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Home My WebLink About03-2822M:Home/B QA/litigat/State frm/Shaffer-Nickle/Minors Petition.wpd IN THE CUMBERLAND COUNTY COURT OF COMMON PLEAS In Re: Jason Nickle, a minor No. ~ --~'"~ PETITION FOR LEAVE OF COURT TO SETTLE AND COMPROMISE MINOR'S CLAIM Pursuant to Pa. R.C.P. No. 2039(a), State Farm Insurance Company, by its attorneys, Brigid Q. Alford, Esquire and Boswell, Tintner, Piccola & Wickersham, petitions this Honorable Court for leave to settle and compromise said minor's claim, and in support thereof avers as follows: 1. Petitioner State Farm Insurance Company is an insurance company, license to do business in the Commonwealth of Pennsylvania which, as of July 23, 2002, had issued a motor vehicle insurance policy to one John R. Shaffer. 2. At the aforesaid date and time, John R. Shaffer was operating his motor vehicle on said date in and around Penn Township, Cumberland County, Pennsylvania, at State Route 233 (Centerville Road) and the exit ramp for I-81, when he was involved in a motor vehicle accident with another vehicle, driven by one Angela Nickle. 3. AngelaNickle, an adult individual, suijuris, is the guardian and natural mother of the minor child, Jason Nickle, who was a rear-seat passenger in her vehicle at the time of the motor vehicle accident at issue. 4. Petitioner Nickle and her son reside at 7 Pine Road, Apt. 506, Mt. Holly Springs, Cumberland County, Pennsylvania. years of age. 6. The minor child, Jason Nickle, was bom on December 30, 1995, and is presently 7 At the aforementioned time and place, an automobile driven by one John R. Shaffer had stopped at a stop sign on the 1-81 exit ramp and then attempted to turn left onto Route 233. At the same time and place, the vehicle driven by Angela Nickle was traveling south on Route 233, and came into contact with the right front of the Shaffer vehicle as it entered Route 233. The impact caused the Nickle vehicle to roll over onto its roof. 7. The minor child, Jason Nickle, suffered personal injuries as a result of the motor vehicle accident, including bruising to his left upper chest, a scalp laceration that required sutures, abrasions to both knees, and a laceration of his right knee. 8. The injuries suffered by the minor child, Jason Nickle, required medical management, including but not limited to EMS treatment, ambulance transport to and treatment at Carlisle Regional Medical Center, and removal of the staples ten (10) days later. A CT scan of the brain performed on the day of the accident was normal; Xrays of the cervical spine were negative for fracture or dislocation. True and correct copies of the minor child's relevant medical records from Carlisle Regional Medical Center (emergency room) and Carlisle Pediatric Associates (pediatrician/follow-up care) are attached hereto, made part hereof, and identified as Exhibits A and B, respectively. -2- 9. The accident and medical care required to treat the scalp laceration resulted in a small amount of permanent scarring on the top of the minor's head, in an area that is covered by his hair. Photographs of the affected area, taken 19 days after the staples were removed, are attached hereto, made part hereof, and identified as Exhibit C. 10. State Farm Insurance Company has offered the sum of $5000.00 to settle the minor child's personal injury claim against its insured, subject to this Court's approval of the settlement and Petitioner's execution ora Release relative to the same. An Affidavit executed by State Farm Claim Representative Nadine Alviani, confirming the existence of the said policy, and the $5000.00 settlement offer is attached hereto, made