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Home My WebLink About01-06381 l~ ~'~ " ';J.;""^ I" ': _',0.;4:,"_'" .'. t.;;J"ilict:L-;; BEVERLY HEALTH & REHABILITATION SERVICES, INC., Plaintiff : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA v. : NO. 01 - t...31>/ Ol'(.)~l ~~ FRANCIS J. TOTH and PAULA. TOTH, husband and wife, Defendants : CIVIL ACTION - LAW NOTICE YOU HAVE BEEN SUED IN COURT. If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after this Complaint and Notice are served by entering a written appearance personally or by attorney and filing in writing with the Court your defenses or objections to the claims set forth against you. You are warned that if you fail to do so the case may proceed without you and a judgment may be entered against you by the Court without further notice for any money claimed in the Complaint or for any other claim or relief requested by the Plaintiff. You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP. CUMBERLAND COUNTY BAR ASSOCIATION 2 LIBERTY AVENUE CARLISLE, PA 17013 (717) 249-3166 \ III ~ i,' .'b .,"':, 1- , -'. ~ BEVERLY HEALTH & REHABILITATION SERVICES, INC., Plaintiff : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA : NO. 01- (.,.3 PI ~o~CT~ v. FRANCIS J. TOTH and PAULA. TOTH, husband and wife, Defendants : CIVIL ACTION - LAW COMPLAINT AND NOW comes the Plaintiff, by and through its attorneys, the Offices of Fenstermacher and Associates, P.C., and files this Complaint, as follows: 1. Plaintiff Beverly Health & Rehabilitation Services, Inc. ("Beverly") is a Pennsylvania corporation trading and doing business as West Shore Health & Rehabilitation Center, with an address for conducting business at 770 Poplar Church Road, Camp Hill, PA 17011. 2. Defendants Francis J. Toth and Paula Toth are adult individuals with a current residence of 112 Bunker Hill Road, New Cumberland, PA 17070. 3. At all times relevant hereto, Francis J. Toth was a patient and resident of Beverly. 4. Beverly is a nursing home facility licensed as such by the Commonwealth of Pennsylvania. 5. On or about January 29, 2001, Francis and Paula Toth voluntarily admitted Francis Toth to Beverly, and entered into an Admission Agreement with -~ ,I" "( L I...." '-",i Beverly. A copy of such Agreement is attached and incorporated fully herein as Exhibit "AU, 6. The Toths applied for medical assistance and were approved, but were required to make private payment of $2,048.33 per moth. 7. The Toths agreed to make such monthly payment, and Beverly relied upon such representation in providing services and care. 8. At the time of admittance, the Toths were provided a detailed list of all charges, including room, board and medical care, for which the Toths would personally be responsible. 9. Beverly continued to provide all necessary services and care to Francis Toth, and Francis Toth accepted such services and care. COUNT I Breach of Contract 10. Paragraphs 1 through 9 are incorporated fully herein by reference. 