0050 0062 0577 0064 0759 0000 0000 0064 0758 0000 0000 0077 0004 0096 0357 0.00 0.00 0.00 100.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 -~.~-~"~~,~ s PB1 In The Court of Common Pleas of York County, pennsylvania 2001/11/28 KERRY R SAINTZ VS JENNIFER SAINTZ Case Number 1993 SU 01064 03 Case Type Custody DOCKET ENTRIES 1995/07/1~ ORDER FOR RESCHEDUlED BY THE CT: PRE-TRIAL CONFERENCE FOR AUG 31 1995 1PM IN CHAMBERS PENNY L BLACKWELL JUDGE 1995/07/19 NOTICE GIVEN RE: PA R. C. P. 236 1995/07/28 ORDER FOR PRE-TRIAL CONFERENCE SCH FOR 9/29/95 @ 8:30AM IN CHAMBERS BY THE CT: PENNY L BLACKWELL JUDGE 1995/07/28 NOTICE GIVEN RE: PA R. C. P. 236 1995/08/08 MEDIATION REPORT 1995/10/23 ORDER FOR PRE-TRIAL CONFERENCE SCHEDULED FOR NOV 16 1995 1PM IN CHAMBERS BY THE CT: PENNY L BLACKWELL JUDGE 1995/10/23 NOTICE GIVEN RE: PA R. C. P. 236 1995/12/22 PETITION FOR CONTEMPT OF CUSTODY ORDER 1995/12/22 DIRECTIVE APPOINTING CUSTODY CONCILIATOR STEVEN M CARR ESQ ON 1/9196 AT 9:00 AM 1996/02/20 ANSWER TO PETITION FOR CONTEMPT ORDER 1996/02/22 ORDER RE: CUSTODY TRIAL SCHEDULED FOR MAY 14 & 15 1996 lOAM BY THE CT: PENNY L BLACKWELL JUDGE i"~-"''',~", C..L"'.' ." "-,. . . 0075 0015 0000 0000 0080 0014 0080 0014 0083 0170 0119 0164 0000 0000 0142 0141 0142 0141 0017 0806 0018 0080 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 100.00 0.00 0.00 ~ --- '" ~~-~"" ,~ f PB1 In The Court of Common Pleas of York County, Pennsylvania 2001/11/28 KERRY R SAINTZ VS JENNIFER SAINTZ Case Number 1993 SU 01064 03 Case Type Custody DOCKET ENTRIES 1996/02/2~ NOTICE GIVEN RE: PA R. C. P. 236 1996/02/23 REPORT OF CONCILIATOR FILED BY STEVEN M CARR ESQ 1996/02/27 CONCILIATION CONFERENCE MEMORANDUM SUBMITTED BY CONSTANCE P BRUNT ESQ 1996/02/27 ORDER RE: CUSTODY COUNSEL DIRECTED TO CONTACT COURT FOR HEARING DATE BY CT: PENNY L BLACKWELL JUDGE 1996/02/27 NOTICE GIVEN RE: PA R. C. P. 236 1996/03/05 CERTIFICATE OF SERVICE OF DEFT/RESPONDENT'S ANSWER TO PET FOR CONTEMPT ORDER 1996/03/13 ORDER OF COURT SCHEDULING HEARING RESCHEDULED FOR JUNE 11 & 12 1996 lOAM CT RM 5 BY CT: PENNY L BLACKWELL JUDGE 1996/03/13 NOTICE GIVEN RE: PA R. C. P. 236 1996/05/10 WITHDRAWAL AND ENTRY OF APPEARANCE WITHDRAW DIANE G RADCLIFF ESQ & ENTER JOHN J CONNELLY JR ESQ FOR PLTF 1996/06/28 ORDER RE: CUSTODY BY THE CT: PENNY L BLACKWELL JUDGE 1996/06/28 NOTICE GIVEN RE: PA R. C. P. 236 "~~','" . . "",'Y\ """,' ~I' ! 0000 0000 0018 0606 0019 0345 0020 0314 0000 0000 0021 0621 0025 0531 0000 0000 0049 0011 0069 0097 0000 0000 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 , PB1 In The Court of Common Pleas of York County, Pennsylvania 2001/11/28 KERRY R SAINTZ VS JENNIFER SAINTZ Case Number 1993 SU 01064 03 Case Type Custody DOCKET ENTRIES 1996/07/0! ORDER OF COURT SHARED LEGAL CUSTODY BY THE CT PENNY L BLACKWELL JUDGE 1999/02/19 PETITION TO RECEIVE COURT APPROVAL TO MOVE W/CERT OF SVC 1999/02/19 DIRECTIVE APPOINTING CUSTODY CONCILIATOR STEVEN M CARR ESQ TO CONDUCT CONFERENCE ON 3/2/99 AT 2PM BY THE CT RICHARD KRENN J 1999/03/31 REPORT OF CONCILIATOR BY JAMES A HOLTZER ESQ 1999/04/01 PRE-TRIAL ORDER CUSTODY RELOCATION/MATTER SCHEDULED FOR JUNE 6/2/99 AT 1:30 CTRM 11 BY THE CT R K RENN J 1999/04/01 NOTICE GIVEN RE: PA R. C. P. 236 1999/04/06 CONCILIATION CONFERENCE MEMORANDUM SUBMITTED BY JOHN J CONNELLY, JR 1999/04/06 ORDER SCHEDULING HEARING JUNE 2, 1999 AT 1:30 PM FOR RELOCATION BY THE CT RICHARD KRENN J 1999/04/06 NOTICE GIVEN RE: PA R. C. P. 236 1999/04/19 STATEMENT FOR RELOCATION W/CERT SVC 1999/06/30 ORDER OF COURT THIS ORDER SHALL SUPERSEDE THE PRIOR ORDER OF COURT ENTERED BY THE COURT RICHARD KRENN J ii~~i'- If'l"$! =,- ., r-!? .. 0069 0592 0022 0032 0022 0032 0040 0072 0041 0246 0041 0246 0041 0362 0041 0361 0041 0361 0048 0220 0086 0011 0.00 0.00 100.00 0.00 1.00 0.00 0.00 0.00 0.00 0.00 0.00 ",-' PB1 In The Court of Common Pleas of York County, Pennsylvania 2001/11/28 KERRY R SAINTZ VS JENNIFER SAINTZ Case Number 1993 SU 01064 03 Case Type Custody DOCKET ENTRIES 1999/06/3Q NOTICE GIVEN RE: PA R. C. P. 236 1999/12/01 DIRECTIVE APPOINTING CUSTODY CONCILIATOR STEVEN M CARR ESQ ON 12/21/99 AT 2:00PM IN CONFERENCE ROOM BASEMENT GOVT CENTER 1999/12/01 PETITION FOR CONTEMPT & MODIFICATION OF EXISTING CUSTODY ORDER WICERT OF SVC 1999/12/16 ENTRY OF APPEARANCE OF CONSTANCE P BRUNT ESQ ON BEHALF OF DEFT W/CERT OF SVC 1999/12/21 WITHDRAWAL OF APPEARANCE FREDRICK B GIEG JR W/ CERT OF SVC 2000/01/20 PETITION FOR TRANSFER OF ACTION TO MORE CONVENIENT FORUM W/CERT OF SVC 2000/02/04 REPORT OF CONCILIATOR BY STEVEN CARR ESQ 2000/02/07 ORDER RE: CUSTODY 6/30/99 ORDER SHALL REMIAN IN FULL FORCE & EFFECT BY THE CT RICHARD KRENN J 2000/02/07 NOTICE GIVEN RE: PA R. C. P. 236 2000/02/16 ORDER OF COURT TESTIMONY WILL BE TAKEN ON 3/8/00 AT 3:00 PM IN CT RM #5 BY THE CT PENNY L BLACKWELL J 2000102/16 NOTICE GIVEN RE: PA R. C. P. 236 i,~fJ"'l' .-^- ~;~:'I'"'T" .'"' .,.. , " , '" 0086 0011 0156 0280 0156 0280 0163 0695 0165 0478 0008 0519 0016 0576 0018 0627 0018 0627 0022 0522 0022 0522 0.00 125.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 ~~ "~.-~~~'-,- PB1 In The Court of Common Pleas of York County, Pennsylvania 2001/11/28 KERRY R SAINTZ VS JENNIFER SAINTZ Case Number 1993 SU 01064 03 Case Type Custody DOCKET ENTRIES 2000/03/0~ APPLICATION FOR CONTINUANCE ON 4/11/00 AT 9:00 IN CT RM #5 BY THE CT PENNY L BLACKWELL J 0.00 0029 0473 2000/06/21 ORDER RE: CUSTODY AND VISITATION BY THE CT:BLACKWELL J(VIDE ORDER ENTERED PUR- SUANT TO A NEGOTIATED SETTLEMENT) 0.00 0077 0066 ** END o F CAS E P R I N T 0 U T ** (PROTR10) ;~~w, ~" ~, "- . ""', ,..-.,,1-,-- - -.~.- <" ~~" ~. PB1 In The Court of Common Pleas of York County, Pennsylvania 2001/11/28 KERRY R SAINTZ VS JENNIFER P SAINTZ Case Number 1993 SU 02597 03 Case Type Custody APPEARANCES D 001 SAINTZ, JENNIFER P 703 YMCA DRIVE NEW CUMBERLAND PA COGNETTI, MARIA P 17339 CONNELLY, JOHN J JR POOl SAINTZ, KERRY R 1005 SILVER LAKE ROAD LEWISBERRY PA 17339 DOCKET ENTRIES 1993/06/16 COMPLAINT IN CUSTODY ACTION 1993/06/16 DIRECTIVE APPOINTING CUSTODY CONCILIATOR DOROTHY LIVADITIS ESQ ASSIGNED TO CONDUCT A CONFERENCE ON JULY 2 1993 AT 9:00 1993/07/07 REPORT OF CONCILIATOR FILED BY DOROTHY LIVADITIS CONTINUING HEARING SEPT 1, 1993 1993/08/03 AFFIDAVIT OF SERVICE OF COMPLAINT FOR CUSTODY 1993/10/12 REPORT OF CONCILIATOR CONF CONTINUED FILED BY GLENN C VAUGHN ESQ 1993/11/23 REPORT OF CONCILIATOR GLENN C VAUGHN ESQ 1997/05/06 CASE INACTIVE PER LOCAL RULE 6036 97-MI-00154 ** END o F CAS E P R I N T 0 U T ** (PROTR10) ~~or..l" " .~ 1,,' -"'," "~-~'I '1--, ' 0068 0185 0068 0185 0079 0190 0091 0440 0121 0033 0138 0008 0049 0680 "- '- 55.00 100.00 0.00 0.00 0.00 0.00 0.00 - -'" ',-. PBI In The Court of Common pleas of York County, Pennsylvania 2001/11/28 JE~NIFER P NOBLE-SAINTZ VS KERRY R SAINTZ Case NUl)lbei Case Type 1993 SU 03181 08 Other APPEARANCES D 001 SAtNTZ, KERRY R 1005 SILVERLAKE RD LEWISBERRY PA 17339 LYONS, JOHN F POOl NOBLE-SAINTZ, JENNIFER P 703 Y M C A DRIVE NEW CUMBERLAND PA 17070 BRUNT, CONSTANCE P DOCKET ENTRIES 1993/07/23 PETITION FOR PROTECTION FROM ABUSE 50.00 0087 0132 1993/07/23 TEMPORARY ORDER. HEARING DATE, 0.00 JULY 28 1993 AT 2:00 (VIDE) BY THE COURT 0087 PENNY L BLACKWELL JUDGE 0132 1993/07/28 ORDER OF COURT 0.00 MATTER CONTINUED 8/27/93 @llAM IN CT RM #5 0089 VIDE BYCT J BLACKWELL 0091 1993/07/28 NOTICE GIVEN RE, PA R. C. P. 236 0.00 0000 0000 1993/09/13 SHERIFF RETURN OF SERVICE 33.52 SERVICE WITHDRAWN BY PLNTF ON 8/2/93 0108 9/10/93 SHF OF YORK CO 0511 1993/10/22 ORDER OF COURT 0.00 PFA ORDER WITHDRAWN - PLT TO PAY COSTS W/IN 0125 30 DAYS BY CT PENNY L BLACKWELL JUDGE 0033 1993/10/22 NOTICE GIVEN RE: PA R. C. P. 236 0.00 0000 0000 1994/07/19 PETITION FOR PROTECTION FROM ABUSE 20.00 0070 0605 , <'I; -,,' :r: .~ .. . -, , r~ ~. . ,~. -;.,.':~'li "~- PB1 In The Court of Common Pleas of York County, pennsylvania 2001/11/28 JENNIFER P NOBLE-SAINTZ VS KERRY R SAINTZ Case Number 1993 SU 03181 08 Case Type Other DOCKET ENTRIES 1994/07/1~ TEMPORARY ORDER. HEARING DATE: JULY 19 1994 AT 1:45 BY THE COURT PEWNY L BLACKWELL JUDGE 1994/07/29 STIPULATION OF PARTIES 1994/07/29 ORDER RE: FINAL RESOLUTION OF PFA BY THE COURT PENNY L BLACKWELL JUDGE 1994/08/04 ORDER OF COURT CON'T TILL 8/23/94 BY THE CT:BLACKWELL JUDGE 1994/08/04 NOTICE GIVEN RE: PA R. C. P. 236 1994/09/02 ORDER OF COURT ORDER OF CT DATED 7/29/94 IS AMENDED PARTIES TO SPLIT COSTS BY THE CT:BLACKWELL JUDGE 1994/09/02 NOTICE GIVEN RE: PA R. C. P. 236 1994/10/20 SHERIFF RETURN OF SERVICE DEFT KERRY R SAINTZ NOT SERVED WITHIN HEARING DATE ** ** (PROTR10) o F CAS E P R I N T 0 U T END ';-,~~, _e , ~ ,I r ~" """""""'! 0.00 0070 0605 0.00 0074 0468 0.00 0074 0468 0.00 0076 0442 0.00 0076 0442 0.00 0087 0459 0.00 0087 0459 54.80 0102 0399 ~~.",~.~ ,~, 11 ,.., .' PENNSYLVANIA DEPARTMENT OF TRANSPORTATION VEHICLE RECORD ABSTRACT 11/27/01 PAGE 1 231000 OWNER KERRY R SAINTZ 731 HARRISBURG PIKE DILLSBURG PA 17019 TITLE NUMBER TAG NUMBER VIN 49534800 ZF14264 J8BC4BIK3S7006793 MAKE l"ODEL RENE.WAL WI D PREVIOUS TAG LIENS STOPS CHEVROLET 011l743m28104a 001. YES NO TITLE BRAND INFORMATION NO TITLE BRANDS ,EXIST FOR IHIS l'ITLE LIEN INFORMATION LIEN HOLDER NO.(" NAME NEW tUMB FCU ADDRESS: 6191lRIDGE ST NEW C,UMBERLAND PA 170711 013310733000138 002 LESSEE NONE TITLE DATE REGISTRATION EXPIRY DATE: BODY TYPE ODOMETER READING ,lEACTUAL MILEAGE DUPLICATE T,ITLE COUNT 'VEHICLE YEAR STOLEN DATE EXPI,RATION DAlE,: 04/25/02 ABA NO : ELT IND: NO 2ND OR 3RD LIENS EXIST FOR THIS TITLE ADDRESS CORRESPONDENCE TO: DEPARTMENT OF TRANSPORTATION VEHICLE RECORD SERVICES PO BOX 68691 HARRISBURG, PA 17106-8691 b',~~, '_'" '"'": ,~"~~~';'_ -1'"",'1'_:, INFORMATION: (7:00 IN STATE OUT-OF-STATE TDD IN STATE TDD OUT-OF-STATE WWW.DOT.STATE.PA.US 04/25/96 03/02 TK 129lE o 1995 AM TO 9:00 PM) 1-800-932-4600 717-391-6190 1-800-228-0676 717-391-6191 ,l~~ ,~ -~~- PENNSYLVANIA DEPARTMENT OF TRANSPORTATION VEHICLE RECORb ABSTRACT 11/27/01 PAGE 1 231000 OWNER KERRY R SAINTZ 731 HBG PIKE DILLSBURG PA 17019 TITLE NUMBER TAG NUMBER VIN . 52562059 BSK5854 lLNFM82W3WY608924 MAKE 1;l0DEL RENEWAL WID PREVIOUS TAG LIENS STOPS LINCOLN SIG 011693902901265 001 NO NO 013310733000245 015 LESSEE NONE TITLE DATE REGISTRATION EXPIRY DATE: BODY TYPE ODOMETER READING ...*ACTUAL MILEAGE DUPLICATE. TITLE COlJNT VEHICLE .YEAR S.TOLEN<DATE TITLE BRAND INFORMAtIoN NO TITLE BRANDS EXIST FOR. TillS TITLE ADDRESS CORRESPONDENCE TO: DEPARTMENT OF TRANSPORTATION VEHICLE RECORD SERVICES PO BOX 68691 HARRISBURG, PA 17106-8691 H '(VjiJI"J) _c ',_, - '''I" ~ INFORMATION: (7:00 IN STATE OUT-OF-STATE TDD IN STATE TDD OUT-OF-STATE WWW.DOT.SIATE.PA.US "'" , 10/15/98 08/02 SDN 107* o 1998 AM TO 9:00 PM) 1-800-932-4600 717-391-6190 1-800-228-0676 717-391-6191 . ," "n~ --'~'1. - 'i 231000 OWNER TITLE NUMBER TAG NUMBER VIN MAKE ~ODEL RENEWAL WID PREVIOUS TAG LIENS STOPS PENNSVLVANIA DEPARTMENT OF TRANSPORTATION VEHICLE RECORD ABSTRACT 11/27/01 PAGE 1 SAINTZ PLUMBING & ELECTRIC 731 HBG PK DILLSBURG PA 17019 53523994 XG90693 IJKDTA203WA000995 INTERSTATE 010881160000510 001 NO NO " TITLE BRAND INFORMATION NO TITLE BRANDS EXIST FORTflI'STITLE\ ADDRESS CORRESPONDENCE TO: DEPARTMENT OF TRANSPORTATION VEHICLE RECORD SERVICES PO BOX 68691 HARRISBURG, PA 17106-8691 <>2j;W~-,,; <"",. ~ ." -" I -~ ."' 013310733000245 010 LESSEE NONE TITLE DATE REGISTRATION EXPIRV DATE: BODV TVPE ODOMETER READING ,~~XEMPTIlVFED. LAw D~PLIC~TETITLE COUNT VEHICLE YEAR SjOLEN" DATE INFORMATION: (7:00 IN STATE OUT-OF-STATE TDD IN STATE TDD OUT-OF-STATE WWW.DOT.STATE.PA.US ~~ 07/21/99 02/02 TRL IE o 1998 AM TO 9:00 PM) 1-800-932-4600 717-391-6190 1-800-228-0676 717-391-6191 ~"'~-'fT~ ~ ~ ~.., L PENNSYLVANIA DEPARTMENT OF TRANSPORTATION VEHICLE RECORD ABSTRACT 11/27/01 PAGE 1 231000 013310733000245 011 OWNER KERRY SAINTZ DBA SAINTZ PLUMBING & ELECTRIC 731 HBG PK DILLSBURG PA 17019 LESSEE NONE TITLE NUMBER TAG NUMBER VIN 53551565 ZS45302 IFTYR90LXHVA14543 TITLE DATE REGISTRATION EXPIRY DATE: BODY TYPE ODOMETER READING ',-'-- ," -, lEACTUAL M~LEAGE DUPLI9A~E TITLE COUNT VEHICLE '{EAR STOLEN DATE MAKE \,!ODEL RENEWAL WID PREVIOUS TAG LIENS STOPS FORD 010931107000745 001 NO NO TITLE BRAND INFORMATION NO TITLE BRANDS EXIST ADDRESS CORRESPONDENCE TO: DEPARTMENT OF TRANSPORTATION VEHICLE RECORD SERVICES PO BOX 68691 HARRISBURG, PA 17106-8691 INFORMATION: (7:00 IN STATE OUT-OF-STATE TDD IN STATE TDD OUT-OF-STATE WWW.DOT.STATE.PA.US ,;\;~i\!'f'W'-""'_' "'1-0,\' - I 07/28/99 03/02 TT 327,176lE o 1987 AM TO 9,00 PM) 1-800-932-4600 717-391-6190 1-800-228-0676 717-391-6191 I~"l"'~ ~ ,. PENNSYLVANIA DEPARTMENT OF TRANSPORTATION VEHICLE RECO~b ABSTRACT 11/27/01 PAGE 1 231000 OWNER KERRY R SAINTZ PLUMBING & ELEC SVC. 731 HARRISBURG PIKE DILLSBURG PA 17019 TITLE NUMBER TAG NUMBER VIN 46073677 ZK35996 2FDLF47M4JCA88729 MAKE !"ODEL RENEWAL WID PREVIOUS TAG LIENS STOPS FORD TITLE BRAND INFORMATION NO TITLE BRANDS EXIST FOR THIS ADDRESS CORRESPONDENCE TO: DEPARTMENT OF TRANSPORTATION VEHICLE RECORD SERVICES PO BOX 68691 HARRISBURG, PA 17106-8691 i'i~X\1i~""',",1'l. _ _ "_ ,'" _~ "'~~,"~I l " 013310733000245 012 LESSEE NONE 010881160000510 002 ZD9.4744 . NO NO TITLE DATE REGISTRATION EXPIRY DATE: BODY TYPE ODOMETER READING . ii.itACTUALMILEA.GE DUPtICi\TETmE COUNT ...VEHICLEVEAR Sl'OLEN.iDATE INFORMATION: (7:00 IN STATE OUT-OF-STATE TDD IN STATE TDD OUT-OF-STATE WWW.DOT.STATE.PA.US .. - 04/28/93 04/02 TK 156,539lE o 1988 AM TO 9:00 PM) 1-800-932-4600 717-391-6190 1-800-228-0676 717-391-6191 I ~~ ~ .--"""""" "~"",.. ::,.,. PENNSYLVANIA DEPARTMENT OF TRANSPORTATION VEHICLE RECORd ABSTRACT 11/27/01 PAGE 1 231000 013310733000245 013 OWNER KERRY R SAINTZ PLUMBING & ELECTRICAL SERVICE 731 HARRISBURG PIKE DIllSBURG PA 17019 lESSEE NONE TITLE NUMBER TAG NUMBER VIN 38686009 85265 194670S416890 TITlE DATE REGISTRATION EXPIRY DATE: BODY TYPE ODOMETER READING lEl\CTUAl MILEAGE DlIPlltA'(E TITLE COUNT V!;HIClE 'yEAR STOlEN.D.ATIE MAKE t;10DEl RENEWAL WID PREVIOUS TAG lIENS STOPS CHEVROLET 0.0148.5320000500 001 BYP0244 NO.. NO TITLE BRAND INFORMATION CLASSIC VEHICLE ADDRESS CORRESPONDENCE TO: DEPARTMENT OF TRANSPORTATION VEHICLE RECORD SERVICES PO BOX 68691 HARRISBURG, PA 17106-8691 INFORMATION: (7:00 IN STATE OUT-OF-STATE TDD IN STATE TDD OUT-OF-STATE WWW.DOT.STATE.PA.US &~ -^ -1 ~"'--I ~ 09/04/86 99/99 CONV 104,070lE o 1970 AM TO 9:00 PM) 1-800-932-4600 717-391-6190 1-800-228-0676 717-391-6191 , -^~,."..~-" ," -~~""".'"'" .: , r' . PENNSYLVANIA DEPARTMENT OF TRANSPORTATION VEHICLE RECORD ABSTRACT 11/27/01 PAGE 1 231000 013310733000245 014 TITLE DATE 07/02/82 REGISTRATION EXPIRY DATE: BODY TYPE SME ODOMETER READING ~ *ACTUAL MIL EAGE DuplfCATETITI..E COUNT 0 VEHWLEXEAR 1981 STOLEN DATE OWNER KERRY R SAINTZ 1005 SILVER LAKE RD LEWISBERRY PA 17339 LESSEE NONE TITLE NUMBER TAG NUMBER VIN 34454580 1050S002864 MAKE l"ODEL RENEWAL WID PREVIOUS TAG LI ENS STOPS JOHN DEERE SME0325 NO .. NO TITLE BRAND INFORMATION NO TITLE BRANDS EXIST FOR. THIS TITLE ADDRESS CORRESPONDENCE TO: DEPARTMENT OF TRANSPORTATION VEHICLE RECORD SERVICES PO BOX 68691 HARRISBURG, PA 17106-8691 INFORMATION: (7:00 IN STATE OUT-OF-STATE TDD IN STATE TDD OUT-OF-STATE WWW.DOT.STATE.PA.US '-1~f1I"F.':'~~ " '.,' <'-C'- ~~ '~''"'"'r~''' ,~ - - ,--, - AM TO 9:00 PM) 1-800-932-4600 717-391-6190 1-800-228-0676 717-391-6191 "....