part hereof, and identified as Exhibit D. 11. Angela Nickle proposes to act as guardian of the funds payable to the minor child, Jason Nickle, and agrees that the said sum shall be deposited in a federally insured interest bearing savings account or certificate of deposit with a financial institution in Cumberland County, Pennsylvania, and that the said funds shall have a notation on the account or certificate that no sums may be withdrawn from said account without prior Order of Court until the minor attains the age of eighteen (18) years, at which time the funds shall be free of restriction and turned over to the minor. 12. Petitioner and Angela Nickle believe and therefore aver that the proposed settlement and guardianship of funds for the minor is fair and just and should be approved by this Honorable Court; Ms. Nickle's verification of the same is attached hereto, made part hereof, and identified as Exhibit E. -3- WHEREFORE, Petitioner State Farm Insurance Company prays that this Court approve the above-described settlement proposed on behalf of the minor child, to which his mother and natural guardian has consented. Respectfully submitted, Date: By: Supreme Court I.D. #38590 BOSWELL, TINTNER, PICCOLA & WICKERSHAM 315 North Front Street Post Office Box 741 Harrisburg, PA 17108-0741 Attorneys for State Farm Insurance Company 07/23/2002 17:16 0000 ~IC~LE, ~A$ON $ /7 PISTE ROAD APT 506 ~MT HOLLY sPGS PA 17065 ]US MT HOLLY SPGS PA 17065 /US EMERGENCY CONTACT NAME WALKER, CAROLYN COMMENTS E1 0 6 181-76-4824 (717)486-3347 201-64-4389 (717) 486-3347 (717) 776-5304 I INATIONWIDE AUTO INS PO BOX 69600 HARRISBURG [~u~ ATO PA 17106 DATE O~ EIRTH ~[~X RA MS 12/30/1995 Z S PATIENT EMPLOYER CHILD ADMISSION RECORD LOCATION PROGRAM MPLOYER PHONE NO. UNTY CUMB E RLAND MPLOYER PHONE JELATIONSHtP TO PATIENT MOTHER RESPC ) PATIENT GRANDMA ANGELA IGROUP NAME HRENBACH, DONNA M. MVA NONSTAFF, FAMILY PHY '~%°ETAULT ACoC~7;~;)E2002 COMPLICATIONS COMORBIDITY(tESI AOOOIA 9230518 MEDICAL RECORDS COPY 0000782247 Carlisle Regional Medical Center (Instructions: circle positive - backslash negative, provide additional pertinent information, NAME: NICKLE, JASON S pt~: 9230518 DOB: 12/30/95 Age: 6 Yrs 0 Mos 0 Wks MR#: 0000782247 Sex: M Wt: 27.3 KG Ht: Chief Complaint: MVA Medicines: NONE Nlergies: NKDA ~-{?~C~~ EDP: FEHRENBACH, DONNA M. PCP: * NON-STAFF, FAMILY, PHY* ~'rival Mode: ALS DATE OF SERVICE: 7/23/02 Pres Time: 17:16 Tdage Time: 17:16 T: PO P: 102 Regular R: 24 Unlabored BP.~0C .... [~¢ qO SaO2: % Normal / Hypoxia Pain Scale: ~ -~ r-,~-~-~_- C / C / HPI: (Narrative): C-collar / backboard PTA ~ Timing: Sx sta~ed~ly ]-gradua y ~ mn/h~ys/wks, ago: continuous ~.term,,ent Duration; Sx last ~ min. / bm. / days /wks. at a time : present / absent Lo~tion of Inj~: upper ext R / L lower ext R / L Quali~: ~nnot desc~be weadng helmet severe 1-10 s~le life ~reatening ~.lmited DUe To: ALOC intoxication Sevedty Dementia Corl~i~u~[~li fevei ~h'Jlls W~akness diap~'0r~sis Ne~;'r0i0giCal: s~i~{Jr~s-' '" ~eakness ENT: sore throat ear pain facial pain Psychological: anxious depressed Cardiovascular: C.P. palpitations DOE PND integument: rashes prufitis lesions Respiratory: S.O.B. cough congestion Hematologic: anemia bleeding disorders transfusion Gastrointestinal: N / V D / C pain melena hematemesis AJlergy/Imm.: frequent infections allergies hives GU: flank pain dysuda hematuria frequency Other: Musculoskeletah joint pain neck / back pain ext. pain - YES / NO All Other Systems Reviewed And Are Negative Past Mod, Mods: NONE AJlergies: NKDA Surg. Nx: none Appy Chole Hyster Family Hx: negative Colon CA PO?..~..~.~DOM / NIDDM R/L_ ~_d__e~d ..... .L_[~e~_..A.!0~_e:.