11. The Toths agreed to pay for all services and care provided by Beverly. 12. As of this date, the Toths have failed and refused to pay for services totaling $43,096.60. 13. Despite repeated requests, the Toths have failed and refused to make payment of the amounts due. 2 -" ~~ _1oO~ I, ' . 'r;f;(~F" WHEREFORE, Plaintiff respectfully requests this Honorable Court enter judgment for it and against Defendants for all monies due, plus interest and costs of suit. Said amount is greater than that requiring compulsory arbitration. COUNT II Quantum Meriut 14. Paragraphs 1 through 13 are incorporated fully herein by reference. 15. Beverly has provided services and care, and the Toths have accepted such services and care, with a current value of $43,096.60. 16. The costs charged by Beverly are reasonable and customary in the industry. 17. It would be unjust for the Toths to accept the benefit of such services and care without remuneration to Beverly. 3 - ,---,- ...'~ ~~ . ,,--- .'", 'l~_ml WHEREFORE, Plaintiff respectfully requests this Honorable Court enter judgment for it and against Defendants for all monies due, plus interest and costs of suit. Said amount is greater than that requiring compulsory arbitration. Respectfully submitted, FENSTERMACHER AND ASSOCIATES, P.C. By: ~9~ Mark K. Emery Supreme Court I.D. #72787 5115 East Trindle Road Mechanicsburg, PA 17055 (717) 691-5400 Attorney for Plaintiff DATED: /1-7- d) 4 ';i ,,,"~~- [," EXHIBIT IAI '0' ,.. l,,"' , "~,,d -- "."-"'- Z~~ '''ic"""",_"""",.-''''~~",......,,=,",,,__~__~_~,",,,,,~,,,,,,,,,,,,,,,,,,,,,---~,,,,,",,,,, ~ _ .. ~''ll~J "'1I.l ~~".~-,," ., 'M'~ "1il! ~~~~j",-4;~,' ...~~..~_......-...... --........- ......"... -...........................-... [q.pri""vate This Facility accepts the following types of payments: (Check all that apply.) [~~are [~~aid 'i.J)let6ans Administration PARTIES {N!~~n~' 1b~ ~ ~ " ~ The panies to this Agreement are: ID~~ ~l~ (Name of Facility) z ~ [ ] Conservator of Person [] Conservator ofEsUlte [ ] Other, specify [ ] Guardian [ 1 Durable Power of AtIorney for Health Care (DPAHC) [..rAgent Acting Under General POA (Name of Residem's Agent) (Name of Resident's Legal Representati"e) If a Legal Representative signs, check the Type of Legal Representative (below): If you are signing this Agreement on behalf of the Resident, note your relationship to the residenr: ~~~~\l ReI 'onship to Resident . aooo Ohthis ~ -:> day of ~.{ .--i1t'_, the above parties agree that on the ~3 day of _ II i .-19 ~Q4be Re!