- II ___ E'!~: IF::; . L, n ~': Ir 5 "','JII-,nr'ma"cga(lcrc/ f1. 'c ;~'=i r .1I_m;::;:nl ,:'f;, 'Ie ~" ~JI~G ,',I 1 j'O: ~ I J I r 11(- ~'f"II' I I :"lIu'_lai) M,d rn~ hr'Q address "o.l'-O" "'" ,1.",1 n""," j",1 '1InJN'dual)ar"ldma,lmgaCldress' SEGUREO r,p,R1Y(lcs} name(s) (Iasl name Ilrs! If ind>vldual) and ~ddress for securl!Y''11nre,11r"lform,111(Jr1: PNCBANK, NATIONAL ASSOCIATION 4242 CARLISLE PIKE CAMP HilL. PA 17001::"8874 , ASSIGNEE(S) OF SECURED PARTY r1ame(s)(lasl name Ilrs! il individual) and "ddre~'s lor S~C\I"ty Inlerest Inlormalion: " SPECIAL.TYPES OF PARTIES (Cneck If appl1cab!er D The terms 'Oebtor' and 'Secured Party' mean 'Lessee" and "l.essor', re~peC!iveIY. o o The terms 'Debtor',~r.d 'Secured Parly' mean 'Consignee' and 'Cons-Ignor",respeellvely. Dabtor]S'a-1't,ansmllllllgulll1ly ..SE~!if!~p'P)\iiTV$il>~#Ti'J.Ij):(S). . ":'.Ti:lls 'ST'A i~MEN+ i'{F'ILE,D-'v./frli-ONl:Y ThE:,'StB'U~EO:PAfrty's 'SrGNj\ T.URE ',16 peft ~~ I.-a se:-;ur'Jly'lnlef'es l i("l coUaf~ral(c neck4ppllcable' ',box(e:s))~" '-c_ c_ " , o "n. : ""L.::J A6,9j:iiA,~P"AF,::n:J'l (>:'CHAN'GE':O~"NAME, ,rDENT'rTY oFi .COR.PQRATE':Slfl'OCTURE'ollhc'Deblor. ,_ii'S'lo,'~h'i~;' iJ:ie "iJJn,~ has lapsed. :,~~',;3;1~,~'a~VS\J:?jilCi \:?:;a;:~5Ctir~IYjn-refesl in ANOTHER COUNTY in penn~VIi(.i'hja-' '. ::it;;L.8 I"~':w'~~~}h~:f:~~kAtEF{;o.l-WAS' MOVED '10 \hIS'~OUIll'y.' .. f[] ';~-Ii~i'i~~;,D:~~~:ti)~>S"~E$l_DI:NCE QR P~ACE 'OF.'BOslN'E'-SS-' '~,"; ':,'; ?:;'_}:r"f;~,_:F~~,~'-?;;;?~.'n"IS i:,OUhfy, ';alr~a?y~ ~_u,~je~-t:t-o-'_i, S :cllHty,: inlere~lln- ANOTHER JUR Ismcno'N -__ azl,S~~i~:;A~ 9,Q(,i.:ATEA;I{C'WAS'MOVED IcPenn$ytir~ a. :'i,',_:: .-V_'_"',,, ,',-;_. ,,--'-'-" ',,:----;. m--:, -:';~;~~~~i'6'(b:~-'~t_6~~~tRE~i'O-ENCE: OR PLACEi OF'BU5'[WiSS ,,';""AS,,~S~Y.!'P'IO'Pfl1f1~Ylv_an(a'. . . - -"'il; c- .;, ;',_e;'-~- G2]' ;-j}~'l:b~h{i#-d_9,~_Ei:H,::oi ,f!'!(j;'~_6'11ateraj-'(:Iescrl_becf InJiloekW:ln': ,: ' - -, ,,{ft1tj~I:j,;a":,s'e,B(j9')'>!Il"(ei;9_s-t._wasJl:~;evl'6u$ly-p1!r1 u.ct'e"d '(arSlJ''tl'estrlbe .' ",,:- prO,ceel:1S'iJJ:r;bfocliAI',;)[p'(jfl;fiii.s'edwrl;h-p_a$h,proC~'HIs,an'Cl nol :' :'cad~Q'_~a:I~r1:~~~crjeerl. 'on t ~e;o~Tgl~al finarrcing 's la:remet',iJ. " ':/.!;'E'~DFfE6~~.i'iR~~:$-r~N:A'TUAE(S~ \r,eq'llinra bnly)f''l:li::lX{esf!s chec!(ed ilbove): '"-!iII""; 'lit lr~------ I I ;:'I_ING N': I a,,",p~( ','i L!ln~ 'JqIG~.): II I'll 1\ i. ')"7')([;>'.". e.("Y'-".,. ; "" "-1' +- " J . 1 )~ J.c_, D"..\, L "_~--'-n~':'-!'.. [,hiS FI_NANCING STATEMENT_is pr'lsentf'd for filing pursuant to the Urlllor.m. com,mercl.a,_ COdu, ar.d,~ " 110 be Illed wIlh the (checK appllcabl,~ box): - ,- j, : ~ :_ :' ~ ., . . . , '1 I' [~ Secretary of fhe Commonwe.llh, ;'. Dpro\l10notafYOf_"_~~. __-1!L [J rc:..lllslale Records of FINANCING STATEMENT u '~iFOr.r", COMMERCIAL. CODE FOPM ",: 01, [, f'f,1c:, j 01 a"~' ': d (, y ,1(," County. Counly. NUMBER OF ADDITIONAl. SHEETS (II any): OPTIONAL SPECIALIO[NTiFICATI,ON,{Max. 10characlerS): COLLATERAL 6 idehlllycollaleral by item and/or type: -K . ,AlI_J~venJory, Chattel P~Re,r, ,Accounts, .Egulpm~_~t ,-a:n-d :<3enej"al_lnf~n9ibl~S,; Jog,et,her W_i,th,:: h],~" follo'wi.r19 ,':sf:ie~mcallY' ,.'ge~cn~'~"d.-';;Ptbl?~rtY: _ : 1,i1strl!nwo~s -_ :and, O~9tiifl~ryt.~; wheth13r -sny ;'of lh,e ,--'f(Jregoll!9_",is', })Wne.d",'-poW'Xbr--adq:U,'~Eld ,.'~!e.r; ,,_aU:,-'N~~,e~Sl?ns; ...a. d. "...'I.I...lon. s. '.J~p...I.a. ...Q.em. .erH.S. ;:,..:il...rf..d... .....s.......U..b.,.,..~t..I.tU....I..l0." ~...s..5..r...li.. ..1.". :ti,n......~.......'JO '.,R...."...!Y.. ...."..:-' It. he., :'.'9._~~._',g.. o,in.9. ;.;.".....'....I.~ J.ec. 0.,.,. d,S. ....... .... --rt . ~f:;~.r!y-J<.j~,d '~~Ii1tir:ig'-.t9 ;.any, '?f\~~e:;;~o.r~~Q~!j"f9.;'--~It. ,p.n?~~ds, Tel~tmg; I? ,-anx, Qf,.J~e: J{rt.~~-, ..f.or~.'9... blnjt(m.C_I_.~..di.h,9.. -lhsU'ral)Ce.,;-'.9... e._-lJ.~r~_IIi1..,1!l.n9.IOles .at)d:~hi.;{.accpuj:1ts..-prp~. 8_8..- ~sj. .'...:.......:.::...'..... ...:...'. 1<--/t;i,j;;:fiN-<~,-,t. Q'id u:;tQl' ,i}"'(.OA')('(;r.'1/) w.-fI; : t' ...~ 'ti";'Il:~r',,-.:ir:_r,X.)?',r;>~i\4_ 44i'~y -a~- ,rx'o/"~ kJ\~lUt)' (:~r ~o~ ,::lOS' 9Ad ~o.? M.Ji6\','l ,::~.6t,i..:,;'!}1_((~,(~-~'-' L!J (check or1lY H deslred)Producls pI the r.ollateral areaISOCo'lered. t1A 1'7(1 CS . '9~ ". ,,~, ']OE~T1FY RELAT,ED REAL-ESTATE" If applicable, The collaleral Is, or Includes (check appr'oprla_l~ 'oo)((e$I)__ a: '_0 CROPS 1,)"0Wlng:or 10 oe'Jltownon-- 1r...0 goods-whIch are 10 become FIXT.URE t;:m_w t. '0 MiN~'RALS,or'tne like:tll\c,I'Udlng'~1l and:~ii-s)-a's-ex.ftj6'ed on-- 'd'. 0 ACCO-li't;l'TS,RE-i;:'UL TIr>JG:FRd~;ft.HE:pAlE'OF MiNERALS or Ihe like (li1tJu!fli1g 6il'~n'(':gas): :': :illh'eviellheadOl'mfne-h'eli'tlqn__ . , . . IhefoHow!llg'r'eal"e~tare.: STREET'ADdRESS: . '_', - . q~$CAfBE'A-trBO'ol(~:or(~,Il'~~\(omif .O,:;6'e,ed& ,D ModgageS;aIPag~(~):>, -,<:_' ..,. for "'Co(Jr'\'ly_.,~rijform-ParceHdent1fler _~ _>-:..,. '-;;:"" ' tJ 6escrib'e On' 4odrl~onM-S/1ee'i , J .. . . . . -. ,~_A'Mi:: OF':RECORD 6Wf,ir;R (requlrea-onIY If ri6"D~-i:ilotAi~i'.~inrrl-er~stof record): 1b ';;FlEitff:l.N'RE'OEJP~TO:, _ _''"'':'__ _:_" ~_-,,'::':: ,,",', 'c .....PNC;llilNlii"J!A1liJN~'lIS~6'CIAl'idN. '.1. ... .1~~~\'li1~~f1l?~'!~1~~T< 'L, .."""~~\ ":~b:rE :-~T:.hiS'-f!~g~"w~jr~~:4t';~,~1f~;qr~~#!~i1~~~~p~rf.~~:nt':o,f"$.tale. " II " 11 '2 ", I=~ ' '. IN RE: KRISTA C90MBS, Individually and as ~nt and Natural!. Guardian of KAY LA COOMBS, a Minor . . IN THE COURT OF COMMON PLEAS. CUMBERLAND COUNTY, PENNSYLVANIA . . NO. 01 - ~/;)'f C(oL'T~\. PETITION FOR APPROVAL OF MINOR'S SETTLEMENT HEARING ORDER AND NOW, this ~ tlJ day of Novu-n/;ve.. , 2001, IT IS HEREBY ORDERED AND DECREED that a Hearing will be held on the Petition for Approval of Minor's Settlement for Kay1a Coombs, a minor, in Courtroom No. S- of the Cumberland County Courthouse, One Courthouse Square, Carlisle, Pennsylvania 17013 on the ;./ 5~ay of NtJ V E..rYJ~ I/t-, 2001, at II: 30 o'clock, ~.m. DU/A/t.d E. Cu.,'dtJ ~ J. ~' .~ \\ ..1 - 6 r;"~W~._^. M,_, .1 ..-, --'-," ,--~ J'~~~~i1!llllM~~~"i";;!>j\>,,~,"-'l,,,~!o,tiiI~,"'iM~~..~D"~? . ;""tt!i~oo_"'- !f,]!J"MIIJi!lIJU1UJ!~,tI!IIf]lll~"o=~"~,,,+ '. """,,,"'" '.." ., ' "I.,. ~^d~..J~,,"'"""-~'" \\l"'\l....;n, ,", ,r",I'\i y 1) " '. ' O:',i; '; ., n.\\," l," ;..: "'\'.1''01 _, ,", \' ;'\l\l t~ ,.-;r.~:,:~,; I\\~L) ,~,-:'~I~' C\jd"",,', '''''~V\.\"I\,,'',\r, "' -\\\'~\ ..,' ?t.~'\l,-' . ~i~""""'~-'~' .ll'~ .-"..,.- -alZ ES Iff < IN RE: KRISTA COOMBS, Individually and as Parent and Natural Guardian of KAYLA COOMBS, a Minor IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA NO. CI-I,IJ..f C.oll '7-~ PETITION FOR APPROVAL OF MINOR'S SETTLEMENT ORDER AND NOW, this day of ,2001, IT IS HEREBY ORDERED AND DECREED as follows: 1. The settlement terms as set forth in the foregoing Petition on behalf of the minor, KAYLA COOMBS, are hereby approved. 2. The Court specifically approves the Settlement in a lump sum of Thirty- Five Thousand and no/ 100 Dollars ($35,000). The funds shall be distributed as follows: SCHMIDT, RONCA & KRAMER, P.C. Attorneys fees (25%). . . . . . . . . . . . . . . . . . . . . .. . . . . . . $ 8,750.00 SCHMIDT, RONCA & KRAMER, P.C. Costs incurred to date. . . . . . . . . . . . . . . . . . . . . . . . . . . $ 88.52 SCHMIDT, RONCA & KRAMER, P.C Costs for filing fees and service. . . . . . . . . . . . . . . . . . .. $ 145.50 COMMONWEALTH OF PENNSYLVANIA, DEPARTMENT OF PUBLIC WELFARE Lien. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 717.87 (The lien is $963.40. A proportionate share of attorneys' fees and costs is $717.87) WAYPOINT BANK, Camp Hill Mall, Camp Hill, Pennsylvania 17011 to be deposited in an account marked as follows: "Krista Coombs, as Parent and Natural Guardian of Kayla Coombs, a . " mmor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $25.298.11 TOTAL. . . . . . . . . $35.000.00 -Wil"~~"",:""", , , '-' 'i. - ... '" """''>'''''~'' " . I ' l' , " . - ~~ "_~K~"'~_,,~ i~ ^ ~- " < 3. The funds shall be invested by the Petitioner, KRISTA COOMBS, Parent and natural guardian for the minor, to invest the said funds as follows: A. to invest the funds in Certificates of Deposit to the extent possible with Waypoint Bank, not to exceed such sums as are fully insured by F.D.1.C.; and B. to invest the balance of said sums which cannot be invested in Certificates of Deposit, if any, in a Savings Account with Waypoint Bank not to exceed sums as are fully insured with F.D.1.C. Each account shall be marked as follows: "This money shall be held in trust not to be redeemed, withdrawn, negotiated, or in any way alienated except for the renewal in its entirety before October 15, 2016, except by Order of this Court." 4. The law firm of SCHMIDT, RONCA & KRAMER, P.C. shall oversee that the directive set forth in the preceding paragraph is carried out. 5. The Petitioner may execute the Release attached hereto as Exhibit "D." BY THE COURT: J. -<1"!:-;P~""""/Cl<jO_ ^~, _., '_,' ,. 1-- "" ~- '"-, q- y " ~ ,..,., ~ ~,' .., ~h , IN RE: KRISTA COOMBS, Individually and as Parent and Natural Guardian of KAYLA COOMBS, a Minor IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA NO. Ot - t.1J.7' C?;0~l~~ PETITION FOR APPROVAL OF MINOR'S SETTLEMENT PETITION FOR APPROVAL OF COMPROMISE SETTLEMENT AND DISTRIBUTION OF PROCEEDS FOR KAYI,A COOMBS. A MINOR AND NOW, comes the Petitioner, Krista Coombs, Individually and as Parent and Natural Guardian of Kayla Coombs, a minor, and respectfully set forth as follows: 1. Petitioner, Krista Coombs, Parent and Natural Guardian of Kayla Coombs, is an adult individual residing at 607B Geneva Drive, Apt. 14, Mechanicsburg, Pennsylvania 17055. 2. Kayla Coombs is a Minor, born on October 15, 1998, who currently resides in the custody of the Petitioner, Krista Coombs. 3. Kayla Coombs, a Minor, suffered lead poisoning while residing in a lead- contaminated apartment located at 116 South Third Street, First Floor, Lemoyne, Cumberland County, Pennsylvania ("the apartment"). Kayla Coombs and Krista Coombs resided at the apartment for one year and three months between June of 1999 and September 21,2000. 4. Kay1a Coombs was tested for lead poisoning and it was discovered that she had a high level of lead in her blood (Please see Medical Records attached as Exhibit "A.") r~"-' - ., ,_h '.>:1'., "',~.~ '__ ,_ c. "'_ "" .. ~ . ~"~...",., -. .-~,","~!"",,,,,, L ~~~',"'~--'. ;:'-;:'1l:~~""~ 5. A lead inspection was performed on the apartment. The lead inspection revealed that the apartment contained lead. (Please see Lead Inspection Records attached as Exhibit "8.") 6. Kerry R. Saintz is the owner of the apartment. 7. The medical costs for Kay1a Coombs' lead poisoning are currently at least Eight Hundred Forty-Eight Dollars ($848.00). (Please see copies of Medical Bills attached hereto as Exhibit "C.") 8. It is most likely that Kayla Coombs will continue to incur future medical expenses arising from the lead poisoning. 9. The Defendant had a policy of insurance with CGU Insurance. 10. The policy contained a pollution exclusion provision. 11. I t was uncertain whether there would have been coverage provided under the policy. 12. The liability limit on the policy was $50,000.00. 13. The Petitioner has entered into an agreement to settle the case for Thirty-Five Thousand Dollars ($35,000). (Please see copy of Release attached hereto as Exhibit "D.") 14. The Petitioner is satisfied that the offer of settlement is just and reasonable and is willing to accept the said offer if approved by the court. 15. In pursuing the claim against Kerry Saintz, the Petitioner engaged the law firm of Schmidt, Ronca, & Kramer, P.C., under a contingency fee providing that the said law firm should be paid 25% of any settlement obtained before the filing of suit. (Please see copy of Contingent Fee Agreement attached hereto as Exhibit "E.") 2 ^ ,-_~" " T, ,'H ,-..1 " - I ,'" ,.. .~ " .,. __T. ~ ", ,-~-~ < 16. Schmidt, Ronca, & Kramer, P.C., has incurred costs associated with the investigation of this matter. 17. The Commonwealth of Pennsylvania Department of Public Welfare has a lien of Nine Hundred Sixty-Three Dollars and Forty-Eight Cents ($963.40) against a recovery or settlement. 18. The Petitioner requests that your Court distribute the present payment of Thirty-Five Thousand Dollars ($35,000) as follows: Schmidt, Ronca, & Kramer, P.C. Attorney fees (25%). . . . . . . . . . . . . . . . . . . $ 8,750.00 Schmidt, Ronca, & Kramer, P.C. Costs incurred to date. . . . . . . . . . . . . . . . . $ 88.52 Schmidt, Ronca & Kramer, P.C. Costs for filing fee and service. . . . . . . . . . . $ 145.50 Commonwealth of Pennsylvania, Department of Public Welfare Lien. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 717.87 (The lien is $963.40. A proportionate share of attorneys' fees and costs is $717.87) Waypoint Bank, Camp Hill Mall, Camp Hill, Pennsylvania 17011 to be deposited in an account marked as follows: "Krista Coombs, as Parent and Natural Guardian of Kayla Coombs, a minor". . . . . . . . . . . $25,298.11 TOTAL. . . . . . . . . . . . . . $35.000.00 19. The Petitioner requests that this account be authorized without the formal appointment of a guardian of estate of the minor or the entry of security, 3 . 'F@~""""'''''''''fll~___ v, ,', "_, '"",- - - " - ~. "" ,~ ~~~-, E with the Petitioner, Krista Coombs, being authorized and directed to invest funds belonging to Kay1a Coombs, a Minor, as follows: A. to invest the funds in Certificates of Deposit to the extent possible with Waypoint Bank, not to exceed such sums as are fully insured by F.D.I.C.; and B. to invest the balance of said sums which cannot be invested in Certificates of Deposit, if any, in a Savings Account with Waypoint Bank, not to exceed sums as are fully insured with F.D.I.C. Each account shall be marked as follows: "This money shall be held in trust not to be redeemed, withdrawn, negotiated, or in any way alienated except for the renewal in its entirety before October 15, 2016, except by Order of this Court." WHEREFORE, Petitioner Krista Coombs requests that this Honorable Court enter an Order approving the foregoing compromised settlement directing the distribution of proceeds set herein. Respectfully submitted, SCHMIDT, RONCA & KRAMER, P.C. ~ erard C. Kramer Attorney at Law Attorney I.D. No. 44715 209 State Street Harrisburg, PA 17101 (717) (232-6300 Attorney for Plaintiffs 4 ;.,",,,,!'I'~""W.~~ -~- .. -,. "~ , - . ~ " ~~~~~ "" ~ '2"' II ' o. .' -, -.,- ~ . VERIFICATION BASED UPON PERSONAL KNOWLEDGE AND INFORMATION OBTAINED THROUGH COUNSEL I, KRISTA COOMBS, Individually and as Parent and Natural Guardian of Kayla Coombs, a minor, verify that I am the Petitioner in the foregoing action and that the attached Petition is based upon information which has been gathered by my counsel in the preparation of this lawsuit. The language of the Petition to the extent that it is based upon information which I have given to my counsel is true and correct to the best of my knowledge, information and belief. To the extent that the contents of the Petition is that of counsel, I relied upon counsel making this Verification. 