~ / N_ Occupation: Immunizations: Up-to-date: Y / hi Tetanus: Reproductive HX: LMP: G P AB Pro-MED Maximus MVA- Trauma Page 1 of 2 Carlisle Regional Medical Center NAME: NICKLE, JASON S DOB: 12/30/95 Age: 6 Yrs 0 Mos Sex: M Wt: 27.3 KG Hr: Chief Complaint: MVA aedicines: NONE ~Jlergies: NKDA -'DP: FEHRENBACH, DONNA M. PCP: * NON-STAFF, FAMILY, PHY Arrival Mode: ALS (Instructions: circle positive - backslash negative, provide additional pertinent information. Pt~: 9230518 DATE OF SERVICE: 7/23/02 0 Wks MR#: 0000782247 Pres Time: 17:16 Triage Time: 17:16 T: PO P: 102 Regular R: 24 Unlabored BP: 000/000 SaO2: % Normal / Hypoxia Pain Scale: conta?~tion:~_..c.~..~ fo~e!gn body ; ~/L,L,L,L,L,L,L,L,L,~J Anssthssi .a~ ~igital block ~c~ 1% lido ~2% lido .5% m~[~ : ~ne irrig RepairCl~t~~) __-0 pr~ene nylon Ces Dermabond steri-strips simple interrupted running mattress horiz / vert subcutaneous # - 0 silk simple interr~¢ied running ~-.i horiz / vert fascia / muscle / tendon # simple interrupted running mattress Sterile Dressing Applied: Y / N Wound Location: Laceration Size: cm Distal neurovsscular status: tendon function intact vascular intact sensation intact Depth: Supedicia! subcutaneous...r~y~!e. '~e~don bone Shape: __ _.!in_e?__ i_r_r_e_g_ _ul_ar flap stell~a_t_e__ av~uls~i_o_n .......................... Contamination: clean foreign body Anesthesia: local _d!~!!_a_l....~3Jp~l~ cc's 1% lido 2% lido .5% marcaine w / epi w / bicarb ........... Wound Prep: betadine hibiclens saline irrigation debridement exploration Repair Ci~;-r~: ~kin# ............ :-(~ ....... ~:~i~ ~e"- --n-~,~'~-- '--'-~i&-p i~'~ ~e r~'~-I~l--'--'-~t~ri~- sim_pl_e~ interrupted_ ...._[?~jng_____m._a~t_re~s_~- hgri_z/_y.e.~_ ~b?~ar~.e(~u.s~ ~~ - 0 vicry( silk simple !~.te?u_p!ed .runqi?g .. ?a~re~. fa~ia ( rnu~cle /tend°n # ;_O.._ v!c~! ~irnple interrupted running mattress ~o_ri~./ve_rt Sterile Dressing Applied: Y / N Other: Patient tolerated procedure well: Signatures: /~'"'~ Pro-MED Maximus('-~'/ Discharge instructions given: Y/N Laceration Repair *ORDER PROCEDURE ~:ORM. Carlisle Reg. ional ,Medical Center · TRAUMA EMERGENCIES Name:NICKLE, JASON S P~230518 Age: 6YRS DOB: 12/30/1995 Sex: M MR#:0000782247 Date I~: 7/23/02 Time: EDP: FEHRENBACH, DONNA I PCP: * NON-STAFF, FAMILY, PI- Orde~ Time Laboratory }rder Sent By CBC Magnesium UA ETOH (Medical), (Legal) Drug Screen (Udne), (Serum) Type & (Screen), (Cross) # Radiology 'T-? CXR (F?A/J..~able) ' ' *~'" ~'"~ ~ (Complete) ~ ~-r~'J' " ZD ~ '-.~ '~-, Cardiopulmona~ "~ Oximet~ EKG L ~U~31E STROUP ~ Cast / Splint ~ Udna~ Catheter Inse~ion Pulse Oxime~ ~ Central Line Placement ~ NGT Inse~on EndoEa~eal Intubafion ~ Su~oning ~ CPR D Wound Dressings Chest Tube Inse~on Peritoneal ~vage ~ j~e~rdiocentesis Medical Cet~ter N~E: NICKLE, JASON S p~: 9230518 MR¢: 0000782247 facial: contusions lacerations abrasions tales rhonchi wheezes ~nde=;-tender guarding ~eboun--~- ..i., te.demess ~-S tende.ess .o.acic tenderness ~KIN: w~- d~ diaphoretic ~shes PSYCH: ~O X3 mood / affect NL O~ER: ~ Labs reviewed and are negative X~ay: MEDS: CXR: NL pneumo Fx IVF: Pulse Ox: Ko NL / hypoxia aN~Sic ~: Time: UA: SG prot RBCs WBCs ~G:pH O2 CO2 UCG / HCG: + ~ - Improved Same Worse DOX: ce~i~l s~ain L-S s~ain closed head inju~ ~acture lace~on ~ See ph~icians exam/procedure sheet ~ ~ ~ Discharged to' Nome Nu~ing Home Family Discussed with Dr. Oischarge Time out: . Reviewed D~ Radiologist Y / N DOA: Pro-MED Max~mus MVA-Trauma Page 2 of 2 EMERGENCY DEPARTMENT Carlisle Regiona~ Medical Center TRAUMA EVALUATION RECORD 1 of 2 Name:NICKLE, JASON S Pt~:9230518 Age: 6YRS DOS:I 2/30/1995 Sex: M MR~:0000782247 Date In: 7/23/02 Time: {L~ ~ EDP: FEHRENBACH, DONNA M PCP: * NON-STAFF, FAMILY, PH~ !PRE.;HOSP[TAL. ?