(we~ shall be admitted to this Facility. As of that day, the Facility shall pro- vide the ervices described in this Agreement to the Resident until the date of the Resident's discharge or transfer. The Resident shall pay for the services provided by the FacHity according to the terms of this Admission Agreement. '" f)l z " ACKNOWLEDGEMENTS By signing the Admission Agreement Signature Page, the ResidentlAgen1JLegal Representative acknowl- edges that he or she has been given and has read this Agreement in its entirety, and all addendums. The Resident also acknowledges that the following information was provided upon or before admission by the Facility. Initial the lines below (if not applicable, write NI A): ..J;: 1. A list of supplies and services that are included in the Facility's private daily rate or that will be -t- paid for by the Medicaid or Medicare programs and a list of supplies and services not included in the Facility's private daily rate or paid for by the Medicaid or Medicare programs for which the Resident will be separately charged, Wbile - Business Office 15 Pin\( - Mediclll Records Yellow - Re,ident ~, _~"~"'I"""><" ,,--,.~ - , ~,,',',.."'''''^~ .............""'-"'-..._~. -~ " ~ .~~, '" ,<~~ ,k..~.... "'''~~''~~,"""__t.ao",",.;;",,.~);;/l,__ Resident Date ::tJ '" '" s.: '" ::> ~ Witness if Residenr Signed with a Mark Date z '" ~ Witness if Resident Signed with a Mark Dale Legal Representative Date Legal Represenmove's Social Security No. -( ) Legal Representative's Telephone Number Date ~OJ) ~ ./ ~ gttuJ-f-b. Ielit- Agent _~L_~-2D-{)(S~ Agent's Telephone Number ~ 2"\>J!1 Facility Administrator or Desi ee Agent's Social Security No. 8~ Date ::<:l '" '" ~ Note: The signatures above refer to the information contained on page$ 1 through 18 oJ the Beverly Enterprises Admission Agreement. Whi,e - Business Office 19 pink - Medical Re<;ords Yellow - Ref,ideD' -'''.''-~'"'",.".,.,.., ~-~". .., """"""""'~'~M'-" '. rt ~,~ _'~...~-....~ . I, ~ VERIFICATION .~"' ,- "",J""""liOL.J ""~~ ~''''''"~''''.''><icl'''';,'%I_-':'i On behalf of Beverly Health & Rehabilitation Services, Inc., /. Judy Skoda, hereby certify and verify that the facte set forth in the foregoing Complaint are true and correct to the best of my knowledge, information and belief. I understand that any false statements herein are SUbject to the penalties of 18 POI. C. S. !i4904 relating to unsworn falsificattion to authorities. DATE; /~ ~. Judy Skoda ~ 1/7/01 ~" :~~~~~,t<~r~,~'!'-'1'if;;~-:t;i!~~~}-M>.~~~;;."'~"'~',<:.i'.Bk;-,"" '1,%W::"";!<"'"S-?&iiJ'I~,Ml._li:ii~~ii:' '~'''~ill iil.l"il!" '....''ill'ajlmHn<i1_B~~'" .=.' ~ ~ 0 CJ [") ~ ~ C "~'l ~ ~ <,,:'" ~",... """''',c, -, ~ ~ r-;'ff:~ -. ;:::: - L'_ I D ()? 0 ~ U? (:;') ~ - ~~; D ~'~'.., ...... 0- >~ I :2~ S) ~~'" ~ ~ I ;;--'-' , ) ,,>C,:: :'.) / f r ~'j :",) -, C;", ~ . <R. _ ~"" ", _ .. ,"_~ ._;,=,L _~ ~,~~<~, ~.~ ^ c -c ".~~~~-", .",.~""'-'- ..-:iL:IJ.L.l_l!l.~ - Hliii- -~~~ SHERIFF'S RETURN - OUT OF COUNTY ..,0. '.' . CASE NO: 2001-06381 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND BEVERLY HEALTH & REHABILITATIO VS TOTH FRANCIS J ET AL R. Thomas Kline . J~ i " L" "",.