1 understand that intentional false statements herein are subject to the penalties of 18 Pa.C.S.A. 13 4904 relating to unsworn falsifications to authorities. Date: ID-,9d.-OI KRISTA CO S, Individually and as Parent and Natural Guardian of Kayla Coombs, a minolr '{';>'Iii''''''''''''''''''--' _ _~ EXHIBIT j /4 ." '. ("' , , ( , 209 State Street ~'llllm'I, Ronca & Kramer PC _ Han1sburg, PennsylvanIa 17"!Q1 rNIIIIUIII'" : .aV'. ERS---- 717 232 6300 Fax 717 232.6467 wwwsrklaw.com .;--- May 14, 2001 6" ,l' ~ Polyclinic Medical Center 2601 North Third Street 0.. Harrisburg, PA 17110 ~# , Attention: Medical Records Department ~ L ~ ",f-..,' (j1) non pI'& one o.rt /' ,"cJY REQUEST FOR HO.TA~:: \0 Client : Kayla J. Coombs, a minor Krista J. Coombs, parent 116 South Thitd Street, 10' Floor Lemoyne, PA 1 - _ .. ~ 180-78-6446 S{j) ~ 4-1 - O'tPJ ~ ~I~t05100tothe Adctren Blrthdate : S.S.Ho. : Records Reque.ted: BlUa Requested present. : All bUla from 10/05/00 to the present. Dear Sir or Madam: Our office represents the above-named patient. Please forward to my attention copies of the following: [x] any and all hospital records, including but not limited to: discharge summary, admittlng notes, history, physical exammations, consultation reports, x-ray or other diagnostic test reports, emergt!ncy raom records, pathology reports, operative reports, medical photographs, if any; all doctors' orders, notes, etc.; I:1ssue committee report, if any; employees' day sheet showing names of nurses; physical therapy records; any and all outpatient records for the dates requested above. [x] any and all billings for services rendered for the dates requested above. On your bill for hospltal services, please do not show any amounts paid by insurance, as we cannot use these m Court. Your blll should include your total charges for servICes without showing the source of payment. (please bill us separately for your report or photocopy charges). "'''''''''='.'~''''-~z!~;'-"''''-'-'~'~ ". .- "~ - . " r \ ... Polyclinic Medical Center May 14, 2001 Page Two Enclosed you will find a signed Medical Authorization authorizing the release of this information to me. Thank you for your kind attention to this matter. Very truly yours, SCHMIDT, RONCA & KRAMER, P.C. ~ erard C. Kramer Attorney at Law GCKj det Enclosure cc: Billing Department ,:I"~'!"f''''H"~'''';''''_,. II' ''',' . !" , r -" '-,.--r'f'.........",;"'-~-.."T,~ ""~........~ '~'-~-,~ , ',I '''I ,; I , ,,~ "_I ;~1 '-p-~~",'\l'o'-'W"''''$-~, , , . lfed1aal Au1:ho"1"at.i.on POLYCLINIC MEDICAL CENTER . To: From: KRISTA COOMBS P/N/G of KRISTA COOMBS and GERARD C. KRAMER, HER ATTORNEY You .re hereby authorized anc:l c:lirected to pennit the exalllination of, anc:l the copying or reproduction in any manner, whether mechanical, photographic, or otherwise, by ~y attorney or such other person as he may authorize, all or any portions desired by him of the following' (a) Hospital records, X-rays, X-ray readings and repOrts, laboratory records and reports, all tests of any type, character and reports thereof, statements of charges, any and all of my records pertaining to the hospitalization, history, condition, treatment, diagnos1s, prognosis, etiOlogy or expense; (b) Medical records, including patient's record carda, X-rays, X- ray readings and reports, laboratory records anc:l reports, all tests of any type and~ character anc:l reports tharllof, statelDents of charges, and any and all of my records pertaining to medical care, history, condition, treatment, diagnosis, prognosis, etiology or expense. '{ou are further authorized and directed to furnish oral and written repoxts to my attorney, or h1s delegate, as xequested by him for any of the foregoing matters. By reasonS of the fact that such infonnation that you have acqUJ.red as my physician or surgeon is confident1al to me, you are also xequested to treat such infonnation as conf1dential and xequested not to furnish any such infoxmation in any form to anyone, without written authorization from me. I hereby revoke any previously dated medical authorization. Thu Authorization does not prevent the health care provider from supplying billing and other infoxmat1on to the first party carrier or medical insurer in order that the bills are paid. It does, however, prevent the III4'ldica1 provider from supplying this information to a third party insurance adjuster or an adjuster for an adverse party. I also authorize Irr:I attorneys or their delegate to photograph Irr:I person while I alii present in any hospital. I agree that a photostatic copy of this authorization shall be considered as effective and valid as the original. . Date. 5/14/01 1'a ,j"" 11 rl ^. " -~ II~ __,e ~~""'''' OS/23/2001 11:05 i $"'" ' ~, (- PinnacleHealth Hospitals A. piper, M.D., Medical Director Harrisburg, PA INTERIM REPORT PAGE 1 James Name: COOMBS,KAYLA H# : 180785446 ACCT: 429338851 Age/Sex: 31M F LOC: UNLISTED DR: VARMA,BHUPINDER W13589 COLL: 10/25/2000 09:30 REC: 10/25/2000 10:23 PHYS: VARMA,BHUPINDER COMP METABOLIC PANEL SODIUM 140 [137-147] MMOL/L POTASSIUM 4.8 [3.6-5.1] MMOL/L CHLORIDE 101 [97-108] MMOL/L CO2 26.0 [20-30] MMOL/L ANION GAP 13 [6-18] ALBUMIN 4.0 [3.5-4.8] GM/DL ALK PHOSPHATASE 305 [80-450] U/L UREA NITROGEN, BLOOD 5 [0-20] MG/DL CALCIUM 10.1 [8.9-10.3] MG/DL CREATININE 0.3 [0.3-0.8] MG/DL GLUCOSE *56 [74-118] MG/DL AST 38 [0-40] U/L ALT *17 [24-65] U/L BILIRUBIN,TOTAL 0.5 [0.4-2.0] MG/DL TOTAL PROTEIN 6.1 [6.1-7.9] GM/DL AUTO DIFF REQUEST CREDITED MANUAL DIFF ORDERED CBCA WBC COUNT 8.59 [5.5-15.5] K/ul RBC COUNT *5.04 [3.70-4.90] M/ul HEMOGLOBIN 11.7 [11.0-14.0] G/DL HEMATOCRIT 35.0 [31. 0-44.0] % MCV *69.4 [70.0-85.0] FL MCH 23.2 [22.0-31. 0] PG MCHC 33.4 [28.0-36.0] G/DL PLATELET COUNT 322 [129-366] K/ul RDW 14.0 [11.0-15.3] % MPV 9.0 [6.5-12.2] FL WBC DIFF NEUTROPHILS 20.0 [16-60] % BAND 1.0 LYMPHOCYTES 66.0 (45-75] "" " EOSINOPHILS 7.0 [0-8] % MONOCYTES 6.0 [0-12] % RBC MORPHOLOGY ANISOCYTES +1 POLYCHROMASIA +1 MICROCYTES +1 COOMBS,KAYLA END OF REPORT PAGE 'Ttm'<r'-":"'~"". F.~" c-' >'C, ..to_ to _'_'~' ", ' I~: '-1_."' "..- . , ,~ .~ ~-" .,,-~ -' , t Schmidt, Ronca & Kramer PC 209 State Street HaITIsburg, Pennsylvama 17101 717 /232-6300 Fax 717 /232-6467 Polyclinic Med~ca 2601 North Third Harr~sburg, PA 1 ,.te , :'~uest If 'ages "01$00 on pie Jienterstd reeit log c~~,~ COrekffS ~:~C\ ~/f; CI'IG <<*t \ abs oomp pl.u scan \ --- ~Pt- October 10, 2000 Attent~on: Medical Records Department rIlilQUIIST 1'01\ BOSl'ITAI. lRlilCORDS C11ent Kayl. J. Co~s, . .!nor Krista J. Coombs, parent Adc:l.ress 116 South Th1rd Street, lot Floor L_oyn., l'A 17043 Buthdate : 10/15 S.S. No. : 180-78-5446 Records Request.d:......, ecords froa 9/1/00 to the present. Bills Requested All 'b111s from 9/1/00 to the present. Dear S1r or Madam: Our off1ce represents the above-named patient. Please forward to my attent~on copies of the follow~ng: . [xl any and all hospital records, including but not l~mited to: d1scharge summary, adm1ttlng notes, history, physlcal examinations, consultat~on reports, x-ray or other d~agnost~c test reports, emergency room records, pathology reports, operative reports, med~cal photographs, ~f any; all doctors' orders, notes, etc.; t1ssue comm1ttee report, ~f any; employees' day sheet show~ng names of nurses; phys~cal therapy records; any and all outpatient records for the dates requested above. [x] any and all b1l1ings for services rendered for the dates requested above. On your b~ll for hosp~tal services, please do not show any amounts pa1d by insurance, as we cannot use these ~n Court. Your b1ll should include your total charges for serVlces wlth?ut show1ng the source of payment. (Please bill us separately for your report or photocopy charges). _n,,\fllW>""C'W'<0'o.''''''''''''l'_<=~ . ~ C' ,-.'," -'''"' '<',I-! ^, 1__,._, .' ., ~~"1'--"""'~ '.'"' ( ~ Polyclinic Medical Center October 10, 2000 page Two Enclosed you will find a slgned Medical Authorization author1z1ng the release of this ~nformatlon to me. Thank you for your k1nd attention to th~s matter. Very truly yours, SCHMIDT, RONCA & KRAMER, P.C. /4/~ Gerard C. Kramer / Attorney at Law GCK/det Enclosure cc: Billlng Department 'fJ1-'i~~","?>"''''''~ -,~ P1n-,:- ,~J " .'--' I! " .- ~~~l' ~ .ii.'fi!i!~'i;"""'''''''''''~',)'l , llsd.1.cal A1:ItboJ::",,'at::I.on To" POLYCLINIC MEDICAL CENTER From: KRISTA J. OOOMSS P/N!G of KAYLA J. COOMllS. A MINOR AND GF,1tAlUl C. KRAMER. HEll. ATTORNEY You are hereby authorized and dtrected to permit the examination of, and the copytng or reproduction 3.n any INlnner, wIlether mechanical, photographJ.c, or otherwise, by my attorney or such other person lIS he may authorize, all or any portions deeired by hilll or the follOWJ.ng. la) Hospital records, X-rays, X-ray rudings and reports, laboratory records and reports, all tests of any type, character and reports the:reof, stat_nts of charges, any and all of my recorda pertnning to the hospitalization, history, condition, treatment, diagnous, pro<Jl'olJis, et3.010gy or expen.sel (b) Medical records, inoludin9 patient'a record c:ards, X-rays, X- ray readings and reports, laboratory records and reports, all tests of any type and character and reports thereof, statements of charges, and any and all of my records pertain~ng to llledical care, history, condition, treatment, diagnosis, prognosis, et1010gy or ellpense. 'tou are further authorized and directed to furnish oral and written reports to my attorney, or his delegate, as requested by him for any of the foregoing matters. By reasons of the fact that such J.nformation that you have acquJ.red as my physJ.cian or surgeon is confidential to me, you are also requested to treat such infonoation as confidential and requested not to furnish any such ~nformation in any form to anyone, without written authorization from me. I hereby revo~e any previouslY dated medical authorization. Thu Authorization doea not prevent the health c:ar:e provider frOlll supplying billinll' and other information to the first party carrJ.er or ~cal insurer in order that the bills are paid. It does, however, prevent the medicd provider from supplying this inforroatJ.on to a thJ.rd party insurance ad,uster or an adjuster for an adverse party. I also authori2:e my attorneys or their delegate to photograph my person while J: am present in any hospital. I agree that a photostatic copy of this authorization Shall be considered as effective and. valid as the ori\l'inal. Date, 10/10/00 Ps . .~.".,. '- , ,I' '. I~ 1 I'" r- ;/ r" r- :.;r"*"~""-W"'1"f"'~~,,....,, r-. ~ .~ r- DATE TIME /Ih? Vb;::) r'''''''\! 1\JI'vlRt"UtiY1LtJu''''O~/MI4.,a (f ~I, , - ~ lJ f) , ~ 'AnENT 1DENTlFJPA,TION ) P'NNACLEHEALTH Hospitals ~,~ PROGRESS RECORD Form'INV1081lUII01)MA n .--, .;. 'I 'J 1',"-" ~ ~ .- --~ "~---~ 10/04/2000 00;28 ( ,....., ~ PinnacleHealth HosRital~ James A. piper, M.D., Med1cal Director Pt. Name: Age/Sex: Hosp. No.: Account #: COOM~LA 23M : 10/15/199S lS0 5446 42990 Loc. : ...IId..IN13 rNII18 1?R....E!TICE-' Ordering Physician T72156 COLL: 10/03/2000 16:00 REC: 10/03/2000 16:20 Dr. VARMA,BHUPINDER COMP METABOLIC PANEL SODIUM * 135 [137-1471 MMOL/L POTASSIUM 4.4 [3.6-5.11 MMOLjL CHLORIDE 103 [97-10S] MMOL/L CO2 24.0 [20-30] MMOL/L ANION GAP S [6-lS] ALBUMIN 4.1 [3.5-4.S1 GM/DL ALK PHOSPHATASE 293 [80-4501 U/L UREA NITROGEN, BLOOD 14 [0-201 MG/DL CALCIuM lO.O [8.9-10.31 MG/DL CREATININE 0.3 [0.3-0.8] MG/DL GLUCOSE 118 [74-118] MG/DL AST * 43 [0-40] U/L ALT * 18 [24-65J U/L BILIRUBIN, TOTAL 0.4 [0.4-2.01 MG/DL TOTAL PROTEIN 6.4 [6.1-7.9] GM/DL AUTO DIFF REQUEST CREDITED MANUAL DIFF ORDERED CBCA WBC COUNT 9.42 [5.5-15.51 K/ul RBC COUNT * 5.20 [3.70-4.90] M/ul HEMOGLOBIN 12.0 [11. 0-14.0] G/DL HEMATOCRIT 35.9 [31. 0-44. OJ % MCV * 69.0 [70.0-85.0] FL MCH 23.1 [22.0-31. Ol PG MeHC 33.4 [28.0-36.0) G/DL PLATELET COUNT 276 [129-366) K/ul RDW 13.5 [11.0-15.3] % MPV 9.2 [6.5-12.2] FL WBC DIFF NEUTROPHILS * 15.0 [16 -60l % LYMPHOCYTES * 81.0 [25-75] % EOSINOPHILS 4.0 [0-8J % RBC MORPHOLOGY MICROCYTES +2 WEC MORPHOLoGY ATYPICAL LYMPHS PRESENT COOMBS,KAYLA END OF REPORT PAGE 1 (',!iIf!f,f"'#'''''''~''''''}''''''"" ,_ ,,-, -1:1 I, , " ~ "C'-11l' . Jf' :~~,-II"'''''-''~'.''') 09/4s/2000 OLSS ( ,....., ! " ~ pinnaeleHealth Hos~ita James A. piper, M.D., MedJ.cal Director pt Name: Age/Sex: HaSp No.: Account #: COOMBS,KAYLA 23M P DOB: 10/15/1998 180785446 429903134 Loe.: "l(J 1"11l 'iJIllHLY PR.~GrT(,F. ):/'C W1588 COLL: 09/27/2000 UNK OrderJ.ng Physician REC' 09/27/2000 16:08 Dr. VARMA,BHUPINDER CBC & MANUAL DIFF WBC COUNT RBC COUNT HEMOGLOBIN HEMATOCRIT MCV MCll MCRe PLATELET COUNT RDW MPV NE'(JTROPHILS LYMPHOCYTES MONOCYTES EOSINOPHILS RBe MORPHOLOGY eOOMBS,KAYLA '-vi~O ~ ,e" 11.37 ANALYSIS REPEATED CONFIRMED * 4.94 11.4 32.8 * 66.4 23.1 34.8 PLATELET COUNT IS PLATELET CLUMPING SLIDE ESTIMATE OF NORMAL LIMITS. 13.4 10.0 20.0 73.0 3.0 4.0 ANISOCYTES +1 MICROCYTES +1 ROULEAUX PRESENT END OF REPORT j'F" [5,5-15.5] K/ul [3.70-4 90] M/ul [11.0-14.0] GIDL [31.0-44.0] % [70.0-85.0] FL [22.0-31.01 PG [28.0-36.0] G/DL [129-366] K/ul UNRELIABLE DUE TO PLATELETS APPEARS WITHIN [11.0-15.3] % [6.5-12.2] FL [16-60] % [25-75] t [0-12] % [0-8J t PAGE 1 - " ",,",,""",,"~ -,,~ ! 09/22/2000 06:25 r--' t'""'\ pinnacleHealth HOsp1tal~ James A. Piper, M.D., Medical D~rector Pt. Name: Age/Sex: HoSp No.' Account #: COOMBS,KAYLA 23M ~B' 1807 446 2100 10/15/1998 Lac.: KLINE PED CTR POLY Ordering Phys~cian H61521 COLL: 09/21/2000 15:45 REC: 09/21/2000 19:33 Dr. VARMA,BHUPINDER LIPID P1\N~L CHOLEST~ROL FOR LIPO TRIGLYCElRIDE HOL CHOLESTEROL LDL (CJU,C) VERY LO DENSITY LIP RISK FACTOR LIP (CAL 195 * 274 48 92.2 55 4.1 RISK 1/2 AVERAGE AVERAGE 2X AVERAGE 3X AVERAGE FEMALE 3.3 4.4 7.0 11.0 [0-200] [<200] [29-89] [0-130] MALE 3.4 5.0 9.5 24,0 MG/DL MG/DL MG/DL MG/DL MG/DL Ordering Phys~cian H61520 COLL: 09/21/2000 15:42 REC: 09/21/2000 19:32 Dr. VARMA,BHUPINDER RENAL FUNCTION PANEL SODIUM POTASSItlM CHLORIDE C02 ALBUMIN UREA NITROGEN, BLOOD CALCIUM CREATININE GLUCOSE PHOSPHOROUS AUTO DIFF CBCA WBC COUNT REC COUNT HEMOGLOBIN HEMATOCRIT Mev MCR MCHC PLATELeT COUNT RDW MPV WBC DIFF COOMBS, KAYLA 137 4.7 104 21.0 4.4 10 10 0 0.3 * 65 5.6 REQUEST CREDITED MANUAL DIFF ORDERED 10.43 * 4.92 11.4 33.1 * 67.3 23.2 34.4 * 369 13.3 9.6 CONTINUED [137-147l [3.6-5.1] [97-108] [20-30] [3.5-4 8] [0-20] [8.9-10.3J [0.3-0.8] [74-118] [3.5-6.8l MMOL/L MMOL/L MMOL/L MMOL/L GM/DL MGIDL MG/DL MG/DL MG/DL MG/DL [5.5-15.5] Klul [3.70-4.90] M/ul [1l.0-14.0l GIDL [31.0-44.0] % [70.0-85.0] FL [22.0-31. 0] PG [28.0-36.0l G/DL [129-366] K/ul [11.0-15.3] % [6.5-12.2] FL PAGE 1 . ".;'. ", 11'<,?,~,~rl""."""~"', .~ _, ."". I' ~-='l~ nt.L f'o l 09/22/2000 06:2-5 ,-... ,'-"" PinnacleHealth Hospitalb JameS A. P1per, M.D., Medical Director Pt. Name: Age/sex: Hosp. No : Account #: COOMBS,KAYLA 23M F DOB: 10/15/1998 180785446 210083732 Loc.: KLINE PED CTR POLY Ordering PhYS1Clan H61520 COLL' 09/21/2000 15:42 REC: 09/21/2000 19:32 Dr. VARMA,BHUPINDER WEC DIFF NEUTROPHILS BAND LYMPHOCYTES EOSINOPHILS MONOCYTES RBC MORPHOLOGY ( CONTINUED) 17.0 1.0 * 76.0 1.0 5.0 [16-60] [25-75] [0-8] [0 -12 1 % % % % NO DETECTABLE RBC ABNORMALITIES FERRITIN 33.6 [10-155] NG/ML COOMBS, KAYLA END OF REPORT PAGE 2 CLIENT REPORT COMPLETED ~f;'~:r.qil'~i"'~_ > ~" > , I~ ,...