~-[nju~'Eme;, |~ 5 nJury Date. ql~3~ ModeofA,'fiva ,ALS: ~, . r-tOther:-. Mechanism of Injury: Pre-Hospital C53re: [] GSW [] MVC: ,~ [] Motorcycle [] Home Arrived fromi~[~"~cene [] Hospital(specify) [] Stabbing ...[;~strained" [] Bicycle [] Farm GCS: Trauma Score: [] Cr~sh [] Unrestrained [] Helmet [] industrial ..~a~k-'~-~oard [] 02 NC: L, min. [] Fall Ht: [] Airbag deployed [] No Helmet [] Abuse ,[;~C-Collar [] 02 NRB100% [] Assault [] Ejected [] Unknown [] Bum est. % BSA: [] CPR [] BagNalve/Mask [] Drowning .,.,E~oilover [] Pedestrian [] Other: [] Other: [] IEtubated Size: Location: [] Driver Describe Details: ~ # 1 ~ Site~.b~AC~ Ga: ~rl~ LTC ..~ont [] Sack Total fluids infused PTA: { C,(~ ¢ ~ HT: WT: ~'~ 1~5 Last Tetanus: L]T~ LMP: Medication Pre-Hospitah Allergies: Current Meds: ~ Vital Signs: E]At the Scene ~E~n Route PMHx: ~ - d~f.~ UL~iC~n.;~ T: P: ilo R: 10 BP: lU~O/c{O 02 Sat: Airway: ~ent []Obstructed []Trachea at Midline []Tracheal Deviation []Right []Left []Other: (specify) Breathing.~Et'~pontaneous .J~nlabored _~ L~ored [] Assisted: (specie) Breath Sounds: Right .~r~.sent []Absent []Diminished []Other: (specify) Left _...~re~.ent [] Absent [] Diminished [] Other: (specify) Chest Movement: .~ymetrical [] Asymetrical [] Other: (specify) Circulation: Capillary Refil. i..~secs. [] > 2 sacs, Skin Temperature: [] Warm [] Cool Neck Veins: [] Flat [] Distended Diaphoresis [] Yes [] No EKG Rhythm: ,~...~..t-i Heart Sounds: Neuro: ..~'A~'ert []Oriented []Unresponsive .~;~operative []Uncooperative []Combative C-spine'.JE~ender [] Non-Tender .J;~?~mobilized ~':~ollar .~E~'13~ckboard Abdomen'~'~ft [] Rigid [] Distended [] Obese [] Tender ..~;~'n- Tender Bowel Sounds: ,....~:~sent [] Absent Fetal Heart Tone; [] Present [] Absent []N/A Rectal Tone: [] Present [] Absent Guiac: [] Pos [] Neg Pelvis: ..J;~'~able [] Unstable [] Tender [] Non- Tender GU: [] Blood at Meatus [] Vaginal Exam: Extremities: RUE Pulses'~s [] No Cap. Ref~;....E~ 2 s. [] > 2 s. Motion'~s [] No Sensatiop..~es [] No Temg.~ [] C Color LUE Pulses;..[;;~s [] No Cap. Reft:..J~"'2 s. [] > 2 s. MotJon:..E~Y'r'es [] No Sensatio;1.J;~Y'~s [] No Temp.~_[] C Color RLE Pulses:.~es []No Cap. Ref.:,~e'2s. E]>2s. MotJon:..~es []No Sensation~..[;~'?'es []No Tem[3..~W~' []C Color~ LLE Pulses:..[;~es [] No Cap. Ref.: ./;~2 s. [] · 2 s. Motion;.~'*~es [] No Sensation.,~es [] No Tem~ ~ C Color Back Exam: ~o.~sw · · 14.~C[~7~'~g~ T~UMA SCORE: A + B + C + D + E = EMERGENCY DEPARTMENT Carlisle Regional Medical Center TRAUMA EVALUATION RECORD 2 of 2 Name:NICKLE, JASON S Pt~:9230518 Age: 6YRS DOB: 12/30/1995 Sex: M MR#: 0000782247 EDP: FEHRENBACH, DONNA M PCP: "NON-STAFF, FAMILY, PH' NECK: ABDOMEN: Gl / GU: PELVIS: BACK: ~me Temp Pulse R~hm Resp. B / P O2 Sat GCS Pupils Time Medication Dose Route RN Genii Line Size: site: Chest Tube ~ 1 size: Site: Chest Tube ~ 2 size: Site: Tho~cotomy Ped~rdiocentesis Pedtoneal bavage Foley Catheter o~ps~lck + INTEL To~l: OU~UT To~l: Ng Tube Dipstic~ + PTA: Udne: IV Fluids: Emesis: : Blood: IChest: ~ Admit So~i~/MD: Repo~ Given To: VALUABLES: ~None ~Family ~ Secud~ ~Poli~ ~ Transfer To: Repo~ Given To: ~S~ Nursing notes for listing ~ Expired Coroner Called by: Body Released ~ Yes ~No NURSE S~N~RE: EMERGENCY DEPARTMENT Carlisle Regional. Medical Center ONGOING NURSING ASSESSMENT Name:NICKLE, JASON S Pt~:9230518 Age: 6YRS DOB: 12/30/1995 Sex: M MR#: 0000782247 Date: 7/23/02 Time: EDP:FEHRENBACH, DONNA M PCP: * NON-STAFF, FAMILY, PH [ NIJRSiNG Dt~GNOSIS (Numbet[n:orderof pnodty,~ Eactl patient-must have atleast;oee selected~') ; ::~',~~'~'~ ,~' ~ ' ' "['~ Airway Clearance, ineffective Communication ~mpaired Infection, Potential Self Care Deficit --Anxiety --Coping, Ineffective '---injury, Potenfia~ '~Skin Integrity Impairment --Breathing Patterns, Ineffective --Fluid Volume, Alteration in --~Knewledge Deficit '~Thought Processes, Impaired _.