~",..",J',,,d(.: , Sheriff or Deputy Sheriff who being duly sworn according to law, says, that he made a diligent search and and inquiry for the within named DEFENDANT TOTH FRANCIS J but was unable to locate Him deputized the sheriff of YORK , to wit: in his bailiwick. He therefore County, Pennsylvania, to serve the within COMPLAINT & NOTICE On December 6th, 2001 , this office was in receipt of the Sheriff's Costs: Docketing 18.00 Out of County 9.00 Surcharge 10.00 Dep York County 52.84 .00 89.84 12/06/2001 FENSTERMACHER & ASSOC attached return from YORK mas Kline ff of Cumberland County Sworn and, subscribed to before me this /3't' day of Ia.t.,..,.t,~ .21>61 A.D. ~Q.~.A# Prothonotary ._"',,"~~"'~"'~ "--'"""",,- ~. "__,_ " c'. ",.._..' . -,-, ~L .IIili Jill .... -......; " lif";" -.=."' ~F ~, ~"''';'rn''-'''''"i,,;~;..,,;,L . . . SHERIFF'S RETURN - OUT OF COUNTY CASE NO: 2001-06381 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND BEVERLY HEALTH & REHABILITATIO VS TOTH FRANCIS J ET AL R. Thomas Kline , Sheriff or Deputy Sheriff who being duly sworn according to law, says, that he made a diligent search and and inquiry for the within named DEFENDANT , to wit: TOTH PAULA but was unable to locate Him in his bailiwick. He therefore deputized the sheriff of YORK County, Pennsylvania, to serve the within COMPLAINT & NOTICE On December 6th, 2001 , this office was in receipt of the attached return from YORK Sheriff's Costs: Docketing 6.00 Out of County .00 Surcharge 10.00 .00 .00 16.00 12/06/2001 FENSTERMACHER & ASSOC omas Kline iff of Cumberland County Sworn and subscribed to before me this /11C:: day of / j)n/~ [ A.D. )~ () /;"J";~ ~ I Prothonota y , -'.,' ,,', "',"",;b",~""~o'<c"L,~"",, ,__",;,""'"'''''l,"""Jt'T''~I<''J'", '-"",..,;,.".,I.j--">,,",,,,,,,,.-;j,h\i,',.k;,,,,, --",^",!-A f (2 of 2) COUNTY OF YORK OFFICE OF THE SHERIFF SERVICE CALL (717) 771-9601 28 EAST MARKET ST., YORK, PA 17401 SHERIFF SERVICE PROCESS RECEIPT and AFFIDAVIT OF RETURN ,. PLAINTIFF/SI Beverly Health & Rehabilitation Services, Inc. 3. OEFENDANT/SI Francis J. Toth et a1 Notice & C laint 5. NAME OF INDIVIDUAL, COMPANY, CORPORATION, ETC. TO SERVE OR DESCRIPTION OF PROPERTY TO BE LEVIED, ATTACHED, OR SOLD. Paula Toth 6. ADDRESS (STREET OR RFO WITH BOX NUMBER, APT. NO., CITY, BORO, TWP., STATE AND ZIP CODE) 112 Bunker Hill Road New Cumberland, PA 17070 7. INDICATE SERVICE: 0 PERSONAL 0 PERSON IN CHARGE JOO(bEPUlIZE 0 CERT MAIL 0 1ST ClASS MAIL 0 POSTED 0 OTHER ~~E);"laOO NOW November 14 ,20~ I, SHERIFF OF~COUNTY, PA do hereby deputize lhe sheriff of York COUNTY to execu' make retu according to law. This deputization being made at the request and risk of the plaintiff. ~ . :P? ~""-c: SHERIFF OF COUNTY Cumberland SERVE .. AT { 8. SPECIAL INSTRUCTIONS OR OTHER INFORMATION THAT WILL ASSIST IN EXPEDITING SERVICE: NorE: ONLY APPUCABLE ON WRIT OF EXECUTION: N.B. WAIVER OF WATCHMAN - Any deputy sheriff levying upon or attaching any property under within writ may leave same without a watchman, in custody of whomever is found in possession, after notifying person of levy or attachment, without liability on the part of such deputy or the sheriff to any plaintiff herein for any loss, destruction, or removal of any property before sheriffs sale thereof. 