- " - - "~~ - '=-"'< - ~"~~" ,..... Result Gen Lab COOMBS , KAYLA F Atn Dr: WILLIAMS RONALD J Adm Dt: 09/21/00 OA ,1 I CLINIC Iso1: I Pt>>: 21008 732 8IlIra'~ 1Qfo.J8' 44 ~ , ""'I"'I~ QI'l ------------------------------------------------------ ----------------- CHEM-ROUTINE SODIUM POTASSIUM CHLORIDE C02 BUN CREATININE GLUCOSE PHOSPHORUS CALCIUM ALBUMIN HDL CHOL TRIGLYCERIDE LDL CHOL RISK FACTOR CHOLESTEROL 137-147 3.6-5.1 97-108 20-30 0-20 0.3-0.8 74-118 3.5-15.8 8.9-10.3 3.5-4.8 29-89 <200 0-130 0-200 09/21/00 15:45 o 121 15:42 ~-"'l031 137 4.7 104 21.0 10 0.3 65* 5.15 10.0 4.4 48 274* 92.2 4,1 195 T ===========================================.===~~==================~======= LIPID EVALUA HOL CHOL TRIGLYCERIDE LDL CHOL VLDL RISK FACTOR 29-89 <200 0-130 09/21/00 15:45 48 274* 92.2 55 4.1 T ==============#===~.====m===_.~===_========_===-===~===:=~=========~======= HEMOGRAM WBC RBe HEMOGLOBIN HCT MCV MCH MCRC PLATELETS ROW MPV 5.5-15.5 3.70-4.90 11. 0-14.0 31.0-44.0 70.0-85.0 22.0-31. 0 28.0-36.0 129-366 11.0-15.3 6.5-12.2 09/21/00 l5:42 10.43 4.92* 11.4 33.1 67.3* 23.2 34.4 369* 13.3 9.6 DIFFERENTIAL NEUTROPHILS LYMPHOCYTES MONOCYTES EOSINOPHILS BAND =======~===a====~=========e===..===#===~===~========~===~================== 09/21/00 15:42 17.0 76.0* 5.0 1.0 1.0 16-60 25-75 0-12 0-8 RBC, WEe, PLT RBC MORPHOLO ==~================~=====================~==========~==-==~==~========.~=.= 09/21/00 15:42 SEE TEXT ==~===~==.====-=========================r===============================m== CKL87286 ~ 11:17 09/22/00 FROM CKD1,ZRPRTGF1 '!'''''''''''''','H'''''",,,, -', ,". ~'l ' .~~ , -, ........ ~~ ~"""""""~ (" r-. ~ Result Gen Lab COOMBS ., KAYLA F Atn Dr: WILLIAMS RONALD J Adm Dt: 09/21/00 OA 1 / CLINIC Isol: KPC PC.1I31:1011H '01'4 Mr#: 1807 ------------.-------------------------------------------~---- ------------- IMMUNOASSAY FERRITIN 10-155 09/21/00 15:42 33.6 SEP 2 2000 .. Q3^13031:1 ~ =====R~==_==s=_==.__==a_====_==End of Report===========~=========~==MQ==--~ 11:17 09/22/00 FROM CKD1,ZRPRTGF1 CKL87286 i?t-"'fj"f4-?"""~'"'1~'...'""~ "-,, 1"""1- ~I ,- 1', M'" ~....."'~"""~ , ~ r C 1""'.. ~ ~EFERRAL DATE AND VPb LEVEL q ~ .:2.0 -00 "''I 5" 'oj Pb - MOTHER'S NAME K n::.\o.. t "I> In be.. ADDRESS \\lJ, 5. ~.IA ~ lunoy l'\e.. (JA IJo4~ FATHER'S NAME ADDRESS ALTERNATE CONTACT ADDRESS SIBLINGS < 6 VRS OF AGE TESTED FOR PbANO Pb LEVELS HEALTH CARE PROVIDER 1v. Kiln n' "dL ADDRESS 50=' &'.!<jL 5:l- .).,)~ C .......bu'\0J\~ ENVIRONMENTAL INFORMATIO~ , DATE OF INSPECTION ~ 00 TELEPHONE # .." "I-~.t.l cO ('"rUi\ I-h 1\ fW. REFERRAL SOURCE ~I+\\ '!\'-_~.,,<-....c..I< TELEPHONE # TELEPHONE # TELEPHONE # -fA Pb SOURce -Pil" A ~1 '" MI j 111I'I'K Does the child spend more than 10 hours a week In anotl1er location? Does any careglller work at an occupatunI Inllolvmg lead? Does any careglller have hobbles that use lead? Is the dweHlng located near lead related Industry? Is the dwelling located near a heavy traveled street? Is there a wood burning stove or furnace If! the home? Does the dwelling have a mUniCIpal water source? How long has the falTuly lilled at this reSidence? ./ ./ ./ /" / ...J'<u ~ 3""d,'> I DATE Cj - 02.1 - 6tJ PATIENT NAME t6..., 1(1.. e.,o rn b !>.. DATE OF BIRTH 10 - J:J - q B NURSE %AlJA. 6~L .~~ I trn PHYSICIAN ~ J{ Vtlfma... 1h.Q ~) PINNAClEHEALTH <4 Hospitals PATIENT IOeNTlFlCATION Pattenl Name: Kit.. I 0.. ~ Don m 6 s- I -- LEAD POISONING CLINIC EVALUATION SHEET >04'....11107) P9Hi.ft Medical RecordN -1'1.h 78 6<f~ ~ DateoIVIS~' q 1').1 /60 :'?;;t'0>."'''''''-''''-'''''~",,_, ~_,. ,- I~l - ~~ ~~ , PHYSICAL HI ~-:>;) ~).l,^wr ::l5~:If He 41(",., cvs N LUNGS ,.J ABD N MINOl'l MALFORMATIONS HAIR WHORL EPICANTHIC FOLDS ~ EARS 'N HYPERTELORISM N PALATE FjJ CLlNOOACTYLY N SYNDACTYLY N PALMS ope ~ SIMIAN ~ FACT SIMIAN N SANDAL GAP HISTORY BIRTH: ' CHILD'S NUTRmON STATUS MEDICAL H/STORY "- GESTATION-'=!.fl <.<J((~ WEIGHT1ItAl~ G~P ..L-AB _ NEWBORN HISTORY Lu...~l- h"...... c IYlIm FETAL AOTIVITY NORMAL ,/ HYPER/HVPOAOTIVE UNKNOWN COMPLICATIONS HYPERTENSION 0 DIABETES @ PRE-EClAMPSIAGl TOXEMIA EJ UTI G FLUNlRUS G PREMATURE LABOR (;J MEDICATIONS TAKEN -!\J 0 DIDVOU SMOKE? ~USEALCOHOL? _~) 0 DELIVERY VAGINAL./ SPONTANEOUS./ OR TAKE NON-PRESCRIBED DRUGS? llJu - INDUCED C-SECTION HASTHEREBEENACHANGE"lNAPPETITE? fdH,...r b"",~ a. ~(l',J....c.-l-.-<r DOES THE CHILD EAT A Will IW.ANCED DIET CONSISTING OF RED MEATS ~JOR EGGS, DRIED BEANS, PEANUT BUTTER, MIU<ANDJDR CHEESE, ENRICHED BREAD AND/OR CEREAL, FRUITS AND VEGETABLES? ( l.{~", DOES THE CHILD EAr A LARGE AMOUNT OF HIGH FAT FOODS? _ fU'l DOES THE CHILD EAT MEALS AND SNACKS REGULARLY SPACED DURING THE DAY? 1.(1 ~ 1-f?:r ~ Hh1 II. ~ ARE IMMUNIZATIONS UP TO DATE? lA If P HOSPITALIZATIONSJO SURGERIESJubc" - )CI-.... OcOO ALlERGIES ID t! Pr H/O PICA~ FOREIGN BODY INGESTION-i\10 T~= v' fIl..... '(."'. INJURIES STITCHES I\.~.J - ~t FRACTVRES DETAILS OF HEAD TRAUMA . fu 1\ ILLNESSES tJ 0 MEDICATIONS Fe..lf\ S<JI I Cf,tf r).g.,J.J'j EVER CHELA TED Ai II DATE AJc> HEAOTRAUMA No OTHER t.l SKIN ~ NEURO CNS STRENGTH N MASS rJ N DTR r1 P- GAIT f( TONE TOES fJ- Nf~ PATIENT NAME_K6.y (to. t. 0.1..... b " ",'-QO'0/9ll Pagc, 2 of" '~~""""lo'_'!'_",*""""'t!',,, , ~~, , ' ~~ " ;" t "'" - . GROWTH ., DEVELOPMENT MOTOR, SAT MOS, WALKED c; ~R, RAN l '( ~R HANDEDNESS, R_ L_AMBIDEXTROUSWITH RIL TENDENCY ,/- h.<f'~" (j) AD_A SPOONJ" <, FORK Y ( ... KNIFE AJ) No l/ SELF HELP CUP l.{ ';' DRESSES SELF -If ~ <.:0 USES FASTENERS BUTTONS, ZIPPERS, SNAPS J )r) LANGUAGE, VOCABULARY (II OF WORDS) ~ WORDS PER SENTENCE COLORS POINTS TO BODY PARTS TIES SHOES ,9- 5 warJs. l{<'i> USES PRONOUNS? YES_ NO APPROPRIATELY CHILD'S FAMILY HISTORY HOW OLD DOES THE CHILD ACT? %~ IS THE CHILD CLUMSY OR COORDINATED? (' nnrd..,,, c,..1J, O,<<prup r\o. k. HAS ANYONE IN YOUR IMMEDIATE FAMILY HAD ANY OF THE FOLLOWING? ATTENTION DEFICIT DISORDER LEARNING DISABILITY "AILED OR HELD BACK A GRADE BEHAVIOR PROBLEMS SPECIAL CLASS IN SCHOOL SPEECH THERAPY SLOWIMENTAL RETARDATION 'TUTORED TREATED WITH MEDS FOR BEHAVIOR PSYCHIATRIC HISTORY COMMENTS v"'.. "',., / / ./ /' / / / / ~ / / / LABS q('J-tff) DATE " LEAD LEVEL v HGSlHeT v FERRITIN V SMAC 20 V OTHER LABS PHYSICIAN SIGNATURE ""-<llllfm\ PIiIiIUd4 - ~~ew.-eJ-- Iro~'ffAY.2..D"ljJtc", ~'"/) ,*'4LJ/~ .tr.",ef.':'t..~P~/!lf'l &-"tllIl.I'o4t~ IN~J."I.,:;;" 4~r";' "'O'fo,f{ . ~ ~-eL /)1.l,c,~ ~ PATIENT NAME k!Qy Iv. C.oOMbs MEDICAL TREATMENT PLAN n"~"'~!;='~":'rF'iR':~~r . _ '_ _ , . , -r~ 1- ~,'~- ~"'~~~'''''--' '" 1 1 . ~ 209 State Street 717 232 6300 ,:!arrIS~UIl;J, ~enns&~ ~7~0~ Fax 717 2326467 wwwsrklawcom - -- -- .-- .. . " May 14,2001 -t~ Iv~ .... vl/ Jerome Korinchak, M.D, Greenhill Family Practice 503 Bridge Street New Cumberland, PA 17070 I AALli cd ~~-~~ 1 MAl 'l 9 'U,\ . I 'I J . . I ~ ,/ ... .......-_... : Kayla J. Coombs, a mlaiai" /J~' t(~ ' Krista J. Coombs, parent 7 1-. tJ, \ I 116 South Tblrd Street, lat Floor Lemoyxae, PA 17043 . t : 10/16/98 [) 180.78-15446 v?1 : All medical reoor. froID 9/'1.3/00 to the preeent. A,) \ : All bW. from 9/1/00 to the present. : \~-A'" ~ti' 10\ , LV Please be advised that I represent the above named patlent. Please forward copies Y' / of all recorda you have e c ditlon, treatment, and progress of this ,..,:' mdividual from Septe r 23, '1.000 t the preaent. . If ,"""'- I} of}' Please mclude copies of m September I, 2000 to the preaeDt. ,r,) I have enclosed an executed Medical AuthorlZatlon for the release of this infor&.C;onf' '> ~ to me. I gm not at this tUne requestlng any SpeCially prepared medical reports. ~ If you have a."l.y questions. ples'Se ff'e! free to call or write. r ~ .; -- Client Addrea. Birthdate S.B.No. Recorda Roqueated BWeReqlleated Dear Dr. Kormchak: Very truly yours, SCHlllIDT, RONCA l!I KRAMER, P.C. ~ C~~s-I()J _ .;; c.r Y~7 ."- \ GCK/ det loate Request # Pages '\ASSOC non .~~ - ~~ ~ ""J .~ erard C. Kramer Attorney at Law Enclo8ure cne abs p/u cert , camP ' scanj r"TWl'."'"""""*"1"ir-. ,-'" ~_~_~ 0 . ^ r"T -~,-~^"""""" (' . e To: M8d1~&l Anthoz~s.~on JEROME KORINCHAK, M.D. From: KRISTA COOMBS P!NtG of KAYLA COOMBS AND GERARD C. KRAMER, HER ATTORNEY You are hereby authonzed and dJ.re<>ted to pe.cmit the ."a/lU,natJ.on of, and the copying or reproductJ.on in any manner, whether mechan1cal, photograph:!.c, or otherwise, by my attorney or such other peraon aa he may authorize, all or any portions des:!.red by h1m of the followJ.ngl (aJ Hospital records, X-rays, X-ray readJ.ngs lUId reports, laboratory recorda and reports, all tests of any type, character and reporta thereof, statements of charges, any and all of my records pertalnJ.ng to the hosp:!.ta11zat10n, history, cond1tJ.on, treatment, ciiagnosu, prognosu, et1010gy or expense; (b) Medical,records, includJ.ng patJ.ent's record cards, X-rays,' x- ray readings and reports, laboratory records and reports, all tests of any type and character and reports thereof, statements of charges, and any and all of 11.11' records pertnnJ.ng to medJ.cal care, tustory, c01'lditJ.on, treatment, ~a9nos18, prognos1s, et101ogy or expense. '{ou are further authorized and duected to furnish oral and written reports to my attorney, or hu delegate, as requested by him for any of the foreqo~ng utters. By reason" of the fact that "uch informatJ.cn that you have acquJ.red as my physioJ.lUI or surgeon is. ..confJ.dentiel to ...., you are also requested to treat euch J.nfol:Dlllt:1on as confidentii.;L and requested not to fumisb any such 1nformat10n J.n any form to anyone, without wr~tten authorization from me. I hereby revoke any previously dated medJ.cal authorization. Th18 Authorization aoes not prevent the health care provJ.der from supplying bill.J.ng and other infox.ation to the first party carrJ.er or medical insurer in order that the bUla arepnd. It does, however, prevent the medical provider from supplYJ.ng this 1nformation to a th1rd party 1nsurance adjuster or an adJuster for an a~erse party. I also authorize my attorneys or theJ.r delegate to photograph my person wtule I am present 1n any hospital. I agree that a photostatic copy of this author1zation shall be considered as effective and valid as the original. Date. 5/14!Ol ..~~~,J... ~<!i!'fl!j'!1""""'''?~~~''''~ ~"-,- ,",-, - ~- ,~ 'I~r ","" " ~ ..~~- ---"." ~.~..~ """,",' "._~' ". " . ~- , .~. -' .,,----.----' . HOLY SPIRIT HOSPITAL GREEN HILL FAMILY HEALTH CENTER PREVIOUS MEDICAL HISTORY ..( ,- '---" , ~ ~ . , --- ' . CHROI IC P OB~EMS ONSET P.AST MEDICAL HISTORY ~ ~ 'tl g' I ~ 1'1({ \ , /" \ ." " 'l~~ 11 \/1 ^ IrA 'V\/Il'i\. ~ ..J l/tu :-~/J , /' ...^, 1 }it f. <.J...1lI.A 'f r . ~ . ACUTE PROBLEMS OATES I FAMILY HISTORY {S ),.oM ~"P 0 II REM VY\ 't" A1,..oJ , e-", . .1 , r;. '(..;,: lfL, , , '\ I t;.1_ {'.I, .~ . " ,~ v'\..--ll ~ 11 { I\.{ ..'. NICO CONSULTANT OATES. -.- ETOH ._. CAFF OCCUP DRUG ALLERGIES .. tJtlfL SCREENOO lESTS Breast Cholestral TINE TESTS ADULT IMMUNIZATIONS . Mamma DATE RESULTS TYPE DATES , 4,hiJt& ~..I.. PAP Prostate 1 Recta 1 PEDIATRIC IMMUNIZATIONS OPT OPV HIB HEP B j - , (i)~,,, S ,:: l Y I.A J MMR OTHER 1 1', 9f 41~427 HJ (6 S',6 ""d Ll Ffl .' GRH 105 I 8/93 I .' I - " 'f..J.I~"'"'~p;v"",,,,; "~'.' -,'",- ."-, <.. I~~ !' - - -~, , " ,~ ~~ - (' };.-,,/ PROS I 1 SOAP I DATE/PROGRESS NOTES 03119/01 KAYLAJ. COOMBS S 'IlnJ IS a 2-year-dd wlntefema1e who pll:SetlI8 mth,ellow nasal dir(:hot:f,l:. QOJIW$OD.8D<lhackmg cough fur the last dnee days She bad fever oflO(Wtlus IIlOllIllIlIo She ~ bas myrmgotomy tubes m pIaoe o <. Tempemlme 97 S" EEN1' Eyes notmaI 1Ms mveal the nsbt tube 10 be ID Pac:e The left 1IIbe can not be seen The dnun app:anI abgblIy a:amd, bot there IS no redness Noso lS ~ congested. Pharynx IS w""-'d pOIlleriorly mth alol of p"""'...1 cIIalnalle Nedr IS supple mlllout nodes Heart reJUlllr rate iIIId 1I1ythm. Loop are cJear ft~ IS soft Skm Wldlout rash. A < 1 Acule SIIlUSIlls 2 Acute brom:bII1s P 1 Z1thromax 200 mg/S \:c _tImds teaspOon today and then ollC-tlmd teaspOOn for four more cIasI. 'l'usa-<:ll'pmdm D ~ one-tIurd q4h p r II, cough awlRynaIaII suspc:1ISlOD one-thnd teaspoon bId 2 Jnaease flwds, use Tylenol . 3 The mother will call mth prlJbIemt, otherw1se she will retnm fur her lIlIIlWIl c"""k lip and P r n. O~SJ:T TELEl' HOI\"E Ml>SSAGE TlM:.ll ()~!) j/ DR <~ l"'rT. IDate last see~ W PHONl!:.[ 7//.-,15J7 PHOr-.F.~2~-If1ifhDOB__. .,_ ~PHAnM4.CY 1A).p~ raoNl CP 7-f'('f) (' - 'f- ~EAD ? - CR!:S'1' ~ ~DOMEN -- . aR HE.o\DAq}'A'. COUGHNON-Pl1.OtlUCTIV'. PA1N 3 g~ T."!P..r:g}fR~ cn..sr p - 1ll"-RRP'.!!A C-J "ltPAIN SOBr(1 NAUSEA l......-./ - y;. VOMITING . A// ~. ? .r. ~ "7 "'t?" wrr DAn J :..J iT 11:> - ...;p, -.J ~ tt~~t/;{jlf~~ JP7,J (:. . . , n . /;L~ ~ ~ " HOiv SPIRIT HOsPITAL GREEN HILL FAMILY HEALTH CENTER PROGRESS NOTES L ) J (WI H S I I~ . ('_ \ ; 1 1~ 9~ 415427 18J 76 5446 GHllt FH ~ -- GRH 100 7106 '- - ":;:!i'~r.I}~''''l''''''~~~ < -~.... '; , .~ r''''' ="'~" "'~~V=""""1'r_~~ [ " -. PROB # I SOAP I DATE/PROGRESS NOTES TELEPHONE MESSAGE llAlI: -Z~U -p I TIME tf:(7) DR., 1- !NIT. 10ate 1 ast see~ PATIENl ~/p. tlOMI4.S" PHONE~I. 7'1-~S-S7 'HONEn /008 CALLER. ~"/'-CYisJt.t,,~lw.CY /Ntis -S'llto\j)s.." ~....r1HONE: '/101 -. ~.lJl1o- ONSItT HEAD CHEST AIIDOMEN I - r-,,*, FEVER. ~ACHE COUGHNON-l'I\OOOcrlVE PAIN I ~.jQ..),f... NOSe COLOR CIlasT,P;.IN DIARPJlE.o\, . I _ ". ^I ." _ SORE THROAT - SOB tt'w.... ~ NAUSE.< "~~ ,....' ''''''"'''- " EAltJ'All' ~ .../ f'" vnt.lM'f1dnl"'"'_LU'/dt.kt....~, _ - , .. IU1..\, c.1XlIt ~ hDh'C'~ d If- v,. t\J)L~~.[ - Ot ~w.If. D( f') ~. ."'-". ,S elfs d,"'1-e. ':P+- ,. ??,I'!'{ ,- PLAN4~~~~ 41J ~~Q~JD~~'u. ),.;I~ - i ~''/f ~. INt., Ii>C>t,u.. Vll-l -1 ~ ~ . ClC :i:./ if pre~ent (or note durat---' o i f ~bs.9"'t feITcr v'. !)cldl' ilCI1('< , -:..,- - .""'" h~atlj'tcJle , 0", "': It~ no~e s'ui";y Z, . J:'" ~ C.Ol (. t.k....O,ll~."I"~_~.. ~ C~i('l("t pal n... _~~.f ~l ~ 1'1 0:1._._.: p""___' R.___ J}/4JA ",,,",ww,.,s W...II..... .....t ....... rl S;.: ~;J ~ (~~ f)~~~fl ~rZ:.~, ';~f ~if;.81.D /~r :P- ^gf'_._-...._,..~... ~._:.lt...._~..~ ._~__. .lorl --....~..Ii- -r:...~l--.- .-.- S')!'ll,.I.!..L,_!.Y~t __ .._..... _. _. " _' 11"~1 -..-..-.. i -.....-.... ~ .~ ~ "~"":'''~''''M_.''' _,......_l~._ ..n._ . :1', I \ ': vr,( :t -..:....=-,j.: .~=:'.~- ),':'~.~M _~ .. ..- ~~ ~........- -...- , -"-,- --.- ..-.- ..-....~ 'M.... r ~_.. __..~v_............ "'.' ...._J____J......_...-:::::... '- ',)1,>1$ ,K \ Y'." J 1,\ 1~ 98 415427' 18J 78 ~6 6HILL rH GRH 100 7/96 - , ''"~i!o~'rNT''-'~''''~~,_~ r-" ",~", ... , , I-~' ' . 1 - " ~,~ .b _~ ~~o__", r' , .....- ,r-~ ! - PROS # SOAP DATE/PROGRESS NOTES T ~ R 1)\1 S1IIIISllls PerslSleDl brouclults Lead toxlc1ty She will follo)V with Polyc;h1lll: We will clledt the leaclleve1 tIl8IIlIs also BegmZltbroiuax 200 roW5 cc: ~ two-tIurds ltaSpOOIl today alld thLm llJIColInrd ltaSpOOIlfilr four more days, Tusst~D M. cmc-duld ~ q 4IL prn. c:oag\llUdoa.tl,w~'11"ll 3 AdY1l q 6b IIIl Deecbl. _ ftw.ds 4 The DlOlber...,u call Mth p'Ob1ems or WO<SCIIJII& S _~_~_ ~ zetumm lbllow-llP m tbree II10IIlhs lIlId p rn GREEN HILL FAMILY HEALTH CENTER PROGRESS NOTES 01/13101 KAnA J. COOMIl8 S Tbls IS a 2.year~ wlute fiImaIe wllo JIR*ldlI m lb\Iow"1Ip cfleld PJI-g She has bad a ooueJIlIlId congcsUon over II1e past week or so. .