~cordiac Output, Decreased '~Gas Exchange, Impaired .~Mobility Impaired ~_."~Thought Processes, A~teraticn in mfort, Alteration in ~Hyperthermis (Fever) .~Non-Compliance ,__Tissue Perfusion, Alteration in --Other -- _._Other Th~ GO~ ~r pEAN~: ff~thi's pat[entt rs to ~ ~ n m~effng fdentJfied needs and* mtiate ntervenflons for,rto-~ ~'~ ~*'~ ~;~;~ ~'~ ~ ~ ~ ~ [] FB REMOVAL [] iMMOBILIZATION / PROPER ALIGNMENT I [] IMPROVEMENT OF BREATHING [] BLEEDING CONTROL [] DECREASE / PREVENT SWELLING m STABILIZE PATIENT IN DISTRESS _..,,.[~N CONTROL .,~4~I~'NTAIN STABLE HOMEOSTASIS [] meet ENVIRONMENTAL NEEDS [] ALLEVIATE NN [] MAINTAIN SKiN / TISSUE INTEGRITY [] meet PSYCHOSOCIAL NEEDS [] FEVER CONTROL [] PREVENT FURTHER INJURY [] meet SELF CARE ABILITY NEEDS [] DECREASE ANXIETY [] MAINTAIN ! IMPROVE CIRCULATION [] meet EDUCATIONAL NEEDS [] SAFETY iN THE ED [] INFECTION CONTROL I [] Other · 0 0 . D/C ins~cU~ give, : / Ve~alized understanding ~~ e~ D/CCondition~oved =S=ble =Serious =Expired ~ -- [~'~~ Pain: SeverityS~le: ~oved =Unchanged =Worse OIC Date: ¢ ~m~ ~B INITIAL ASSESSMENT. FORM PRIORITY:' 3 Patient: NICKLE, JASON S DOB: 12/30/1995 AGE: Urgent EDP: FEHRENBACH, DONNA M.' DATE: 07/23/2002 PCP: * NON*STAFF, FAMILY, PHY* 6YRS Carlisle Regional,Medical Center Pt~: 9230518 Sex: M MR#: 0000782247 Worker's Comp: Emp. Referred: Presentation Time: 17:16 Tdage Time: 17:16 Arrival Mode: ALS Height: "Weight: 60.0 lbs. 27.3 kgs. LMP: Last Tetanus: Acc By: FAMILY Chief MVA Complaint: Bdef Assessment: PASSENGER IN FRONT SEAT INVOLVED IN AN MVA. LACERATION TO HEAD BANDAGED. THERE WAS WINDSHIELD DEFORMITY. NO MEMORY OF ACCIDENT. APPEARS SCARED AND DOES NOT ANSWER QUESTIONS. ON LONG BOARD WITH COLLAR. NIGHT SWEATS NO WEIGHT LOSS NO ANOREXIA NO HEMOPTYSIS NO FEVER NO RESTRAINED UNK DRIVER NO AIRBAG DEPLOYED UNK C-SPINE TENDERNESS NO NEURO MOTOR DEFICIT YES EJECTED NO HEAD TRAUMA YES LOSS OF CONSCIENTIOUSNE~ UNK AMNESIA OF EVENT YES Vital Siclns T: PO P: 102 Regular R: 24 Unlabored BP: 02: % Pain Intensity Scale: / 10 Pain Location: Sudden Onset: Pre-Hospital Treatment: Pediatric Assesment: Past Medical History: Allergies: G&D App. for Age - NO, Immunization UTD - NO, Height ft. in., Head Circ. - Grade -, with FAMILY EAR INFECTIONS NKDA Medicines: NONE Nurse Signature: Additional Notes: DMJ Carlisle Hospital - Emerclencv Department NICKLE. JASON 246 Parker st. Carlisle. PA 17e13 --(7.17) 245-5500 7/23/02 7:491~m 0782247 DISPOSITION SUMMARY Patient: ~,!ICKLE, JASON SS #: CURRENT Address: Citv: Current Ph: _ Zip: Arrival: 7/23/02 7:49 m Disch: 7/23/02 8:08om Age/DOB: Medical Record: 0782247 Disposition: MD ED: Donna Fehrenbach. D.O. Res/PA/NP: Duane StrouD. PA-C Dx #1: MVA (Unsoecified~ lCD-9 #1:E819.9 Dx #2: Head Iniurv. Superficial fUns~ecified3 lCD-9 #2:_910.8 Dx #3: Laceration. Scald lCD-9 #3:8_73.0 Follow-up: HOFFMAN. HOLLY C. H. 8_04 BELVEDERE STREET PMD: PMD Ph: #1 Dx En¢: MOTORVA.ESW ¢¢2 Dx Engh HE_ADINJ.ESW #3 Dx En¢il: ~ #1 Dx Span: MOTORVA.SSW #2 Dx Span: HEADINJ.SSW #3 Dx Span: LACERATS.SSW F/U MD Ph: 7172431943 FlU D/T: 2 Davs FOR A WOUND CHECK Other Instr: ~-CE PACKS. GIVE TYLENOL OR MOTRIN AS NEEDED FOR PAIN, RETURN TO THE ER AS NEEDED - INCREASED PAIN, BLEEDING OR AS PER HEAD INJURY SHEET MY SIGNATURE BELOW INDICATES: > I have received and understood the oral instructions regarding mv current medical problem. > I will arrange follow-up care as instructed above. > acknowledge