9. "tYPE NAME and ADDRESS of ATTORNEY f ORIGINATOR and SIGNATURE 10. TELEPHONE NUMBER 11. DATE FilED MARK K. EMERY, ESQ. 12. SEND NOTICE OF SERVICE COpy TO NAME AND ADDRESS BELOW (This area must be completed if notice is to be mailed). 13. I acknowledge receipt of the writ or complaint as indicated above. RESIDENCE"( POSTED ( POE( ) SHERIFF'S OFFICE ( ) OTHER ( SEE REMARKS BELOW 16. HOW SERVED: PERSONAL 17. (J 1S. 23. Advance Costs 40. Costs Due or Refund HOSE ~ 41. AFFIRMED and subscribed to before me this 42. day of DECEMBER ,200143. 4TH 44. Signature af Dep. Sheriff 46. Signature of York CouiRY Sheriff WILLIAM M. _Sf; ..~ ~-- I 12/4/01 49. DATE 51. DATE RECEIVED 1. WHITE - Issuing Authority 2. PINK - Attorney 3. CANARY. Sheriffs Office 4. BLUE - Sheriffs Office L_ " "......c.,. . '~f"'""."\jT" r'["]'I"I" L ., "'n -, " '." """ '" RECEIVED OFFICE OF SHERIFF NOV 1 5 2001 YORK, PA .An __AM r/1V PM .):l!e-:,<' '...._,_c ,;), : l\IM!$ii~1lJf'~J:~1l!~x~>,~t~:m1'~Th1~'*'~f~~~"',<l\l:~jii"f1~!1,W&!);~i~W~!!1'~:'i#,,<;r~y,;;'; \;;,y "ji";:'N";~';-'";-!;!' ,;,'" 'Y';:",i, '-"~\! '~i'-';' :"':"""':"-i):':'~::~~~~{!ff!".J;:,:...""~>,,.l t (2 of 2) COUNTY OF YORK OFFICE OF THE SHERIFF SERVICE CALL (717) 771-9601 2B EAST MARKET ST, YORK, PA 17401 S-HERIFF SERVICE PROCESS RECEIPT and AFFIDAVIT OF RETURN 2. CgURT NUMBER. . 1 01-6381 c:tv:t 4. lYPE OF WRIT OR COMPLAINT 1. PLAINTIFF/SI Beverly Health &. Rehabilitation Services, Inc. 3 DEFENDANT/SI F't'ancis ,J. Teth et al Notice I;, Cal'lPlaint 5. NAME OF INDIVIDUAL, COMPANY. CORPORATION, ETC. TO SERVE OR DESCRIPTION OF PROPERlY TO BE LEVIED, ATTACHED, OR SOLD. Paula 'fech 6. ADDRESS (STREET OR RFO WITH BOX NUMBER, APT. NO., CITY, BORD, TWP., STATE AND ZIP CODE) 112 Bunker Hill Road New Cumberland, PA 17070 aPERsoNINC RGE ,CERtMAIL' Q1STCLAS MAIL . OPOSTEO o OTHER ,20---'--. I, SIiIERIFF OF) ",lfl COUNTY, PA, do hereby deputize the she~iffof ., J Cb~NTY to 'ElXecute . '.' '. makereturrl according to law. This deputization being made at the re~uest and risk of'the plaintiff. . SERVE .. AT { 7. INDICATE SERVICE: NOW 8. SPECIAL INSTRUCTIONS OR OTHER INFORMATION THAT WILL ASSIST IN EXPEDITING SERVICE: NOTE: ONLY APPLlCAe;LE aN WRIT OF EXECUTI9N: N;,B. W.A,IVEROF WATCRMAN ~ Any deputy" sheriff,levYing 'upon or attaching"any property under within writ m,ay'Ieave same without a watchman, in custOdy of who~ver is found in possession, ,after notifying person ,of Jel/y'or attachment, without Iiability'on the part of such deputy 9t-,tfie sherifftQ;any plaintiff herein for 8f,lY.lOSS, destruction, or ,removal,of any property, before sheriffs sale thereof. 9. TYPE NAME and ADDRESS of ATTORNEY f ORIGINATOR and SIGNATURE '10. TElEPHONF NUMBER 11. DATE FILED ~ 11.. EMERY, ESQ. , 12. S 0 NOTICE OF SERVJCE COPY TO NAME AND ADDRESS BELOW: (This a~ea must be completed if notice isla be mailed). ,........