~ 1110 __ hu lIlll beelI aWlIIIl of1tNer She'u IIlIt 011 IllY CUltS! ~~ Sbe bad a lead level redrawn after \ieaIIIlCIIt 1br lead ~""1IJ1t ~ Ilat DO 1a1Ik.. beelI ~"'Cd yet She \I pel1y lI81DlId, 1& very acuve and_ 8dwnced m many dmlIQpmea1ll1areu ' o WCI8hI up 2 JICIUIll!s to ,21b T........~ 100 S' EmIT Eyes normal TMs an: 1KB:IIIIIl With \I1}'JlIlIOIOII tubes bIateralIy NOIC III ~ t'l.ynx.1lI very It~' a mt1loat exIIdaIe Nel:k IlII1UpJl1e Wlthaul: 1Illdes. Hea1t regular tale lIDd rlIytbm L\IDllII are clear SIIe lias a very loase h8nh coogb, DO wbccrzes ~ is soft. bomga. SkIn wtthmlt wb. Extnmul1eS llCgat\Ve A: 1 2 3 1 2 p ~ 1" 1\ n HJ to S~~6 4 l~'+" Gill '. c. Ffl -. GRH 100 7/96 ':',!-q'J'i1i""'ifH."""'CW~_ "'II ,~_. r .': - .' ,- ."~ ;, , '-'. ....... , PROB # DATE/PROGRESS NOTES I" Fe fA/ld 10l2Jl00 KAYL.U:, COOMBS S TIns III a Z-)'OII'-oId w_1i:mlIIe who praems for woIllllby ~beI:k lIP As per Ihe IIIllcs in Ihe cbllrt, sbe was lbuDd 10 have lead plISllIIIII& lIll4alW ~nn 1t was lbuDd IIllIt tbetll_ lead-111. f JIIIIIt IIIIt _ dllpped 8IId a lot of clast adbm\lIIt to du: wmdinn. * ,in tile llJlUbIIeIIt wIII:nlsbe aDd herlllOlher -1Mua. ThelllDclordbas lllbIlac\tOlltoplilll8Dd llecms: \be rut, althnu&h tile __1ll1lUl'llllS out ofdus _buwd. The ehlId bas beea seeD .. POqcbulc LClII\'~ ClI1m: 8IId llasalIeady <YUn~ a two WIlllk_ ofmecllcatroa to Jower tIJe lead Ievd 'There was 8IIllIWI1 dRIp m tbo level 8IId IIhc IS IPIl8 tomon'Ow for 8.iepeat lewd Sllellas beea eva1aaIl:clby BiIII.y I~ has __ forms OIltbo dIIrt SIIe lIIdallCll1ll811ew1 m July, SIlll was cin'Iy two to three IIIIJIIlhs 1hat 1IhcY1811 apo&al to tlus 1lIg\l1lBl1evol She does 1Illl_ to have aay deIic:Il ac:cordmg to the mother, aJtbou&h dIac IS CllIIlllIIIIlld Ilbaut lIltCIItIOIl flIIIll by tile exammers 0' HeJgbt. 'IIeIIiIt 8IId h81....~....d't;.".,cc alia tile 50111 peR:eIIllIe TCIIIJIllllI\1ll'e 98 10 EENT ADtenor llmIanelle cIo&e4 Eyes I8.clIDDg Illd mftex IIOIII18i TMs IDlIIIL Nose, IIIlRdh 8IId plmryDx beman '!nth the exceplloII of a very lUly cystocele on tbe ngbt bIta:al_ Neck 18 5UIIPe I'Illhout .... or tI1yromepIy Heart regular !lite 811d!hythm WI1ho1It mutmllr L~ are clear Bld:1\'Ilbout llQ)JlOSI' ,*,L'" eP 18 soft, tolIIly 1IllIIIaIdeIr8Ddbntgn. Geallaba lIIlImI1for. HllldI8IIdextrelll1l1e$ nepllVe NeIlI'Ologtc exam WJl:bm 1lllmIIII JmuIs A 1 Rec:cat Icad JlOISOIIIIII. 2 Hislmy ofllOll~l:Ilq' - vf- P 1 The motIIcI' w1l1 tbIlow With Po\ychmc W11h regard 10 the lead ~ 2 Sbewill-on_ .~I8DdvUambls 3 SIIe will caD wJtb I"~ aacI will otberwue retum m two mon1hs for teeheck an4 P r n J'-..-. '. . ----- -. HOLY SPIRIT HOSPITAL GREEN HILL f:AMILY HEALTH CENTER PROGRESS NOTES J 'I 1 S ~ 2'"1 d'l'_L F1' --. GAH 100 7196 ~ -;,\~,~~jb;->-""",, >" ....~ '-'--.' , I;'! ~ - ".>~- \\ \< " r , 'Schmidt, Ronca & Kramer PC 209 Srate Str..et Hamsburg, Pellmylvama 17101 717/232-6300 Fax 717 /232.-6467 f/) \ \ Attome)'s and ~e!ors at Law ,I:. I, - -'.-.- y ~ October lO, 2000 '" Birthdate B.S. No. Records Requested: B1ll11 Requested Kayla J. Coombs, a m1nor Kr111ta J. Coombs, parent 116 South Th~rd Street, 1.~ Lemoyne, l'A 17043 10/15/98 180-78-5446 All DledJ.cal records from All bills from 9/1/00 to Floor ~pfivt, ...-f2P- ~ I- ,f: CI\'/ ~ present. ",' 8 fl,.. nliV _ 01 '"I Jerome Kor~nchak, M.D. \ Greenh111 Family Pract~ce\ 503 Br1dge Street \ New Cumberland, PA 17070 .: \;, I.- ......-- - \ , Client Adc:l.ress 911/00 to the the present. Dear Dr. Kor1nak: Please be adv1sed that I represent the above named pa~ent. Please forward copies of all records you have kept on the cond~tlon, treatment, and progress of thi, ~nd~v1dual from Septemper.l, 2000 to.__:~e present. ("//U/VD ) - Please ~nclude cop1es of all b~ll~ngs from September 1, 2000 to the present. . I have enclosed an executed Med1cal Author~zat~on for ~he release of th~s lnformat1on to me. I ~ not at th~s t~me requ~stlng any specially prepared medical reports. If you have any quest1ons, plea5e feel free to call or wrlte. Very truly yours, - \ eM' SCHMIDT, RONCA & KRAMER, P.C. Date ,dhtJJ~ Request II ~.;)l/0_ v---- Pages Z -~ -; AsSOC . F r\ rard C- Kramer one ~lJ ttorney at Law non ~ ggtftP pat etd ab!l p/u s6tlI1-'-" GCK/det spc .... 9 Enclosure .- )!}.w..,;.<;'r,,""-''''=-"W;' ."-,~ , . 'T "'~ ~"~M f' t To: . Heche'\! 1W.tli",;,ba.1:>.on 'JEROME KORINCHAK, M.D. ~'rom' KRISTA J. COOMllS P/N/G of KAYLA J. COOMBS, A MINOR AND GERARD C. KRAME1l, RER ATTORNEY You are hereby authonzed and dl.rected to pertnit the eXaJlIJ.nat1on of, and the copyi"ll or reproduct1on in any manner, Whether mechan1cal, photographic, or otherw1se, by my attorney or such other person as he may authorlze, all or any port10ns desired by h~m of the folloW;l.ng' (a) Hosp1tal records, X-rays, X-ray readl.n9s and reports, laboratory records and reports, all tests of any type, character and reports thereof, statements of charges, any and all of my records perta~ning to the hospitalizat1on, history, condition, treatment, dl.agnos~s, prognosis, et1010gy or expenqe; (b) Medical records, including patient's record cards, X-rays, X- ray readings and reports, laboratory records and reports, all tests of any type and character and reports thereof, statements of charges, and any and aU of my records pertaJ.nlng to medical care, Iustory, condl.tion, treatment, dl.agnosis, prognosis, et~oloqy or expense. You are further authorized and directed to furnish oral and wr:Ltten reports to lilY attorney, or his delegate, as requested by h11l\ for any of the fore\lo1ng IIlAtters. By reasons of the fact that such 1nformatlon that you have acqulred as my phYSlcian or surgeon is conf1dentul to me, you are also requested Co treat such informatJ.on as COnfldential and reque5ted not to furn15h any such ~nformat~on in any form to anyone, w:Lthout wri.tten authorizat10n from..... I hereby revok.. any prev>.ouslv elated med1cal authoruation. This Authoruation does not prevent the health care provider frOlll supplying billing and other ~nfo~tion to the first party carrier or medlcal lnsurer in order that the bills are paid. It does, however, prevent the _di.o.al prOV>.der from supplyin!l tlu.s infoJ:tl\atlon to a third party "nsuranee adjuster or an adJuster for an adverse party. I also author1ze illY attorneys or the~r deleqate to photograph illY person wh11e I am present in any hospital. Pat copy of this authorization shall be considered &s effective '-\<<lI[""''''''''~''~<H'l'f_ ~", ,,'.,- -" -, '- "'^~,~ 1=' 1';' - .~, , ~"~ d ~ ---^ ~ ^ I '" ~, l ,..., l , PROB # SOAP Jo HOLY SPIR HOSPITAU GREEN HILL FAMILY HEALTH CENTER PROliRESS NOTES ~J~'~' , 1J 15 91 415427 180 78 5446 GHl~~ FH r- .-.. GRH 100 7/98 .%W""';q<'"''''",:<:'',"''' ,~. -,,,' - '-,~" ,.- , . 1 ~ -- r'" , , ~ ~ .~ .-,,,"",,,",,,,..-- ~ ~:!"ti\l~~~~~~fI!~ ''Ii}{,~'- t~. j.fl:.... ,..~ ~~:t":;~~_llttr:.t":4:~ )1'1~l' ,~.t;.(" ,~.J,tHo ""r.tt"... fv~ .' , :-, v v PROB 1/ I SOAP I DATEIPROGRESS NOTES . TELEPHONE MESSAGE DATE: q -( f~oCJ TIME> IV: '-r t) D-" /<-- - PATmIl'. J("",/'d ('I!XJ...J...-:. , PBONE~ 737-,31." PBOl'lIU. C"U''''~'''''-:- ~"'I'l~, "~ 331 'BONZ. 0!lS!T. BEAD car.sr JlEVD, HItI.D1>CRE c:ooGlI~ NOSE COLOll_ CIlIlST'AIN soll!T1IlROAr SOIl BAR-PAIN 1l'llT: AllIIOMEN PAIN oWllUlEA NAtlSEA VOMIIlNG ---/- 1.oa:.Y'.1...1 "111I.11._ GREEN HILL MIlLY HlALTH 4IN11f1ol PROGREfll NOTES GRH 100 1196 ,.r-->S CJJ~,RS .K~Y' i1 J ,,) 'S 98 - 4154~7 180 ]8 544~ GHILL FH ~ I'(,~"ke'-""-"'~"'-"''''r., <"., . .' I~-~" . I I~ ~~~~. '1 - ;~ , ,I' f ............ PROB # I SOAP .1 DATE/PROGRESS NOTES TELEPHONE MESSAGE DATI::9 - II t:.:>D TIME: tb-. <.f.b DIl_ K INIT' Ihf: PAm:NT:_rQ ~ \0. Cro'NlbS mONU1' I ~ :3 ~;>Ci.~u; CALLER: ~ {{j b PlWlMACY; PHONE' ONSET: IlEAD I.' :;U~E 1IEADACIlIl ~~ ' SO I.T '" c~~~~; '. . j};,;~-b}At,~#-c, 11", - ~~/j. '--f/.. I ~AN:~.h ^~/ 1ft1 Iv ~ h-< ,k] _ 0- CIlIST COUQH NON-PllODUCTlVE CIlIST PAIN SOB ( ..e IJ. or Il. 'f'.cP ~ o,,;Vbf. AIIDOMJ:N PAIN DIAIUlIIEA NAUSEA vOMl'l'lNo " cD K. 1I'!IT DATE. HEAD . J;:-.rfVER HEAD"C.~ ~OSE COLOI<<' ? SORE THROAT 1-,EA~ PAlN PJIONE f , rHoN~ 7 -zi: oI.:.:5Q CHESl ~ ABDO~EN COUOH "ON.PRODUC~~ PAIN . CHI!SI.PAIN DlAIUUISA - SOB 7 NAUSEA - VOMITING _ I!l;' "'I r~4~ ~d t.k'; /- e ~ Yl .<J~ 4(,L. btbr$-'2-, JJ~f r1iJt.fefl)? 9~od'. Ove,tS 50 01.v~ o cOt -tIt~ sf!i;;l~rD",~RJ<cd ~~ 6'~~it~ ~!'E ct:~k.-= -"~d -!L r HOLY SPIRIT HOSPITAL GREEN HILL FAMILY HEALTH CENTER PROGRESS NOTES c~/)~~' ,. ,Y'." J , y,- 41'"2~ , . 6 G I., '. ~ F H ~..... - GRH 100 7/96 ." i!,;KlW<"'~"H'W~"1<j;,,_"'1j! _, ~ ,. ~ ,-- 'I, -- - 1 ' '1 !~_1I!III'fIIlIIII ""~",,, , , . . ' '. "'rv1 ilr.- rt. -qoe ,KAYU 1ah(NALft((A-~) Atn Dr: VARMA BHUPI )F J Adm Dt: 10/03/00 ofDER ,,_0 ,. VPh - ''fl~dd; u ~ / ~p7t- 4)- REF Pt#: 429903147 IV i 2>{0tl 0;).(... '-...-- LAB 1801, Mr#: 180785446 --~---~---------._-------------------_..._----------------------------------- 09/21/00 09/21/00 CHEM-ROUT1NE 15:45 15:42 SODIUM 13'1-147 137 POTASSIUM 3.6-5.1 4.7 CHLORIDE 97-108 104 CO2 20-30 :n.o BUN 0-20 10 CR.E:ATININB 0.3-0.8 0.3 GLUCOSE 74 -118 65* PHOSPHORUS 3.5-6,8 5.6 CALCIUM 8.9-10.3 10.0 ALBUMIN 3.5-4.8 4 4 RDL CHOI.. 29-89 48 TRIGLYCERIDE <200 274* LUI.. CHOI.. 0-130 92.2 RISK FACTOR 4.1 T CHOLESTEROL 0-200 195 =~~===============~~===~~=.=~=s..~==============~===~=========~=========~== 09/21/00 . LIPID EVALUA 15:45 ::1 HOL CHaL 29-89 48 'I TRIGLYCERIDE <200 274* ii , LOL CHaL 0-130 92.2 ';, , VLDL 55 ,',I RISK FACTOR 4.1 '1' =========~=====~====~.~~O~__.._R_=.=~.=_===_.==~~===.====~=~==~====.=~~.~.. HEMOGRAM WBC Rac HEMOGLOBIN HCT MCV MCH MeHC PLATELETS RDW MPV 5.5-15.5 3.70-4.90 11.0-14.0 31. 0-44.0 70.0-85.0 22.0-31 0 28.0-36.0 l29-366 11 0-15.3 6.5-12.2 09/21/00 15:42 10.43 4.92* 11.4 33.1 67.3- , 23.2 34.4 369* , 13.3 9.6 I cj- ~~#====.==~D.==~.#================~====~====*====~~==~~~==~===~~~~==#=z=~=# IFFEREN'l'IAL NEUTl<OPHILS LYMPHOCYTES MONOCYTES EOSINOPHILS BAND 16-60 25-75 0-12 0-8 09/21/00 15 ,42 ( 17.0 76 0*' 5.0 1.0 1.0 ~=$====~====~====~c~======~~====#~=========~==~========~~===;=~===~~~===~ 09/21/00 . ',WBC,PLT 15,42 BC MORPHOLO SEE TEXT ~=~~==~~====~~===~======~==~=.~=~====~=======~=$====~~=~~~==~.=~~=~=$~=#~ q~'F"'J""''''''"'''''' '^~r< , 13;37 10/09/00 FROM CKD1,ZRPRTGFl 1'1 ,~ ".",'!l_~,,_ ~~ ......,"'~'9'~_~~ ,.." ,.- "..~ < /' , , r W '< - ReSult Gen Lab COOMBS , KA~LA Atn Dr. VARMA BHUPINDER Adm Dt. 10/03/00 OA F 1 / REF Pt#: 429903147 Mr#. 180785446 LAB Isol: ---~-------~-~------------~------------------~----~----------------------------- IMMUNOASSAY FERRITIN 10-155 09/21/00 15 ;,i.Z 33.6 ( [:~ .. \,Jh / ,~1 f"'\ -('..,:' ~," \ r ,~ · (::1 :',: ~ ;. 1J- , ~l ====q$~s=====~=~==~=======~====End of Report===~====~==========~~~~======== 13:31 10/09/00 FROM CKD1,ZRPRTGF1 CKL88899 -~"Jtw-'''~ <t, " , _ . ~<. -"1 r '. ~ 1 I I.-~~ '1 '''.r.'' , (,,4,I"1C, I, 0~1 . .WJ. f'tbC(l4fl;J ,- Result Gen Lab COOMBS ,KAYLA F Atn Dr' WILLIAMS RONALD J Adm Dt: 09/21/00 OA r . -- 1 / CLINIC Is01: KPC pt#: 210083732 Mr#: 180785445 ~-------------------~----------------------------------------------------------- ~ i' " i, 09/21/00 09/21/00 CHEM-ROUTINE 15'45 15:42 SODIUM 137-147 137 POTASSIUM 3 6-5.1 4.7 CHLORIDE 97-108 104 CO2 20-30 21 0 BUN 0-20 10 CREATININE o 3-0,8 0.3 GLUCOSE 74-118 55* PHOSPHORUS 3.5-6.8 5.6 CALCIUM 8.9-10.3 10.0 ALBUMIN 3.5-4.8 4 4 HDL CHOL 29-89 48 TRIGLYCERIDE <200 274* LDL CHOL 0-130 92.2 RISK FACTOR 4.1 T CHOLESTEROL 0-200 195 n' !:' [I ==~;=~=====~===;====~========~==#===============~~======~=~======;====~==== r;-' .' LIP ID EVALUA HDL CHOL TRIGLYCERIDE LDL CHOL VLDL RISK FACTOR 29-89 <200 0-130 09/21/00 15:45 48 274* 92.2 55 4 1 T ';. 1\1 =====~=====~==========~===========~=====~==================~=============== ,< 09/21/00 HEMOGRAM 15.42 WBC 5.5-15.5 10.43 RBC 3.70-4 90 4.92* HEMOGLOBIN 11.0-14.0 11.4 HCT 31.0-44.0 33.1 MCV 70.0-85.0 67 3* MCH 22.0-31.0 23.2 MCHC 28.0-36.0 34.4 PLATELETS 129-366 369* ROW 11 0-15.3 13 3 MPV 6 5-12.2 9.6 b ===============~==~;======================~================== ~.===-=====~ 09/21/00 DIFFERENTIAL 15:42 NEUTROPHILS 16-60 17.0 LYMPHOCYTES 25-75 76.0* MONOCYTES 0-12 5.0 EOSINOPHILS 0-8 1 0 BAND 1. 0 i" l-' RBC,WBC,PLT RBC MORPHOLO ==~=========~==~=~====~~=~==~a=====~=====~~=.==s==~===a====~=============== 09/21/00 15:42 SEE TEXT ===============~=======~================T=======~===================~====== CKL87286 ~ 11:17 09/22/00 FROM CKD1,ZRPRTGF1 ~-",-";11'.%_""""'''' " ",'"C I,r " ""PI' "~~J! lf~'''lr_"'W' ,- /~ \ ~ ( - Result Gen Lab COOMBS , KAYLA F Atn Dr: WILLIAMS RONALD J Adm Dt: 09/21/00 OA 1 / CLINIC Isol' KPC Pt#: 210083732 Mr#: 180785446 -----~------------------------------------~--------------------.----------------- IMMUNOASSAY FERRITIN 10-155 09/21/00 15:42 33.6 11 f'! ['I I'; i; :- ~ iJ ~i i'! I;: n I' Ii " !l' Iii " , f1 I' ~ I i": C Ii i ~ ~:. " " ::, :: I,' h c( i'i' , Ii Ii I' 1-' Ii :: !.! ii, i-;' i.i'; ," i" ~: . ~;;=;;;=;=;;;;=;===;;===;;===;=End of Report=======;~=;=~===~=======~====== 11.17 09/22/00 FROM CKD1,ZRPRTGF1 CKL87286 I':' " , I:, I' 1':'[ f,:i " I;:, !i i; r__.~Jl@~'o/>"''"''''-"'''''__ "" .~,~; 1~7 " o. ,"!'--'~' ,~ Schmidt, RoCca & Kramer PC 209' State Street Harrisburg, Pennsylvania 17101 717/232-6300 Fax 717 /232-6467 October lO, 2000 Attorneys arul Counselors at Law Holy Spirit Hospital North 21" Street Camp Hill, PA l7011 Attention: Medical Records Department ,.J :'~L, VI l, / 2 r!I'~') (<.!uu L..: , ': REQUEST FOR HOSPITAL RECORO'~'"' ".",...,-; .," I!: I ",' I ! '--...I Client Kayla J. Coombs, a minor Krista J. Coombs, parent 116 South Third Street, 1st Floor Lemoyne, PA 17043 10/15/98 180-78-5446 All medical records from 9/1/00 to the present. All bills from 9/1/00 to the present. Address Birthdate S.S. No. Records Requested: Bills Requested Dear Sir or Madam: Our office represents the above-named patient. Please forward to my attention copies of the following: !'- [x] any and all hospital records, including but not limited to: discharge summary, admitting notes, history, physical examinations, consultation reports, x-ray or other diagnostic test reports, emergency room records, pathology reports, operative reports, medical photographs, if any; all doctors' orders, notes, etc.; tissue committee report, if any; employees' day sheet showing names of nurses; physical therapy records; any and all outpatient records for the dates requested above. L-l i-',j i'.; !" I::! " [x] any and all billings for services rendered for the~ates requested above. On your bill for hospital services, please do not show any amounts paid by insurance, as we cannot use these in Court. Your bill should include your total charges for services without showing the source of payment. '(Please bill us separately for your report or photocopy cha~ges) . ,;tVJW~~(>MW'~""f.".'i'fif,_ _ _ , --"',~' ,..-- I,'; '-. ~. ~ .r.'- "". ~---'" '-0- 2."" ~,- ~,~. (" r Holy Spirit Hospital October 10, 2000 Page Two Enclosed you will find a signed Medical Authorization authorizing the release of this information to me. Thank you for your kind attention to this matter. Very truly yours, SCHMIDT, RONCA & KRAMER, P.C. ,/1 erard~ A~~~'~ney at Law GCK/det Enclosur/ cc: ~ing Department " Yf'i~'-*~-'''''''' >f"-.-,_ r~ --^. ,--." r' - ~~ ~~", , i ;;'<;_"if="~~"_~_ ".,., T.~: r , HOLY S'P,IRIT HOSPITAL ".