receipt of the written instructions as outline~¢ on this and any previous'page(s). Iwill read and review these ,nstru~t~ns. ,, x Patent (or Legal Guardian) Signature ~/ /Staff (Witness) Signature / CARLISLE REGIONAL MEDICAL CENTER P~ADIOLOGICAL INTERPRETATION PATIENT NAME: NICKLE JASON S MED REC #: 782247 X- P_AY~: 782247 ACCOUNT 0: 9230518 EXAM DATE: 7/23/2002 D.O.B.: 12/30/1995 ORDERING: DONNA M. FEHRENBACH,MD ME ROOM: ER ATTENDING: CONSULTING: FAMILY PHY NON-STAFF MD HISTORY: MVA /~/ MVA · CT SCAN OF THE BRAIN The ventricular system is normal. There is no evidence of intracranial hemorrhage, mass, infarct, edema, or mass effect. The calvaria is intact. IMPRESSION: Negative unenhanced CT scan of the brain. REVIEWED A_ND SIGNED KEITH S. PUMROY,MD MED DATE DICTATED: 7/23/2002 DATE TRANSCRIBED: 7/23/2002 DATE SIGNED: 7/24/2002 TRANSCRIPTIONIST: MTS 8165032 E.R. CT HEAD/BRA~ W/OCONTRA~ M DANE WALLISCH,MD MED DICTATED BY PAGE 1 OF 1 CARLISLE REGIONAL MEDICAL CENTER PJtDIOLOGICAL INTERPRETATION PATIENT NAME: X-RAY~: EXAM DATE: ORDERING: ATTENDING: CONSULTING: HISTORY: MVA NICKLE JASON S 782247 7/23/2002 DONNA M. FEHRENBACH,MD ME FAMILY PHY NON-STAFF MD LAT TO CLEA_~ MVA MED REC ~: 782247 ACCOUNT ~: 9230518 D.O.B.: 12/30/1995 ROOM: ER CERVICAL SPINE A complete cervical spine series was obtained. demonstrates no fracture or dislocation. IMPRESSION: Negative. This study REVIEWED AND SIGNED KEITH S. PUMROY,MD MED M DANE WALLISCH,MD MED DICTATED BY DATE DICTATED: 7/23/2002 DATE TPJtNSCRIBED: 7/23/2002 DATE SIGNED: 7/24/2002 TRANSCRIPTIONIST: MTS 8165031 E.R. SPINE CER~CALMIN4V PAGE 1 OF 1 24.6 Parker St. Carlisle, PA 17013 Ph:717-249-~212 CONDITIONS OF TREATMENT AND ADMISSION PATIENT'S NAME NICKLE, JASON S ATTENDING PHYSICIAN FEHREN'BAC~{, DONNA M. ACCOUNT NO. 9230518 DATE & TIME OF ADMISSION 07/23/2002 17:16 CONSENT TO HOSPITAL CARE AND TREATMENT I AM PRESENTING MYSELF FOR EMERGENCY SERVICES OR ADMISSION TO THE HOSPITAL AND I VOLUNTARILY CONSENT TO THE RENDERING OF SUCH CARE, INCLUDING DIAGNOSTIC TESTS AND MEDICAL TREATMENT, BY AUTHORIZED AGENTS AND EMPLOYEES OF THE HOSPITAL, AND BY ITS MEDICAL STAFF, OR THEIR DESIGNEES, AS MAY IN THEIR PROFESSIONAL JUDGEMENT BE DEEMED NECESSARY OR BENEFICIAL TO MY WELL BEING. I ACKNOWLEDGE AND UNDERSTAND THAT MANY OF THE PHYSICIANS ON THE STAFF OF THIS HOSPITAL, iNCLUDING THE ATTENDING PHYSICIAN(B) NAMED ASOVE. AND RADIOLOGISTS, ANESTHESIOLOGISTS. PATHOLOGISTS AND EMERGENCY PHYSICIANS, ARE NOT EMPLOYEES OR AGENTS OF THE HOSP/TAL. BUT RATHER ARE INDEPENDENT CONTRACTORS WHO HAVE SEEN GRANTED THE PRIVILEGE OF USING THE HOSPITAL FACILITIES FOR THE CARE AND TREATMENT OF THEIR PATIENTS. I AGREE TO ACCEPT THEIR CARE EVEN THOUGH THEY ARE NOT EMPLOYED BY THE HOSPITAL. I UNDERSTAND THAT THE EXAMINATION AND TREATMENT THAT I RECEIVE ON AN EMERGENCY BASIS IS NOT INTENDED AS A SUBSTITUTION OR REPLACEMENT FOR COMPLETE MEDICAL CARE. CONSENT TO RELEASE INFORMATION ~ HEREBY AUTHORIZE THE HOSPITAL TO DISCLOSE TO INSURANCE COMPANIES, INCLUDING WORKERS COMPENSATION CARRIERS, OR OTHER PARTIES THAT MAY BE LIABLE FOR ALL OR PART OF THE HOSPITAL CHARGES, ALL OR PART OF MY HOSPITAL RECORDS AS MAY SE NECESSARY {INCLUDING ANY TREATMENT FOR ALCOHOL OR DRUG ABUSE OR DEPENDENCEI, TO DETERMINE BENEFITS ENTITLEMENT AND PROCESS PAYMENT CLAIMS FOR HEALTH CARE SERVICES PROVIDED. MEDICARE CERTIFICATION RELEASE I CERTIFY THAT THE INFORMATION GIVEN BY ME IN APPLY]ND FOR PAYMENT UNDER THE TITLE XVII[ AND TITLE XIX OF THE SOCIAL SECURITY ACT IS CORRECT. I AUTHORIZE ANY HOLDER OF MEDICAL OR OTHER INFORMATION ABOUT ME TO RELEASE TO THE SOCIAL SECURITY ADMINISTRATION OR ITS INTERMEDIARIES OR CARRIERS ANY INFORMATION NEEDED FOR