~, 13. I acknowledge receipt of the writ or complaint as indicated above. .16. ~OW SERVED: P~RSDNAL (~RESIDENCIi,( PO~TEo,( l POE ( ) S~ERIFF'S OFFICE ( lOTHER ( SEE REMARKS,BELD~ . 17. Q I\hereby certi~ a~d retum a NOT FOUND becau~ 'i-am unable to I~te ~e individual, company, etc. ~amed ~bove. (See remarks below. 18. N~r!;J~~~~:rrLl~ OF ~IXI!~:L SERVEO I LIST ADDRESS HERE IF NOT SHOWN ABOVE (Relationship to Defendant) ~~a Of ~erv' 21. ATTEMPTS Tire Miles D~e r . t 22. REMARKS: : 23. Advance Costs "'I" 33. Costs Due or Refund [ Check No. 40. Costs Due or Refund 41. AfFIRMED ~~~')~fore"~e'this _ 42. day of ' 'c",~ " ',2Q ~J,43.. "" ,~ _ ; PRO~f\!LIi2TA. ~--- , 44. Signature of . Dep. Sheriff 46. Signature of York 99Ur-~ ~heriff , ,~I AM M. , 459~1 j }/. "j'Jf> k-:' y 47. DATE 4" (; 12/4/01 49. DATE 51. OATE RECEIVED 1. WHITE ~ Issuing Authority 2,. PINK - Attorney 3. CANARY. Sheriffs Office 4. BLUE _ Sheriffs Office 1- " .~- ':";:<~-' "."'''''''''H'1.,'-,I''I,',__ (1 of 2) COUNTY OF YORK OFFICE OF THE SHERIFF SERVICE CALL (717) 771-"111 28 EAST MARKET ST., YORK, PA 17401 SHERIFF SERVICE PROCESS RECEIPT and AFFIDAVIT OF RETURN 26f~~~vil 1. PLAINTIFF/SJ Beverly Health & Rehabilitation Services, Inc. 3. DEFENDANTISI Francis J. Toth et al Notice & Complaint S..ERVE { 5. NAME OF INDIVIDUAL, COMPANY. CORPORATION, ETC. TO SERVE OR DESCRIPTION OF PROPERlY TO BE LEVIED, ATTACHED. OR SOLD Francis J. Toth 6. ADDRESS (STREET OR RFO WITH BOX NUMBER, APT. NO., CITY, BORO, TWP., STATE AND ZIP CODE) AT 112 Bunker Hill Road New Cumberland, PA 17070 7. INDICATE SERVICE: a PERSONAL a PERSON IN CHARGE XXXDEPUTIZE aCE T: a 1ST CLASS MAIL CIPOSTED C10TllER NOW November 14 ,20~ I, SHERIFF OF COUNTY, PA do herebydepulize the sheriff of York COUNTY to execute . according to law. This deputization being made at the request and risk of the plaintiff. '0'''' ~ 4. TYPE OF WRIT OR COMPlAINT 8. $PECIAlINSTRUCTIONS OR OTHER INFORMATION THAT WIll ASSIST IN EXPEDITING SERVICE: ADVANCE FEE PAID BY CUMBERlJIND COUNTY SHERIFF NorE: ONLY APPLICABLE ON WRIT OF EXECUTION: N.B. WAIVER OF WATCHMAN - Any deputy sheriff levying upon or attaching My property under within writ may leave same without a watchman, in custody of whomever is found in possession, after notifying person of levy or attachment, without liability on the part of such deputy or the sheliffto any plaintiff herein for any loss, destruction. or removal of any property before sheriffs sale thereof. 9. 1'Y~:!('~A~~f~~EY/ORIGlNATORandSIGNATURE 10. TELEPHONE NUMBER 11. DATEFllED 5115 EAST TRINDLE RD., MECHANICSBURG. PA 17055 691-5400 11/8/01 12. SEND NOTICE OF SERVICE COpy TO NAME AND ADDRESS BElOW: (ThIS area must be completed if notice is 10 be mailed). CUMBERLAND COUNTY SHERIFF 13. I acknowledge receipt of the writ or complaint as indicated above. J. LUDWIG 16. HOW SERVED: PERSONAL ( . RESIDENCE ~ POSTED ( ) POEt SHERIFF'S OFFICE ( ) OTHER ( ) SEE REMARKS BELOW 17. Q I hereby certify and return a NOT FOUND because I am unabfe 10 locate the individual, company, etc. named abOve. (See remarks below.) 