- ( Medical Auth~rization From: KRISTA J., COOMBSP INf.G of KAYLA J. COOMBS, A MINOR AND GERARD C. ::Kfu\MER, 'HER ATTORNEY You are hereby authorized' and directed to permit the examination of, and the copying or reproduction in any ,manner, whether mechanical, photographic, or otherwise, by my attorney or such other person as he may authorize, all or any portions desired by him of the following: ' (al Hospital records, X-rays, X-ray readings and reports, 'laboratory records and reports, ali tests of any type, character and reports thereof, statements of charges, any and all of my records pertaining to the hospitalization, history, condition, treatment, diagnosis, prognosis, etiology or . expense; (b) Medical records, including patient's :record cards, X-rays, X- ray readings and reports, laboratory records and reports, all tests of any type and character and reports thereof, statements of charges, and any and all of 'my records pertaining to medical care, history, condition, treatment, diagnosis, prognosis, etiology or expense. You are further authorized and directed to furnish oral and written reports to my attorney, or his delegate, as requested by him for any of the foregoing matters. By reasons of the fact that such information that you have acquired as my physician or surgeon is confidential to me, you are also requested to treat such information as confidential and requested not to furnish any such information in any form to anyone, without written authorization from me. 'I hereby revoke any previously dated medidal authorization. This Authorization does not prevent the health care provider from supplying billing and other information to the first party carrier or medical insurer in order that the bills are paid. It does, however, prevent the medical provider from supplying this information to a third party insurance adjuster or an adjuster for an adverse party. I also authorize my attorneys or ,their delegate to photograph my person while I am present in any hospitai. I agree that a photostatic copy of this authoriZation shall be considered as effective and valid as the original. Date: .\ I 10/10/00 Pa ~ . -. !---,- -y ,<I Test Results x" I 'SPECIALTY LABORATORIES , 2211 Michigan Avenue Phone 800' 421 . 711 0 Santa Monica, CA 90404-3900 Fax 310-828-6634 Holy Spirit Hospital A TTN: Laboratory 503 N, 21st Street Camp Hills,P A l70 II Tel! Fax:717 763-294117177632947 " il ,'1 :1 LEAD WHOLE BLOOD /1 I Analyte II Result II Reference Range I ISpecimen IIVenous II I ILead Whole Blood 1149,5* II < 10.0 mcgfdL I REFERENCE RANGES for Lead Whole Blood: Age Reference Range Alert < IS years old < 10,0 mcgfdL > 20 mcgfdL IS years and older < ]0,0 mcgldL > 30 mcgfdL OSHA Industrial Alert ~~ -- > 40 mcgldL Lead Whole Blood: Confirmed by repeat analysis, This test result or one or more of its components was developed and its performance characteristics determined by Specialty Laboratories, It has not been cleared or approved by the U,S. Food and Drug Administration. The FDA has determined that such clearance or approval is not necessary, 10915K27-0UTII Recelved Date: IResult Status: IIComplete Reported Date: Ipatient: ISex: IAge - DOB: IPatient ID: !Physician: Collection Date: Client Accession # Report Comments: r i .Page lS 014.\ IICOOMBS,KA YLA J IIF III - 1011511998 11415427 IIM,~, Jerome L. Konnchak 19115100 6:31 :00 PM Specialty Accession # 098-5197029 91171004:05:00 AM PST 9120100 1:15:00 AM PST James B. Pete" M.D.. Ph.D, Page I ofl \'''n'ffu""~,, ,1otO""<<nmtmcl~nmlFi1es/17r26541447,htm ~~f!i;'!!I'4~"""""""~:li~_ ~ '-, ,'~-- ;'- ...,;- ,"--4 ' '. '''-"''-'1' 9/2112000 ,'" ...~"'\. ..."....."'U.l\.'" SPECIALTY LABORATORIES 2211 Michigan Avenue Phone 800-421-7110 Santa Monica, CA 90404-3900 Fax 310'828'6634 Holy Spirit Hospital A TTN: Laboratory 503 N. 21st Street Camp Hills,? A 17011 Tel/ Fax:717 763-2941/717 763 2947 ?, LEAD WHOLE BLOOD r~' I Analyte II Result II Reference Range I ISpecimen IIVenous II I ILead Whole Blood 1142.1 * II < 10.0 mcg/dL I REFERENCE RANGES, for Lead Whole Blood: Age Reference Range Alert < 15 years old < 10.0 mcgldL > 20 mcgldL 15 years and older < 10.0 mcgldL > 30 mcgldL OSHA Industrial Alert ~- .~ > 40 mcgldL Lead Whole Blood: Confirmed by repeat analysis. This test result or one or more of its components was developed and its performance characteristics determined by Specialty Laboratories. It has not been cleared or approved by the U.S. Food and Drug Administration. The FDA has determined that such clearance or approval is not necessary. IPatient: ISex: IAge - DOB: IPatient ID: Iphysician: Collection Date: A. o.~"'" ;7 U.l V/ IICOOMBS,KA YLA J IIF III - 10/15/1998 11415427 I M.D. Jerome L. Korinchak 19/7/00 4:49:00 PM Specialty Accession # Client Accession # 10907K28-0UTII 098-5130644 Received 1919/003:57:00 AM PST Date: IResult Status: IIComplete Reported Date: Report Comments: 9/111002:47:00 AM PST (I i;.'.1 ;-'.! :.'1 ~ James 8. Petel. M.D" Ph.D, Page 1 of 1 http://www.datapassportmd.com/Files/17r25541615.htm T~>";'<_"'/W-<'_,," :" -I'! '" ~ 9/11/2000 -:-f'~ ~ .~"~,~~ .~ r \_!~~ Dl)"fE:; 10/18JOO ~..iN lINEt ~t:;;~29 '''.,'- - .., '-'_'_Oh_,'c',__'C,- qOLV ;?-PIRIT HOSPITt~L, C,(~!~}I-' Hiu':',! l~'[-l J.~.VJ.l K, '~RTMENr OF LMlORATORY MEDlCINE' ' STEPHENSON S.P. SIoIAMIDOSS' ~l.D., OmECTOn n"ll.~c. .::. l!ii***DISCHAf,GE SUMMARYuu* "" _~ _ ,,_u _N _ .. _ ..~ _ _. _._._.~ .__ _ N~_ ....._..~ ... _ _. _._ ___._..a _.~.._ _ ..~_... __ _ _._ ..~ N~ .__ ....._ _ ..~__ _ ,,*_... ..- .. -_ ....-. ..a__....__.__ ...__~. -.--,.. .-,.. _._.....N._ ... ---.---- - .-. EG IlR' KORINCHAK,JEROME L Mil AceT f: 00001M47290 AGE/SX: lV i1M/F STATUS: REG CU OP RHi U t': '[1.6427 flEG, 09/16/00 DIS: (\HENT: COOMBS,KAYLA cl LOC, ROO~j, 8FO, _,,, ._.... _ ..~ _ -. _ a_ ~~ _ ... ....__ WM.__ _._ _ ._.. .__. _ .~ _.__ ___ ___... ___.._ _ _ _ ~._ _.__ ... _ ...._ ~~ ....____ .~.~. ~ ..~. ..~..- ._- ....- a... -.- - ....----. -.-- ..~... --~~.---. - .----- - -... REFE:l<ENCE LAB TESTING . .....~ ...._._....... ~_ _ ._..._ _._ _.._ _. M~ "N__"_ _ ...._ ...__._ _ __..~...._. .____.__. ~._..._ .... .H_ __ ...._ _ .-_ .__.... ._-.. a _.... ........ ~._ .__ a.____ ,~.-....-... -- - -- .--..~.-- .~- -- ---- _.~ LEAO,8LOOO lat~' T I me .._ _ _",_..M _......_ ~~ ........~_ _ "M_ _. _ .__.~..__. ...._ ,,~__ _ __ _..~ ___ _ .____._...a_ _ .~.- ..~ - -- - -... --..~ --.- .. - .....-- ...- ._- ...---.... --..~,..-. -.- ...-_. .-- ........-- - ----- ....-.. )9115/00 18')9 (ill IOTES ~ (i1 I SEE SEPARATE REPORT * d~notes PANIC valu~ ---.----- ._---------------~--------- --...------ .__.~._--.. - ----- .. ..... ..- ...--...--- .._---------_..~-_..._--_._-....----_.- Patient: COOM8S,KAYLA cl Age/Sex: 1)' l1M/F Acct;f<000015,S47290 Un i t#415427 ". ..._ - - ...._._ _ .. __ __ __ -0 .~....___ _ _ .__._.._ ..~ _....____ .... '__ __MM _.~ .~. _... _ ,.~_.... ~~._ ..~._ ~M __~M _<OM __ .._ ,,~__ _._ .__ ...____ ___..._ __ __... __._._______ ____ P?;p;'p-''I,'5'O~T ,____, - , C", - I ~ " - "",0'" '~-""",,,,-. ,-~ ,,,(,,^"'c:'~rrft -"-'y ,~,-,~~-- ':U(\~ UA ~ l:-~:; J Ul }':::fI~;\} :,:IN TIl'~E:; :t229 ", '" .' . ',-, -",., HUL Y ~~~..l.Xl \ i-uJ!3i"'.t I AL; t:r~Mt'. H.tLL'I l"'(.) l,~~n..J. ~ 4fnMENT OF LABORATORY MEDICINE\, STEPHENSON S.P. SI~AMIDOSS M.D., IHf~ECTor, , . 1~'Af.:H:. 1 ***,~*[iISCHMGE SUMMARY"**** _ ~~ __.._ _.._~ _'h _..~ ..~ _.._ _ _. ~~ _.__.~~ _._._....._ _~_....~".- __ _~" ._. ._._ __._ _~_ _.~ _.." _.~" _ ~~_. ~~ _ ~..____" __... _.~.._ ~..._ __ _w _...._ _'_W-"'" '__ __.__ .~. -- -... -- -.--_ ___.__~_ "I\TJ:ENT: COOMBS, KAYLA J ACGT ffi: ()()<)Oi660396;?, AGE/SX: 1'1' lOM/F STATUS: REG eLl OP RI::G U #: 415427 REG: 09/07100 DIG: '~EG DR: KORINCHAI( ,JEROME': L MD LOC: Rom-I: Br:o: 'H 'H' _.~.._.... H~ _. ,,_ _ _ _~" M _ _ _._ _ ....._ _ .~._..,,_ _.___ ___ _..__ _._ __ __~.~._.~.. ._~" _._ _. ...._. _ _ ___ _". .__.._ _ _. ._.....H _M"_" .".- -- .........".----~.. -.-- -~,,-~~-.- --- ----- REFERENCE lA8 TESTING _..~------------------------------------------------------------,---------..----------------------------- LEAD,tlLOOD )l~tt:f Time ... ....~ ,,~~"_ ..._... __ __... __ _ __.__._."._....__.... _.____ _._ .~_.~. _ _ __.__.".. w~.", ,.~._. _._ _.... _. _._.___..__... _ "" ,,~___._. ...... ~..--.-".. -_._ ___ "" ____.~..__._. _- __.__.__.. )'1/07/00 164'1 (a) ~OTES: (a) SEE SEPARATE: REPORT * denotes PANIC value -__._ __ ___ _""__.____.~_._."w_.. ~~ -------_."--_._--_._.~--- ------." _ .------ .--... -"..--.----.. _.~._-.. -- .---.-.--.-.------------.--. ~atient: COOMBS,KAYLA J Age/Be>:: i V 10M/F At:d;i!OOOOi%0396~~ Un j't;lE41!:'427 'jJ ._--.~ ----" --.---------."-~....._ __~._______ ".________.~ _.., _.____ .__._______~ _._.____.__.. _____.______~,,_________._______. "-~~0'1<'?f~~;; ,~,r:tf!1l'!l .-, -,- "'. '~',--, 'I~ I . ,~ " . ","",,'~ ,.. ,-, -,. " ....,.,..,.. EXHIBIT j 13 ~~~"~lr .r '''>J',~.,~.'m'<>l''i!i!'f' PINNACLE HEALTH POLYCLINIC HOSPITAL CHILDHOOD LEAD POISONING PREVENTION CENTER 2601 NORTH THIRD STREET HARRISBURG, PENNSYLVANIA 17110 (717) 782-2884 or 1-1300-374-7114 TO: Krista Coombs FROM: 'lJKaren Orlando, RN Public Health Nurse DATE: September 22, 2000 RE: Environmental inspection for lead-based paint Enclosed is a copy of the environmental inspection for your child, Kayla Coombs. If you have any questions regarding this inspection please do not hesitate to call me. Thank you, Enclosures (3) This program is partially funded through a contract with the Pennsylvania Department of Health. , " '. ~ . r._.~, """ _ ,I"'ie -.," .,., '" .",<"~ 0 .,~~ ii. LEAD PAINT INSPECTION REPORT REPORT NUMBER: 09/21/00 11 :27 INSPECTION FOR: Kayla Coombs PERFORMED AT: 116 S. 3rd Street Apt #1 Lemoyne, PA 17043 INSPECTION DATE: 09/21/00 INSTRUMENT TYPE: R M D MODEL LPA.1 XRF TYPE ANALYZE Serial Number: '1528 ACTION LEVEL: 1.0 mg/cm2 OPERATOR LICENSE: 000510 SIGNED: 1!WAL O~M/.Lr-{ pm ,:\;"*jlf,,,~ - "'-""~" ,. .",.".. , "I,~r~. .'1 ., Date: 31 j){}j Co -~ ~ ~,~~ PINNACLE HEAL rH POL YCUNIC HOSPITAL CHILDHOOD LEAD POISONING PREVENTION CENTER 2601 NORTH THIRD STREET HARRISBURG, PENNSYLVANIA 17110 (717) 782-284 or 1-800-374-7114 Date: September 22, 2000 Owner: Address: Kerry Saintz , 731 Harrisburg Pike Dillsburg, PA 17019 Re: Lead-based paint inspection at 116 South 3rd Street, Apartment 1 Lemoyne PA 17043 Dear Mr. Saintz: As owner of the above named property, you are hereby advised that a child who lives at or frequently visits the above named address is being followed for an unacceptably high blood lead level. An environmental investigation was conducted at the above named address and revealed the presence of lead-based paint ha:zards. Enclosed is, the report of the inspection. The detailed report has the readings segregated first by rO,omnumber and then by type of structure with the exterior rooms appearing first. This report is for your reference and shows all areas tested. A P (poor) under paint condition designated a defective siJfface (chipping, peeling, cracked). An I (intact) indicated the sufface is not a hazard at the present time. The areas positive and intact are not an immediate hazard, but would be hazardous if the surface should fall into disrepair or if the sufface is disturbed during renovation work. The summary report is organized exactly like the detailed report, however, only readings or averaged sets that have a lead value that is equal or greater than the action level are listed. A lead hazard constitutes painted surfaces that contain lead greater than or equal to 1.0 ilg/cm2 and are in disrepair, (chipping, peeling, cracked or blistering), even if the leaded layer(s) does not constitute the top layer(s) of paint. The areas listed in this summary report with a paint condition of (PI must be corrected. As painted sufface's age, lead-based paint becomes brittle and produces chips and fine dust particles that are easily picked up on children's fingers. Due to the normal hand to mouth activity of small children, this leaded dust is ingested. Exposure of young children to lead can result in developmental delays, attention deficit disorder, learning disabilities, mental retardation and in extreme cases death. The only way to prevent and treat lead poisoning is to eliminate the child's intake of lead by reducing the lead hazard in his/her environment. '~.f~'tflh~""''''',," r,"'" , - ,. I~ l' ~ - Prior to undertaking any actions to achieve a lead safe environment it is necessary to read the enclosure "LEAD BASED PAINT: HAZARD REDUCTION GUIDELINES" . Our goal is to assist families of children with lead poisoning in their efforts to reduce the lead hazards in their environment. Through our education efforts and your cooperation in correcting the lead hazards in the child's home environment we can reduce the risks of lead poisoning for these children, If you have any questions or concerns please call the Childhood Lead Poisoning Prevention Center at (717) 782- 2884 or 1-800-374-7114. Sincerely. fklJA1JYV OUI /(1/1 Karen Orlando, RN Public Health Nurse cc: Cumberland County Housing Authority Lemoyne Codes Enforcement Officer Child's Physician ' Cumberland County State Health Center Family Enclosures: (6) This program is partially funded through a contract with the Pennsylvania Department of Health. 1~;P'>l:m""''W- f >_",J. "..' I' --" , ~ ~- DETAILED REPORT OF LEAD PAINT INSPECTION FO~: Kayla Coombs Inspection Date:' 09/21/00 116 S. 3m Street Report Date: 9/22/2000 Apt #1 Abatement Level: 1.0 Lemoyne, PA 17043 Report No. 09/21/00 11 :27 Total Readings: 135 Job Started: 09/21/00 11 :27 Job Finished: 09/21/0012:56 Reading No. Wall Structure Location Member Paint Cond Substrate Color Lead (mglcm') Mode Exterior Roam 001 Front Porch 005 C Door Lft agt jamb P Wood White 1.8 OM 004 C Door Lft Rgt casing J: Wood White 2.0 OM 006 C Door Lft U Ctr I Wood Green 1.2 OM 008 C Door Rgt agt jamb P Wood White 1.6 OM 009 C Door Rgt Lft casing P Wood White 3.5 OM 010 C Door Rgt U Ctr p Wood White 1.4 OM 007 C Threshold Lft p wood Green 3.7 OM 011 C Threshold Rgt p Wood Green 0.1 OM Comment: Readingft's 8-11 are for the entrance to house * 114. Mom states that ahe and the child do sit on the front steps, and the child does have access to the door. The front porch overhan9,....is noted as having chipping and peeling ..hite paint. Unable to test with the XRF due to the height. Exterior Room 002 Side Porch 069 B Door ctr agt casing J: Wood White 1.3 OM 070 B Door Ctr U Ctr p Wood White 1.4 OM 071 B Threshold Ctr P Wood Gray 2.7 OM 072 D Windo.. Lft Rgt casing J: Wood White >9.9 OM Interior Room 001 Li~ing Rm 030 A Windo.. Ctr Rgt jamb P Wood White 1.3 OM 031 A Window Ctr Rgt jamb P Wood White 1.4 OM 024 A WindoW' Ctr Rgt casing P Wood Beige -0.1 OM 026 A Window Ctr Sash J: Wood Beige 0,0 QM, 027 A Window ,Ctr Well P Wood White 1.0 OM 028 A Window Ctr Well p Wood White 1.0 OM 029 A Window Ctr Well I? Wood White 0.2 2M Average = 0,6 025 A Window Ctr Sill I? Wood Beige -0.1 OM 032 A Window Ctr I?art. bead P Wood White 0.6 OM 013 A Door Rgt Rgt casing' I Wood 88ige -0.1 OM 012 A Door Rgt Lft casing I Wood Beige -0.1 OM 014 A Door Rgt U Ctr I? Wood Green 0,1 OM 016 C Door Lft Rgt jamb I Wood Beige -0.2 2M 015 C Door Lft Rgt casing J: Wood Beige -0,1 \1M 017 C Door Lft UCb.' I Wood Beige -0.1 OM 018 C Door Ctr Lft .casing I Wood Beige -0.1 OM 019 C Door Ctr U C\;r I Wood Beige -0.1 OM 021 C Door Rgt Rgt jamb I? Wood Beige 1.3 OM 020 C Door Rgt Rgt c;:asing J: Wood Beige -0,1 OM 022 C Door Rgt UCb.' P Wood Beige 0.2 \1M 033 D Wall U Ctr P Plaster Beige 0.3 OM 023 D Baseboard Ctr I Wood Beige 0.1 OM 035 D Door Lft Rgt jamb I Wood Beige 0.2 OM 034 D Door Lft Rgt casing I Wood Beige 0.0 OM Comment: Readings . 