THIS OR A RELATED MEDICARE CLAIM, I REQUEST THAT PAYMENT OF AUTHORIZED BENEFITS BE MADE ON MY BEHALF TO THE HOSPITAL OR TO THE PHYSICIAN WHO ACCEPTS ASSIGNMENT. PERSONAL EFFECTS AND VALUABLES I UNDERSTAND THAT THE HOSPITAL SHALL NOT SE LIABLE FOR THE LOSS OR DAMAGE OF ANY PERSONAL EFFECTS DR VALUABLES )MONEY, JEWELRY, GLASSES, DENTURES, DOCUMENTS, CLOTHING, ETD.) UNLESS SUCH iTEMS ARE DEPOSITED IN THE HOSPITAL SAFE. THE HOSPITAL WILL NOT BE LIABLE iN EXCESS OF SE0 FOR THE LOSS OR DAMAGE OF ANY PERSONAL EFFECTS OR VALUABLES DEPOSITED WITHIN THE HOSPITAL SAFE. ABOUT YOUR BILL I UNDERSTAND THAT I WILL RECEIVE A BILL FROM THE HOSPITAL FOR PROVISION OF THE HOSPITAL SERVICES, INCLUDING STAFF AND EQUIPMENT, AND FOR ANY SUPPLIES OR MEDICINES UTILIZED. I WILL ALSO RECEIVE A BILL FROM ANY PHYSICIAN WHO PROVIDES PROFESSIONAL CARE TO ME. FOR EXAMPLE, I MAY RECEIVE A SEPARATE BILL PROM ONE OR MORE OF THE FOLLOWING TYPES OF PHYSICIANS WHO RENDER SERVICES TO ME; MY ATTENDING PHYSICIAN OR PERSONAL PHYSICIAN, EMERGENCY ROOM PHYSICIAN, RADIOLOGIST. ANESTHESIOLOGIST. PATHOLOGIST, OR ANY OTHER SPECIALIST. INSURANCE ASSIGNMENT I HEREBY ASSIGN TO AND AUTHORIZE THE HOSPITAL AND PHYSICIANS INVOLVED IN CARE DURING THIS PERIOD OF iLLNESS OR TREATMENT (HEREINAFTER "PHYSICIANS"), OR THEIR DULY AUTHORIZED ASSIGNS TO TAKE ALL NECESSARY STEPS, WITHOUT LIMITATIONS, TO ENSURE THAT ANY INSURANCE BENEFITS OTHERWISE PAYABLE TO ME OR MY ESTATE ARE PAiD DIRECTLY TO THE HOSPITAL OR PHYSICIANS. THIS ASSIGNMENT OF INSURANCE BENEFITS INCLUDES BUT IS NOT LIMITED TO SILLING INSURANCE, FILING PETITIONS, PILING SUIT, IN MY NAME OR ON BEHALF OF THE HOSPITAL OR PHYSICIANS, FILING PROOFS OF CLAIM, FILING PROSATE CLAIMS AND FILING GRIEVANCES AND ALL OTHER SIMILAR PROCEDURES, AS MAY BE AMENDED FROM TIME TO TIME WITH THE STATE OEPARTMENT OF INSURANCE. I ALSO AGREE TO PROVIDE AND SiGN ANY OTHER DOCUMENTS THAT MAY BE REASONABLY NECESSARY TO ACCOMPLISH ANY OF THE OTHER PURPOSES. STATEMENT OF FINANCIAL RESPONSIBILITY I UNDERSTANO THAT I AM F]NANCIALLY AND LEGALLY RESPONSIBLE FOR CHARGES NOT COVERED IN FULL BY ANY THIRD PARTY. I FURTHER AGREE THAT SHOULD I NOT PAY THE BALANCE WITHIN THIRTY iS0) DAYS AFTER THE DATE OF DISCHARGE, MY ACCOUNT WILL SE CONSIOERED DELINQUENT. [ AGREE TO PAY COSTS OF COLLECTION, INCLUDING REASONABLE ATTORNEY'S FEES AND COSTS, COLLECTION AGENCY FEES ANO COSTS. AND INTEREST WHICH SHALL ACCRUE AT THE MAXIMUM RATE ALLOWED BY LAW. FRAUO ANY PERSON WHO KNOWINGLY ANO WITH INTENT TO INJURE. DEFRAUD, OR DECEIVE ANY INSURANCE COMPANY, OR FILES A STATEMENT OF CLAIM CONTAINING FALSE, INCOMPLETE OR MISLEADING iNFORMATION MAY BE SUBJECT TO PROSECUTION UNDER APPLICABLE LAW. ADVANCE DIRECTIVE {FOR ADMISSION TO HOSPITAL ONLY) iF I AM TO BE ADMITTED TO THE HOSPITAL, I HAVE BEEN GIVEN WRITTEN MATERIALS ABOUT MY RIGHT TO ACCEPT OR REFUSE MEDICAL TREATMENT. I HAVE BEEN INFORMED OF MY RIGHTS TO FORMULATE ADVANCE DIRECTIVES. I UNDERSTAND THAT I AM NOT REQUIRED TO HAVE AN ADVANCE DIRECTIVE IN ORDER TO RECEIVE MEDICAL TREATMENT AT THIS HOSPITAL. I UNDERSTAND THAT THE HOSPITAL AND MY CAREGIVERS WILL FOLLOW THE TERMS OF ANY ADVANCE DIRECTIVE THAT I HAVE EXECUTED TO THE EXTENT PERMITTED BY LAW. IINITIAL THE FOLLOWING OPTION THAT APPLIESI · I HAVE EXECUTED AN ADVANCE DIRECTIVE AND WILL PROVIDE A COPY OF THIS FOR MY MEDICAL RECORD WITHIN A REASONABLE ~MOUNT OF TIME. -- · I HAVE NOT EXEDUTED AN ADVANCE DIRECTIVE AND DO NOT WISH TO DO SO. __ INIT' )FOLLOW-UP DONE BY DATE · I WISH TO COMPLETE AN ADVANCE DIRECTIVE DURING THIS HOSPITALIZATION. INIT. HAVE BEEN READ) THE ABOVE CONSENTS AND CERTIFI TIONS AND UNDERSTAND ANO AGREE WITH THEM. , CERTIFY THAT I HAVE READ {OR ~,/~ i( ~ (/4~t ~ ~.