22. REMARKS: .~.~) h " \11th. . . Signature of 0/ Dep. Sheriff "v1Z ~" 46. Signature of York County Sheriff WILLIAM M. HOSE 48. Sig~ature of Foreign County Sheriff RN SIGNATURE ~ 12/4/01 49. DATE 51. DAlE RECENED 1. WHITE-Issuing AuthOrity 2. PINK -Attomey 3. CANARY - Sheriff's Office 4. BLUE - Sheriffs Office " " - '--.;r-""- j COUNTY OF YORK OFFICIE/OF THE SHERIFF 28 EAST r&ARKET ST., YORK, PA 17401 SERVICE CALL (717) 771-9601 II of 2) SHERIFF SERVICE- PROCESS RECEIPT and AFFIDAVIT OF RETURN 1. PLAINTIFF/SI Bever.1y Health & Rehabilitation Services, Inc. 3. DEFENDANT/51 4. lYPE OF WRIT OR COMPLAINT Francis J. Toth et 91,' Notice & Canplaint SERVE { 5. NAME OF INDIVlDOAL,COMPANY. CORPORATION, ETC. TO SERVE OR DESCRIPTION OF PROPERlY TO BE LEVIED, ATTACHED, OR SOLD. ..... Francis J, Toth ..". 6. ADDRESS (STREET OR RFO WITH BOX NUMBER, APT. ,NO.. CITY, BORO, T\NP" STATE AND ZIP CODE) AT , , .112 BunkE!r Hill R ad New Cumberland, FA 17070 7. INDICATE SERVICE: ; 0 p"RsoNA 0 ERSON IN C ARGE EPU11ZE 0 }\1ST 0 OTHER NOW November 14. , ' 2. {)~,. 1,. S~. :~IFF OF.' " ' TY, p , York,4' ". COUNTY to 1!xedl" . to law. This deputization being made at the request and risk of the plaintiff. 8. SPECIAL INSTRUCTIONS OR OTHER INFORMATION THAT WILL ASSIST IN EXPEDITING SERVICE: :' "~ ADIi'l'.NCE FEE PA.ID BY CUMBERLAND COUNTY SHB1UFF NOTE,: ONI.,. Y APPLICABLE ON WRIT OF EXECUTION: -N.S. WAIVER- OF WATCHMAN. Any deputy sheriff levyihg upon or attaching any propectY.under within writ, may J,eave sar:ne without a wc;ltchman, in custody, of whomever is found ,in possession, 'after notifying person of levy or attachment, without liability on the part of such deputy or the sheriff to any plainTiff herein fOr any loss, destruction, or removal of any property before sheriff's sale thereof. 9. lYP~'Il".A~!A139!l~EY/ORIGINATORandSIGNATURE 10. TELEPHONE NUMBER 11. DATE FILED "5il15 EAS'l' TRINDLE RD., MECHANICSf:!URG, PI\. 17055:691~5400 11/15101 12. SE 0 NOT1CE OF SERVlCE COPY TO NAME AND ADDRESS BELOW: (This area must be completed if notic::e is to be mailed). " UMBERIAt-ID, COUNTY SHF..RIFF" . 13. I acknowledge receipt of th -writ or complaint as indicated atjolle. 16. 15. Expiration/Hearing Date 12/8/0i SEE REMARKS BELOW ,. , : v ^, --23. AdvanCe Costs 100.00 .\' . " .' . ',' 'l'H 41 AF'j::IRMED and subscribeQ,:lo'berore me this .':, .;da of DECEMBgR:2D'Ol"4"'\r.r;:;./ .' y ,'. 'PROT lliQIAR .. '1-. Signature of i Dep. Sheriff 46. ~jgnatur.e of York Cou"!y .SIi.eriff ,_ / " V~IT...&ilAM M ~ J'...r / ( ': 48. SIgO'atlire of Foreigo W>A~ . 0----/' County Sheriff F;g RETORN ~IGNATUR.E TITLE .' HOSE 12/4/01 49. DATE , 51', DATE RECEIVED . 1. WI-IlfE. Issuing AuthoritY' 2. PINK . Attorney 3. CANARY. Sheriffs Office 4. BLUE . ,Sheriffs Office