34 and 35 are for the entrance to the dining room. The 1 '-;,#~"p*"*",,,",, .." , ~}, - -< ~- I '-~ ilf~m'f~"'~ ,'~' - I r ~ I - DETAILED REPORT OF' LEAD PAINT INSPECTION FOR: Kayla Coombs Reading Paint Lead No, Wall Structure Location Member Cond Substrate Color (mg/cm') Mode 074 A Door ,Ctr U ctr P Wood Beige -0.1 QM 086 B Door Rgt Rgt jamb p Wood Beige 0.0 QM 085 B Door Rgt Lft casing :r Wood Beige 0.0 QM 087 B Door Rgt Uctr p Wood Beige 0.1 QM 083 C Door Lft Rgt casing :r Wood Beige 0.1 QM 084 C Door Lft U Ctr :r Wood Beige 0.2 QM 080 C Door Rgt Rgt casing p Wood Beige 0.2 QM 081 C Door Rgt Lft jamb P Wood Beige 0.0 QM 082 C Door Rgt U Ctr :r Wood Beige 0.0 QM 078 0 Door Lft Rgt jamb p Wood Beige 0.1 QM 077 0 Ooor Lft Rgt casing :r Wood Beige 0,0 QM 079 0 Door Lft U Ctr p Wood Beige -0.1 QM 075 0 Ooor Rgt Rgt casing :r Wood Beige 0,2 QM 076 0 Door Rgt U Ctr :r Wood Beige 0.1 QM Comment: Readings 73-74 are for the door to the Living roolll. 75-76 are for the side closet door, 77-79 are for the door to the Master Bedroom, 80-82 are for the door to the bath, 83-84 are for the rear oloset door, and 85-87 are for the door to Kayla's room. Interior Room ODS-- Bedroom 110 A Baseboard Ctr P Wood Beige -0.1 QM 093 A Door Rgt Rgt casing :r Wood Beige 0.0 QM 094 A Door Rgt Uctr :r Wood Beige -0.1 QM 091 A Closet Lft Door p Wood Beige -0,1 QM 090 A Closet Lft Door Casing :r Wood Beige 0.1 QM 092 A Closet Lft Door Jamb :r Wood Beige 0.1 QM 106 C Window Lft Rgt jamb P Wood White 1.0 QM 107 C Window Lft Rgt jamb p Wood White 1.0 QM 108 C Window tft Rgt jamb P Wood White 1.0 QM Average = 1.0 109 C Window Lft Rgt jamb P Wood Beige -0.1 QM 102 C Window Lft Rgt casing :r Wood Beige -0.1 QM 104 C Window Lft Sash :r Wood Beige 0.2 QM 105 C Window Lft Well p Wood White >9,9 QM 103 C Window Lft Sill :r Wood Beige -0.2 QM 099 C Window Rgt Rgt jamb P Wood White 1.0 QM 100 C Window Rgt Rgt jamb P Wood White 1.0 2M 101 C Window Rgt Rgt jamb p Wood White 1.0 QM Average = 1.0 097 . C Window Rgt Sash :r Wood Beige 0.1 QM 098 C Window Rgt Well P Wood White >9.9 QM 096 C Window Rgt Sill P Wood Beige "0.2 QM 095 C Window Rgt Lft casing :r Wood Beige -0.1 QM 088 .0 Door Rgt Lft casing p Wood Beige 0.2 QM 089 D Door Rgt U Ctr F Wood Beige -0.1 QM Comment: Kayla's room. Both window tracks and we11s need to be stablized with -paint, then t~e we1ls need to be covered with aluminum coil stock and the edges sealed. Interior Room 006 Bathroom 112 A Door Lft Rgt jamb p Wood Beige 0.1 QM 111 A Door Lft Rgt casing :r Wood Beige 0,2 QM 113 A Door Lft UC1:r I Wood Beige -0.1 QM 3 1Ulj1>-*"l9""W~';<1~ ", ,c ?, - , \. - '" 1'- -1 ~7 "~ DETAILED REPORT OF 'LEAD PAINT INSPECTION FOR: Kayla Coombs Reading Paint Lead No. Wall Structure Location Member Cond Substrate Color (mglcm') Mode 115 c Window Ctr Rqt casing I Wood Beige 0.0 QM 117 C Window Ctr Sash P Wood Beige 0,1 QM 118 C Window Ctr Well P Wood White 1.6 QM 116 C Window ctr Sill p Wood Beige 0.0 QM 119 C Window ctr Part. bead I Wood Whi.te 2.0 QM 120 C Window ctr Lft jamb P Wood White 1.3 QM 114 0 Wall U Ctr I Plaster Beige -0.1 QM Interior Room 007 Bedroom 124 A Closet Lft Door I Wood Beige -0,2 QM 123 A Closet Lft Door Casing I Wood Brown 0.2 QM 122 A Closet Rgt Door I Wood Beige 0.2 QM 121 A Closet Rgt Door Casing I Wood Brown 0.2 QM 127 B Baseboard Ctr .1 Wood Brown -0.2 QM 125 B Door Lft Rgt casing p Wood Brown 0.2 QM 126 B Door Lft U Ctr I Wood Beige 0,0 QM 132 C Window Ctr Rgt jamb I Wood White 0.8 QM 128 C Window Ctr Rgt casing I Wood 8rown 0.0 QM 130 C Window ctr Sash I Wood Brown -0,2 QM 131'" c Window Ctr Well p Wood White 7,6 QM 129 C Window Ctr Sill p Wood Brown 0,2 QM Calibration Readings 001 0.8 Std 002 1.0 Std 003 0.8 Std 133 0.9 Std 134 0.6 Std 135 0.8 Std I:' ---- _End of Readings' ---- 4 ;~'~i')i~"",~'1i""~_~'__'" "'0 - ~. ,-" ,r-'~- I, .." ""'~ <",""" SUMMARY REPO~T OF LEAD PAINT INSPECTION FOR: Kayla Coombs Inspection Date: 09/21/00 11.6 S, 3rd Street Report Date: 9/22/2000 Apt #1 Abatement Level: 1,0 Lemoyne, PA 17043 Report No. 09121/0011 :27 Total Readings: 135 Actionable: 35 Job Started: 09121/00 11 :27 Job Finished: 09/21/0012:56 Reading No. Wall Structure Location Member Paint Cond Substrate Color Lead (mg/cm'J Mode Exterior Room 001 Front Porch 005 C Door Lft Rgt jamb P Wood White 1. 8 QM 004 C Door Lft Rgt casing I Wood White 2.0 QM 006 C Door Lft U Ctr I Wood Green 1. 2 QM 008 C Door Rgt Rgt jamb P Wood Whi te 1. 6 QM 009 C Door Rgt .Lft casing P Wood White 3.5 QM 010 C Door Rgt U Ctr P Wood White 1.4 QM 007 C Threshold Lft P Wood Green 3.7 QM Comment: Readingtls 8-11 are for the entrance to house :It 114. Mom states that she and the child do sit on the front steps, and the child does have access to the door. The front porch overhang is noted as having chipping and peeling white paint. Unable to test with the XRF due to the height. ExterioJ:' Room 002 Side Porch 069 B DOOl: Ctr Rgt casing I Wood White 1.3 QM 070 B Door Ctr U Ctr P Wood White 1.4 QM 071 B Threshold Ctr P Wood Gray 2.7 QM 072 0 Window Lft Rgt casing I Wood White >9.9 QM 051 0 Window Ctr Well P Wood Whi te >9. 9 QM Conunent: The side window needs to receive the same treatment as the living room window. Interior Room 003 Kitchen 061 0 Door Rgt Lft, jamb P Wood Beige 1.0 QM 062 D Door Rgt Lft jamb P Wocd Beige 1.0 QM 063 0 Door Rgt Lft jamb P Wood Beige 1.0 QM 1 ?_~_"'~l_ "" ,,'~-~ - "":,,.,-~. , .~''J'' ,-. ~~ ,~ - 2 i -"~';!)~r~,w"!"~',~,~V --," , , EXHIBIT J >> .',-"""" ~ ( ( , LAW ;~,tSttfrllaf~}Ronca & Kramer PC ....,\;~i,;;7,~t~s];~t~YERS .-,,~. ,0 ~_:~~}~~:;'> May 14,2001 209 State Street Harrisburg~ Pennsylvania 17101 './ 717.232.6300 Fax 717.232.6467 www.srklaw.com , . .~ \? ~C\V " \. V~' \).;~ \"'~. . 0.~)\~~,.' ,-~\J~ . , U"i Jerome Korinchak, M.D, Greenhill Family.Practice 503 Bridge Street New Cumberland, PA 17070 Client Kayla J. Coombs, a minor Krista J.,Coom,l>s, parent ; 116 South Third Street, ist Floor Lemoyne, PA 17043 ; 10/15/98 __-;:>:---- ; 180-78- ~i' All m 'calrecords from 9/23/00 to the p esent. All Ills from 9/1/00 to the present. ~ Address Birthdate S.S. No. Records Requested Bills Requested Dear Dr. Korinchak: Please be advised that I represe the a'Gove named lease forward copies of all records you have kept on the con lon, eatment,and progress of this individual from September 23, 2000 to the present. Please include copies of all billings from September 1, 2000 to the present. I have enclosed an executed Medical Authorization for the release. of this information to me. I am not at this time requesting any specially prepared medical reports. If you. have a..'1y questions, plea.seJeeHree to caUor write. Very truly yours, SCHMIDT, RONCA & KRAMER,P.C. .~/~~ ~erard C. Kramer . I AttorneyatLaw' . J GCKj det ;. Enclosure <W "*+f'~'''T''''''''=',l.1(I " --1"-"1 - '" SPIR!T' PfWSIC\AN { J\CES. iNC. 205 GR1\.NOVIEW AVENUE SUITE 210 DTL S\JMMARyCWjP 6b'lrlrogt9N7~l1COOMBS KAYLA J GU 000000594879 CA 5$4870016 GHILL OFFICE VISIT COV/AMT SCHM 1 D21 1 GUR -90.00 LINE# DOS TYPE DOE 21 10/02/00 10/02/00 till. 22 10/02/00 10/02/00 23 10/23/00 fO/23/00 24 01/04/01 01/05/01 SVC PV 8 .00 CD DESC DX MEDICAID BPO CiA BL PV 05/24/01 TOTAL GHILL 0751 -90.00 3501 077107 BD SUP #RESP PTY 0 1501 MEDICAID PAYMENT 077107 BD SUP #RESP PTY 40086 EPSD'!'. 077107 V20. 2 BD N SUP #RESP PTY 3501 MEDICAID CiA 077107 BD suP #RESP PTY IQ PV QTY BATCH# INV# 87591 23000470 TOT AMT RESP AMT -25.00 -25.00 DTL# RESP 30 D21 POS RESP-TO o 87591 31 -25.00 23000470 D21 -25.00 70.00/r~d 1397 23 11 30000539 D21 .00 14679 32 -5.00 30000539 D21 -5.00 1 1 --------------------------------------------~----------------------------------- o PFl INQ MENU PF2 GU CA LST PF3 CA PV LST NPARDLQO '~"'~'''''-~ <--~ PF4 RESP PRTY PF5 CHGE DTLS PF6 PYMT DTLS PF7 CS LVL DTLS PF8 GU LVL PRPY PF9 ADDL FIELD , ., _~~ r,1 : .'. ,.- PF13 PT INV LST PF16 BDEBT TRAN PF14 PAGE BACK *LN#: PF15 RETURN *ENTER NXT LN 25 i!-t DTL SUMMARY PT: 000000594879 COOMBS KAYLA J OS/24/01 0751 GU 000000594879 CA 594870016 GHILL OFFICE VISIT TOTAL -90.00 COV/AM:r SCHM 1 BL PV GHILL IQ PV D21 1 GUR 8 -90.00 .00 LINE# DOS SVC CD DESC BATCH# DTL# POS TOT AM:r TYPE DOE PV DX BPO QTY INV# RESP RESP-TO RESP AMT 25 01/04/01 1501 MEDICAID PAYMENT 14679 33 -65.00 01/05/01 077107 30000539 D21 -65.00 ~LI.kW BD SUP #RESP PTY 0 26 01/23/01 99213 EP LEVEL 3 18506 24 11 57.00 lJ:i7Z:>T01 077107 466.0 1 102600517 D21 ,00 BD N SUP #RESP PTY 1 27 03/09/01 3501 MEDICAID CiA 28240 34 , -32.00 03/09/01 077107 102600517 D21 -32.00 BD SUP #RESP PTY 0 28 03/09/01 1501 MEDICAID PAYMENT 28240 35 -25.00 03/09/01 077107 102600517 D21 -25.00 BD SUP #RESP PTY 0 -------------------------------7------------------------------------------~----- PFl INQ MENU PF2 GU CA LST PF3 CA PV LST NPARDLOO PF4 RESP PRTY PF5 CHGE DTLS PF6 PYMT DTLS PF7 CS LVL DTLS PF8 GU LVL PRPY PF9 ADDL FIELD PF13 PT INV LST PF16 BDEBT TRAN PF14 PAGE BACK *LN#: PF15 RETURN *ENTER NXT LN 29 "^~!l<~I."'*' , "- ~ I, "~ ~! DTL SUMMARY PT: 000000594879 COOMBS KAYLA J GU 000000594879 CA 594870016 GHILL OFFICE VISIT COV/AMT SCHM 1 D21 1 GUR -90.00 LINE# DOS TYPE DOE 29 Q3/19/01 '03/19/01 30 05/09/01 05/10/01 05/09/01 05/10/01 31 SVC PV 8 .00 CD #RESP PTY #RES PTY BATCH# INV# 30050 108100692 o BL PV DTL# RESP 1 D21 36 D21 37 D21 OS/24/01 TOTAL GHILL IQ PV 0751 -90.00 POS TOT AMT RESP-TO RESP ~o ll'\~ -32.00 -32.00 , -25.00 ,25.00 -------------~------------------------------------------------------------------ PFl INQ MENU PF2 GU CA LS'r PF3 CA PV LST NPARDLOO -H-~2"_""""""'--'l'I;'" ~__": ~,^'":, DESC DX BPO QTY 99213 EP LEVEL 3 077107 466.0 BD*UP '#RESP PTY 3 1 MEDICAID CiA 077107 BD Sl} #RESP PTY 0 1501 DlCAID PAYMENT 077107 BD SUP BD SUP PF4 RESP PRTY PF5 CHGE DTLS PF6 PYMT DTLS I.: PF7 CS LVL DTLS PF8 GU LVL PRPY PF9 ADDL FIELD PF13 PT INV LST PF16 BDEBT TRAN PF14 PAGE BACK *LN#: PF15 RETURN *ENTER NXT LN 1 -,. ~. ','~' TI'P' " BILL DATE 'Of' nUL "' GLJARAlITOR "M" ~ ADDRESS KAYLA COOMBS 116 S 3RD ST LEMOYNE PA 17043 101428188 , ,J EST. COVEIlIIGE ,on INS.CO. NO. ""'>IT DETA L OF CURRENT CHARGES, ADJUSTME TS 10/25 0264006 001 15.00- CBC & AUTO DIFFERENTIA85025 10/25 0264006 001 15.00 15.00 CBC & AUTO DIFFERENTIA85025 10/25 0265107 001 49.00 49.00 CBC & MANUAL DIFF 85023 10/25 0265394 001 54.00 54,00 COM REHENSIVE METABOLI80053 BA CE FORWARD 0.00, S Y OF CURRENT CHARGES 86 LABORATORY 103.00 103.00 SUB- OTAL OF CURRo CHARGES 103,00 103.00 GU RELATIONSHI P: P SEX: F UAR NO: 1807854 6 ACC DATE: TYPE: TI E: P CE: EMPL REL: DIA NOSIS: 984.9 PINNACLE HLTH HOSP HARRISBURG, PA ADDITIONAL PllTIDI'I BILLIRG illY BE NECESSARY FOIl ANY CHARGES HOT FOS1:ED WHI!lI nns ST'ATE- HEHT WAS PREPARED. OR IF IHSUIlllIICE CARRIERS no HOT PAY ANY PART OF nm AHllUNTS SHOW UNDER ESTIMATED IRSIJJIANl:E COVEIlAGE. ( fYUd PotL-{C 1(\IC C -tflW' +f.t:i'JI)'-8"""'",-~'li""'UI'f~~ ~. ._" _~"'"T,,". I'~"! " . M ~~ n . ,~",,,,",'~--~ -- >~, ~ ""- ~ -"'-~ - YI~[ OF BII.l . DATE OF Bill -""",~ DATE qF PREY. Bill HULl b~lNIIBUb~IIAL 5('1" !II 21ST ST cli'til" HIll, PA 717 763-2141 FEI ft 23-1512747 ,- , ( (~I [,:NO \ I,' 1 17011 \~~ BIRTH-DATE H08P.NO. 10/15/98 ~9000 , 'CbE OUTP. ~OOMB R PATIENT NAME I PATIENT NUMBER 8EX AGE ADMISSION DATE DISCHARGE DATE I DAYS I S KAYlA J I 15603962 F?2M 09/07/00 I I ~ ,.---'- G.O.B. INSURANCE COMPANY NAME GROUP NUMBER POLICY NUMBER GUARANTOR 71014~8188 KAYlA J COOMBS 1 MED ASSIST OP D'lI8 NAME 116 S 3RD STREET AND LEMOYNE,PA 17043 ADDRESS KORINCHAK,JEROME -C- PLEASE RETURN THIS PORTION WITH YOUR PAYMENT. 7~ ~ I AMOUNT OF I $ PAYMENT DATE POSTED DESCRIPTION OF HOSPITAL SERVICES I SERVICE CODe TOTAL CHARGES EST. COVERAGE INS. co. NO.1 EST. COVERAGE INS. CO. NO.2 EST. COVERAGE INS. co. NO.3 EST. COVERAGE INS. CO. NO.4 PATIENT AMOUNT DETAIL OF CURRENT CHARGES, PAY~ENTS AND 09/07 lEAD LEVEl,Bl,Q0125102369 62.00 09/07 SPEC COLLECT FE0125101031 7.00 ADJUSTME ns 62.00 7.0 BALA~CE FORIJARD 0.00 SUMM~RY OF CURRENT CHARGES LABORATORY 300 69.00 62.00 7.0 SUB-TOTAL OF CURRo CHARGES 69.00 62.00 7.0 DIAGNOSIS: nO.6 PAYMENT IS DUE UPON RECEIPT OF THIS STATEMENT. YOU MAY SUBMIT THIS FORM TO YOUR INSURANCE CARRIER FOR REIMBURSEMENT, FEDERAL IDENT. NO. 23.1512747 TOT A l S PATIENT NUMBER I 1 S6 03962 I 6'l1.00 62.00 7.~ REFER ALL QUESTIONS TO THE BUSINESS OFFICE (717) 763-2136. PLEASE SEND PAYMENT TO: HOLY SPIRIT HOSPITAL 503 NORTH 21 ST STREET CAMP Hill, PA. 17011-2288 I PAY THIS AMOUNT 7. ~ HOLY SPIRIT HOSPITAL CAMP HILL, PA ADDITIONAL PATIENT BILLING MAY BE NECESSARY FOR A CHARGES NOT POSTED WHEN THIS BILL WAS PREPAR OR IF INSURANCE CARRIERS DO NOT PAY ANY PART THE AMOUNTS SHOWN UNDER ESTIMATED INSURAN COVERAGE. '-'"'T"'--'_~'"~ "'-cr;"""'ll",lM!k,_'''' "c. '-~~1"71::~ ".~"'~"-9'-- ."~." " I""t \".\ 1t 1'\ TYPE OF \ DATE OF BILL I DATE OFl Bill I ,r'" i' PREVo BIL ~i\~q;;n/nn i " I nV~l ~~ift1i AU~~iiH~ 50-'''~ 21 ST ST CM., HILL, PA 717 763-2141 FEI # 23-1512147 -', (~\ I "'''" "Vi I 17011 ' C~~) BIRTH-DAlE HOSP, NO, 10/15/% 39000 A R PATIENT NAME PATIENT NUMBER SEXI AGE I ADMISSION DATE I DISCHAAGE DATE DAYS I COOMBS ,KAYLA J 15647290 FI23M 109/15/001 I C,O,B. INSURANCE COMPANY NAME GROUP NUM8ER POLICY NUMBER CiUARANTOR KRISTA COOMBS 1 MED ASSIST OP D98 7101428188 NAME 116 S 3RD STREET AND LEMOYNE,PA 17043 ADDRESS KORINCHAK,JEROME PLEASE RETURN THIS PORTION WITH YOUR PAYMENT. 7~ ~ I AMOUNT OF I $ PAYMENT , DATE POSTED DESCRIPTION OF HOSPITAL SERVICES I SERVICE CODE TOTAL CHARGES EST. COVERAGE EST. COVERAGE EST. COVERAGE EST. COVERAGE INS. CO. NO.1 INS. CO. NO.2 INS. CO. NO.3 INS. CO. NO.4 PATIENT AMOUNT DETAIL OF CURRENT CHARGES, PA'MENTS ANt 9/15 LEAD LEVEL,BL,Q012510236~ 62.00 9/15 SPEC COLLECT FE0125101031 7.00 ADJUSTMENTS 62.00 7.0l BALA~CE FORWARD 0.00 . SUMM~RY OF CURRENT LABORATORY CHARGES 300 69,00 62.00 7.01 SUB-'OTAL OF CURRo CHARGES 69,00 62.00 7,01 DIA~NOSIS; V15.86 . PAYMENT IS DUE UPON RECEIPT OF THIS STA EMENT. YOU MAY SUBMIT THIS FC RM TO YOUR INSURANCE CARF IER FOR REIMBURSEMENT. FEDEAAlIDENT. NO. 23-1512747 TOT A L S PATIENT NUMBER I 15647290 I 69.00 62.00 7,0' REFER ALL QUESTIONS TO THE BUSINESS OFFICE (717) 763.2138. PLEASE SEND PAYMENT TO: HOLY SPIRIT HOSPITAL 503 NORTH 21ST STREET CAMP Hill, PA. 17011-2288 I PAY THIS AMOUNT 7.01 HOLY SPIRIT HOSPITAL CAMP HILL. PA ADDITIONAL PATIENT BILLING MAY BE NECESSARY FOR AN' CHARGES NOT POSTED WHEN THIS BILL WAS PREPAREI OR IF INSURANCE CARRIERS DO NOT PAY ANY PART 01 THE AMOUNTS SHOWN UNDER ESTIMATED INSURANCI COVERAGE. . 'i"K~q...'1<""'''''''~ _ _~~~,.._ _ ,", " I, ...,.,. p. ~ "''''r"'~ iC I ~2 (VP€ OF DHE 0' BILL OA7E ti, 0 .. PREV, (1([[ 10/ 16 /00 8AUDD .. . '="":''-''~<'.:.:.-:* -' ;:::~:~"t:::;:..~ PINNAClE HLTK KOSP Sf': 2353 H ll.'k'R I SBURG... P A 717 23{t':'5n r UK . >i=t!"2517t8644 V105> ." . ,I 1dl .)11 RTrr.:. D A 'r E- HO". NO. . .1 O/t~!I~.}. CO 6 7 PU;ASE '~~>>.G.";~'~~l:'i:~:~;;~ .W:;~~1~ltl1"V~~;~;~;~~ft.,;.f.llil..j.IIIlI~zi1N;. ;....r~... .'."'" ....< ....." 'n.... ,'-.' ,,' .- ..,..."...,.....,.,...:.:'"..,.::.:.....:..,.... . .-.-.., SERVICE: I TOTAl EST. COVERAGe- EST, COVERAGE EST. COVEMGE EST. COVERAGE PATIENT I CQ:JE CHA;=tC;:S. INS. CO. )I,'C.! ;/'<3. CO. NO. 2 Jr:$. C0, NO. ~ INS, Co.. r:o. II A/A0l.lN" ..'....,... -:-_.~".. .~'~;-y..~,:.".,~.,.._,""".,..- PATlENT l'iAME GUARANTOR ,\ { KRISTA COOMBS 116 S 3RD ST LEMOYNE PA 17043 h) N....ME AND ADDRESS -' . I DETAIiL OF CURRENT CHARGES, PA'V!MENTS AND J9/21 p115071 001 43.00- CBC E AUTO DIFFERENTIA85025 09/21 0115071 001 43.00 CBC ~ AUTO DIFFERENTIA85025 09/21 10115130 001 FERRITIN 82728 09/21 p116023 001 CSC ~ MANUAL DIFF 09/21 p117043 001 LIPID PANEL 09/21 0117060 001 RENA!IL FUNCTION PANEL 80069 09/21 1266420 001 EXPA'INDED VISIT - EST T99213 09/21 1266421 001 EXPA:~DED VISIT - EST P99213 09/27 u116023 001 CSC ~ MANUAL DIFF 09/29 p037499 001 SYSGrN MEDICAL ASSIST CONTR SALAN1CE FORWARD SUMMAry OF CURRENT PAY/ADJ SUMMARY OF CURRENT CHARGES 86 LABORATORY 60 OUTPATIENT VST I OAT< ! DESCRIPTION Of H05P;'~AL sr;iWtC!;S 76.00 55.00 85023 26.00 80061 68.00 15.00 43.00 55.00 85023 262.00- 0.00 262.00- 280.00 58.00 L SUS-TfTAL OF CURRo CHARGES Tn TAT',:: PAHENr- NU~6i;c--:; :4~bt~~~ ~~JJE!hT?N6~i"R~W 2 1 00 8 3 7 3 2 l ANO COR",,'ONO,"C'. 338.00 iENl .' .,"< . . . .....n-..__':,;.. 1 MAPA 7101428188 WIllIAMS RONALD J ADJUSTMENTS ~ 43.00- 43.00 76.00 55.00 26.00 68.00 15.00 43.00 55.00 262.00- 262.00- 280.00 58.00 338.00 "vtlN .71(.0('(...'''',... .. ..., ....;'::. . _ AD.DJTJOlitol. P,ll,TlENT B:JlUNG M.!l,'r BE NECESSARY I FOR AN'! CHARGES NOT POSTED WHEN. TH\S BILL WAS P~EPAREO OR If INSURANCE CARRIERS DO PAY TH I S AMOUNT NOr- ~AY ANV PART OF THE AMOUNrs SHOWN "- UNDER ESTIMATED INSURANCE COVE11:ACiE. lQ. NI RJ PINNACLE HLTH HOSP ~. ,,;':,::'.'';' 0.( f'_1Ji"--- , " <~ He I '-ZJ f:';~' Of :.1D~r;:~8;L~o: p~:~ ,~~L 118AUDD ...>)i . 'P{iliNACLEHLff{ROSP" is( .2353.> . .. ....... .... iiH~RRISBURC"....f'A ,.' 7172~O~:U11' ..... ...LgL. iPEr. ... ..........251778644.... ............ .'-"-;-';-,-,;",--._-. .. ":;,:c-,,_-",. ...........iC 1 OACE "l0. .;W~1~~~~~h.~#PA1~il HOS: . NO. to?n(;1tg.~i .......~..~ C 0 6 7 NAME KAYLA COOMBS 116 S 3RD ST LEMOYNE PA 17043 MAPA 1'101428188 (lL~\RANTOR AND ADDRESS EST. COVERAGE PATIENT INS. co. NO. 4 AMOUNT DETAI~ OF CURRENT CHARGES, PAYMENTS AND ADJUSTMENTS 10/03 '10116023 001 55.00 55.00 CBC & MANUAL DIFF 85023 10/03 0117041 001 87.00 87.00 COMPiREHENSIVE METABOLIC PANE 10/11 p037499 001 124.00- 124.00- SYSGEN MEDICAL ASSIST CONTR BALANIC E I SUMMA'RY FORWARD 0.00 OF CURRENT PAY/ADJ 124.00- 124.00- SUMMARY OF CURRENT CHARGES 86 LABORATORY 142.00 I 142.00 SUB-TFTAL OF CURRo CHARGES 142.00 142.00 TYPE 780.6 SEX F TIME 6UAR NO 180785446 PLACE EMPL REL GUAR RELATIONSHIP ACC DATE D I AG,NOS I S , P ADDITION,A,L PATIENT BILLING MAY BE NECESSARY FOR ANY CHARGES NOT POSTED WHEN THIS SILL WAS PREPARED OR IF INSURANCE CARRIERS DO NOT PAY ANY PART OF THE AMOUNTS SHOWN UNDER ESTIMATED !NSURANCE COVERAGE. PAY THIS AMOUNT 0.00 PINNACLE HLTH HOSP HARRISBURG, PA ;-]_;':;",i_p~,k""',~~, ~,~ --' ~ ~ - ~" '" ~I'"'-r~-~". I ','" ,- , , EXHIBIT I D ';'" -<;;'~'!j"'.-n"-""""';;;nc"""" Settlement Agreement and Release This Settlement Agreement and Release is made and entered by and between: Claimants: Kayla Coombs (a minor) and Krista Coombs (her mother) Insured: Kerry R. Saintz Insurer: OneBeacon Insurance Group Recitals A. The claimants have presented a claim against the insured for alleged lead poisoning arising our of conditions at 116 South Third Street, First Floor, Lemoyne, Cumberland County, Pennsylvania. B. The insurer is the general liability insurer of the insured for the relevant time period (6/99-9/21/00) and would be obligated to pay any judgment against the insured that is covered by the policy. C. The parties desire to enter into this Settlement Agreement in order to provide for certain payment in full settlement and discharge of all claims now existing or which may hereafter arise out of the above incident, upon the terms and conditions set forth herein. Agreement The parties hereby agree as follows: 1. Release and Discharge In consideration of the payment called for herein, the claimants completely release and forever discharge the insured and the insurer, and their past, present and future officers, directors, stockholders, attorneys, representatives, employees, predecessors and successors in interest, and any other persons, firms or corporations with whom any of the former have been, are now or may hereafter be affiliated, from any and all past, present and future claims, liens, demands, costs, obligations, actions, causes of actions, damages, expenses and compensation of any nature whatsoever, whether based on a tort, contract or other theory of recovery, and whether for compensatory or punitive damages, which the claimants now have, or may hereafter accrue arising out of any and all known or unknown claims for bodily and personal injury to the claimants, and the consequences thereof, which have resulted from the above-described claim for lead poisoning. ..,. -. .,-.--~ ~I" '1 . .-- ~ This release on the part of the claimants shall be a fully binding and complete settlement between the claimants, the insured and the insurer. 2. Pavment In consideration of the release set forth herein, the insurer, on behalf of the insured, hereby agrees to pay the claimants Thirty-Five Thousand Dollars ($35,000), 3. Warrantv of Capacity to Execute Agreement The claimants represent and warrant that no other person or entity has had any interest in the claims, demands, obligations or causes of action referred to in this Settlement Agreement except as otherwise set forth herein, and that they have the sole right and exclusive authority to execute this Settlement Agreement and receive the sum specified above. The insurer warrants and represents that it has the sole capacity and authority to execute this Agreement on its own behalf and on behalf of the insured, 4. Entire Agreement This Settlement Agreement contains the entire agreement between the claimants, the insured and the insurer with regard to the matters set forth herein, 5. Representation of Comprehension of Document In entering into this Settlement Agreement, the claimants represent that they have relied upon the legal advice oftheir own attorneys who are the attorneys oftheir own choice, and that the terms of this Settlement Agreement have been completely read and explained to them by the attorneys, and that those terms are fully understood and voluntarily accepted by them. 6. Governing Law This Settlement Agreement shall be construed and interpreted in accordance with the laws of the State of Pennsylvania. 7. Confidentiality The parties understand and agree that the terms and conditions of this Settlement Agreement are confidential and shall not be disclosed to any person or entity other than: auditors, accountants, the IRS, attorneys, directors, officers, managers, insurance agents and brokers, and reinsurers of the parties, or as otherwise required by a court of law. 2 '-:;',\;~*I!l'c;o;."_",,,~., . .-., "~; l' , ,.t,1 ^.. "',W~""t,-"-"-"'il"'f>;f:l'i! ~ ~,,_ 8. Construction This Settlement Agreement is not and shall never be construed as an admission of liability, fault or wrongdoing by any of the parties, each of which/whom specifically denies any liability, fault or wrongdoing, Instead, the Settlement Agreement reflects a settlement and accord and satisfaction of contested, doubtful and disputed matters, by which each of the parties has forever bought their peace as to the claims released herein. This Settlement Agreement shall become effective following execution by the claimants and the insurer. Executed this day of , 2001. OneBe~onInsuranceCompany And its Insured Kerry R, Saintz Victoria S. Price, Esq. Krista Coombs, Mother of Kayla Coombs, a Minor 3 'h," .-', ,1'-, , ~"'-" ~-~. \ EXH\B\T ---- r.- ~ }' .~' ! i r'. , ',t\'--t"\ 6v CONTINGENT FEE AGREEMENT THIS AGREEMENT entered into the 81--( day of (\11 (:I- \l , 20.Qi, by and between SCHMIDT, RONCA & KRAMER, P.C. and KRISTA J. COOMBS p/n/g of Kayla J, Coombs, of 250 Pleasant View Drive, Etters, Pennsylvania 17319, hereinafter referred to as "Client." WITNESSETH: The law firm of SCHMIDT, RONCA & KRAMER, P.C., will act as Client's attorney in negotiating for a settlement, and in bringing a claim against KERRY SAINTZ and/or anyone else with respect to a potential medical malpractice claim for complications relating to lead paint incident which occurred on or about September 1, 2000, in Lemoyne, Cumberland County, Pennsylvania. In return, the Client will: 1. Promptly supply accurate information, as requested by SCHMIDT, RONCA & KRAMER, P.C., and cooperate fully, including making herself available for meetings with attorneys and for legal proceedings. Client promises all information supplied will be truthful and accurate. 2. (a) In any claim brought on Client's behalf, to pay to SCHMIDT, RONCA & KRAMER, P.C., for its services an amount equal to twenty-five (25%) of all funds or property accruing to Client as a result of SCHMIDT, RONCA & KRAMER, P.C.'s services in securing a settlement of these claims without litigation; an amount equal to thirty-three-and-one-third percent (33-1/3%) of all funds or property accruing to Client as a result of SCHMIDT, RONCA & ;~'~>:"~'?;',,-,,-,~"-.,," ="- , .. ".- - ." ~',' "-'I I ! :r"if~~:<l"ifl!SI'~~_", ~_ r f " , , , KRAMER, P.C.'s services in securing a settlement of these claims after a suit has been filed; and an amount equal to forty percent (40%) if such funds or property are secured after start of trial or as a result a verdict or judgment. Trial begins at jury selection. In any matter submitted to arbitration, suit is . filed when the arbitrators are appointed or when a Petition to Appoint Arbitrators is filed, whichever first occurs. In any matter submitted to arbitration, trial starts the first day the arbitrators have convened to hear testimony. (b) Client agrees not to settle or negotiate the above claim or any proceedings based thereon. (el If Client terminates this Agreement before recovery, Client agrees that SCHMIDT, RONCA & KRAMER, P.C., shall be entitled to a fee based upon work done and benefit conferred. (d) Client agrees to read and follow SCHMIDT, RONCA & KRAMER, P.C.'s "Instructions to Our Clients." 3. Client agrees to reimburse SCHMIDT, RONCA & KRAMER, P.C., out of any recovery, in addition to attorneys' fees, all costs and expenses incurred on Client's behalf in order to make the claim. All such costs and expenses will be advanced by SCHMIDT, RONCA & KRAMER, P.C. as they are incurred. Such costs and expenses include, but are not limited to, filing fees, cost of medical records, copying costs, fax costs, long distance tefephone costs, expert witness fees and sheriffs service costs. In the event there is no recovery, the Client will not be responsible for any costs or interest charges. "'-, ~ _ 1','" -"r'~I," " , . " r ! . ( Costs will be repaid to SCHMIDT, RONCA & KRAMER, P.C., out of any funds or property collected either by settlement or judgment. The Client has read and does understand this Agreement. Signed the day and year set forth above. WITNESS: Client: .~~c~ KRISTACOO . S p/n/g of 'KAYLA COOMBS Approved: SCHMIDT, RONCA & KRAMER, P.C. ~ I have received a copy of this Contingent Fee Agreement. u~ Initials I 'c~~-''''~' - ~ -- ,". " _' ,~_ ,-~ ~ .1, 1" . ,., -.........- ,~=, ~,' '"""""'"'""U"""'I':~"tl.TiT'jrLfr'"ltlfi!!jn1W$i11.1~IIlill[JtlI' lr'I'Il"" . . , ~ (:) "'<L (") (::J .0 ..;'~ 'l ~ C "11 f<:::. t ~,;,- '::J -un:: ,) ~.~'l~ ""L? (1) mf'i'j --I 9 Z::;.': N 10 7,-- (:] ~ "- cl 0 (j)X: cr-, 0- --<:.::.... r;:) ...... '- !<C' ? '~b ~ ~ I () )>c -"-- ---,~ ,~<) 6) ~C::l ;:c:-')n1 e, I )>-'" OJ r ~ 24 -- ~ :..) :D ,~ -< ~ 4- \..(, IJI~\f;~"f<41~- ~! ;)!1"~ ' _'_ 1l!l/!l~"~~"'f'jMI';;'jflJ;;1'-"jm,H;;;::ffj{):'I-&"'''''0iFc.cc.i~~i'~i''"-'dil%1l~~r~-m'*~~~r,iJ"_";-~',_"i'o/ INRE: : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA KRISTA COOMBS, Individually and as Parent and Natural Guardian of KA YLA COOMBS, A Minor : NO, 2001-6129 CNIL TERM ORDER OF COURT AND NOW, this 17TII day of DECEMBER, 2001, at the request of Plaintiff, the hearing on the Petition for Approval of Minor's Settlement is continued generally to be rescheduled at the request of Plaintiff. Gerard C. Kramer, Esquire , '(\ \ 209 State Street /I ($]UAD .If) /JJ..h.a) Harrisburg,Pa, 17101 /lJ-;7-IJ,. <..* For the Plaintiffs :sld .:,,"-'J~.,,_ ~~tt- ,f;t:m)~ii!~l~~~~ ,<~ 'J!l]OO.lilIIlt~~lti;1@ii.!lIi!I,ili,',",~~, ~ ,: '\, p ,'1, ,"'il ", ,j. ,"I"; " .' ,~ ~~~2\~J.~)~~r$1", J"Mt~Llrr.JW,J-.,~.)/_,Q-b.t!rj,-r_,,^,~,g"!~-I :,..~,:t~l';';;~~~~~~~~';[1~,~-,,~iH_,.~, id );,.L"~;~ y~h..AJ:J~::~, -.~ ._nf~r~J t~ K ll~ ~"",".,,!'~r""_';'_ ".. ',Pt ,.,-"~,,_ ~'. .. '1' SHERIFF'S RETURN - U.S. CERTIFIED MAIL CASE NO: 2001-06129 P COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND COOMBS KRISTA VS. PRICE VICTORIA S R. Thomas Kline Sheriff of Cumberland County, Pennsylvania, who being duly sworn according to law served the within named RESPONDANT ,PRICE VICTORIA S ESQUIRE by United States Certified Mail postage prepaid, on the 29th day of October ,2001 at 0000:00 HOURS, at ONE BEACON INSURANCE GROUP PO BOX 9546 BOSTON, MA 02205-9546 , a true and attested copy of the attached PETITION Together with The returned receipt card was signed by SIGNATURE ILLEGIBLE 00/00/0000 on Additional Comments: THERE WAS NO DATE ON THE GREEN CARD FROM POST OFFICE. Additional Comments Sheriff's Costs: So Docketing Cert Mail Affidavit Surcharge 18.00 7.16 .00 10.00 .00 35.16 Thomas Kli e Sheriff of Cumberland County Paid by SCHMIDT RONCA KRAMER on 11/06/2001 . Sworn and subscribed to before me this t3~ day of~ .)+of A.D. ~ It;t""- tJ ~P#,,,.I ~b'r othonotary I"_"~";'_"';""O<',C_,",O,~~ ~<~~_~~ '" ~ I'" . ':!i:"~~lIirnfj~j"_'fi!~j;jiE&4fli!t~'.~'-=;;!h'~""'_"".~',,'''_j;-'-'' o",;",_,,,if,""'~le."'jC;''#Jt1W*,,..Jl,r!)ii.r~'ii;$..,''.-,~~~ilIMliIOlW.i&illi\!,~e~~.ttlliil~t OF FiLED--DfFICf: ,':en'1L'.y, 'O-rARY . ',_.'I!;'_,';I,\.. 1 1$' 01 NOV I 5 PM I')' "1 n ....(..,;, CUM8ERlJ~"D COUN"iY PENNSYLVANiA , -. \:~(,;.~~,,\~;P~'@!('0,~,WJ,t~II~~jJ~b,;h~~~,{:!~,,:;,;~i.,,~,~r;,~~~";}" <);>;{;~;!,LAU[,1J~;~,t~~:~t",. '" _., ,- "., J_ d_,'1 ,,'_.~,'< - p. ~-'"'' ~", .,,~,,~T"'I'""~Y, ~,_ .," ._~....",,,,...,,~_. -, I~", ". . Gompleie ~~ms 1, 2.; and 3. Also complete item 4 if Restricted Delivery is desired. . Print your name and address on the reverse 50 that we can return the card to you. . Attach this card to the back of the mailpiece, or on the front ]f space permits. 1. Article Addressed to: Victoria S. Price. esquire One Beacon Insurance Group pO Box 9546 Boston, MA 02205-9546 2. Article NumQ.9rlCQ..'Pyjro.m $eIVic8. "./abell'_ 10,00 1670" uOOit 8790]038 wx o Agent o Addressee Dyes D No 3. Service Type .>om Certified Mail o Registered o Insured Mail o Express Mail o Return Receipt for Merchandise DC.D.D. 4. Restricted Delivery? (Extra Fee) Dyes 01-6129 civil 102595-99-M.1189 PS Form 3811, July 1999 Domestic Return Receipt , -,.,,~ 000=1 ._,.-, '-r