~,~, CI~III, PA t7013 PROGRESS RECORD c&;,.;.o PA 17011 EYeS Grolier. PA 11013 Interval History ,hoo, IIIness/inju~/surge~ Ueds ~ ~ Health mainted'ance D e ntist ~,,~. (~(,...~ Vision Hearing Concerns Psychosocial Family relationships Peer relationships Activities / interests Mood Apgetite / Sleep DOB: /,L - 3,~-?~ PE. / Notarial V' Abnormal aa Gen. App. ¢;~th I~. Head . ck C~3'~eu ro Eyes Q Lungs C;t~S kin Ears ~Head 1:3"~ack Nose 1~3'"-Abdom en Throat ~U. · ~-;~;~;;--1 ...................... ; ............ Impression J lreatment ~o," ~ -u~ ~ ~7~/_ .. gyrs. Date: Interval History School Illness/injury/surgery Meds Ht. Wt Psychosocial Family relationships Peer relationships Health maintenance Dentist Q Vision (3 Hearing (3'3 Concerns Activities / interests Mood Appetite / Sleep Television Allergies PE. / Normal ./' Abnormal · Gen. App. O Teeth r3 G.U. ~3 Head . (3 Neck (3 Tanner stage Eyes Q Chest (3 Ext. Q Ears (3 Lungs (3 Neuro Q Nose (3 Head (3 Skin C3 Throat (3 Abdomen (3 Back [] '~;,';,',;,';;;;" I ................................... Impression J Treatment j Follow-up POL:C¥ '~C. OATFjLOSS_ tNSIJRE~._ CLAIMANT PICTURE NO.. OATE/TIME TAKEN DY. WEATHER LOCATION AND VIEW' COMMENTS. ADDITIONAL INFORMATION i-lOVER PICTURE NO DATE/TIME TAKEN. BY. WEATHER LOCATION AND VIEW.__ COMMENTS ADDITIONAL INFORMATION i-lOVER OUR FILE NO FORM 200-2-~,~-X P.G.S, INOUSTR)ES, P.O, BOX 1348, ASBURY PARK, NJ 07712/1-800-484-7419 - S.C. 74~J POLiCV ',10 DATE/LOSS INSIjRED. CLAIMANT PICTURE NO DATF_./TIM E TAKEN. BY. WEATHER. LOCATION AND VIEW. COMMENTS ADDITIONAL INFORMATION I-lOVER PICTURE NO.. DATE/TIME TAKEN WEATHER LOCATION AND VIEW COMMENTS ADDITIgNAL INFORMATION I-lOVER OUR FILE NO. CO. CLM # FORM 200-2-85-X P.G.S. INDUSTRIES, P.O. BOX 1348, ASBURY PARK, NJ 07712/1-800-484-74Ig - S.C. 7475 FAX 1-~'32-919~7319 POLICY ~'qO .... DATE/LOSS INSURED. CLAIMANT PICTURE NO,. DATE/TIME TAKEN BY WEATHER LOCATION AND VIE~ COMMENTS ADDITIONAL INFORMATION E]OVER PICTURE NO. DATFJT] M E TAKEN BY WEATHER LOCATION AND VIEW COMMENTS ADDITIONAL INFORMATION I-loVER OUR FILE NO., CO CLM #. P.G.S. FORM 200-2-35-X P.G,S. INDUSTRIES, P.O. BOX 1348, ASBURY PARK, NJ 0771 2/1-800-484-7419 - S.C. 747 !1, r~ I.-732-919-~'3! 9 .... ~¢-J ¢,¢~= 7 7¢:. POLICY ~10. DATE/LOSS,, INSURED CLAIMANT WEATHER LOCATION AND VIBN COMMENTS ADDITIONAL INFORMATION E~OVER PICTURE NO. DATE/TIME TAKEN BY WEATHER LOCATION AND VIE~. COMMENTS ADDITIONAL INFORMATION r-lOVER OUR FILE NO.. CO, CLM #. P.G.S, FORM 200-2-35-X P,G.S. INDUSTRIES, P.O. BOX 1348, ASBURY PARK, NJ 07712/1-800-484-7419 SC. 74" ~ F"c~ ' * 7 ' , 732-9 ~9-, 319 AFFIDAVIT OF NADINE ALVIANI I, Nadine Alviani, Claim Representative for State Farm Insurance Company, do hereby state the following: 1. I am the Claim Representative assigned to handle the bodily injury claim made by Angela Nickle, in her capacity as guardian and natural mother of Jason Nickle, a minor child, in connection with injuries sustained in the motor vehicle accident described in the foregoing Petition (Claim # 38-J985-774); and 2. At all times relevant hereto, John R. Shaffer, driver of the vehicle in which Jason Nickle was a passenger, was a named insured on a motor vehicle policy issued by State Farm Insurance Company (Policy#6842-722-38M; and 3. Upon presentation of the claim made on behalf of Jason Nickle and review of the applicable facts and medical records, I extended a settlement offer in the amount of Five Thousand ($5,000.00) and further represented that such monies would be paid upon receipt of an Order of Court approving the same and an executed Release of Claims. Nadine'×~viani, Claim Representative State Farm Insurance Company Sworn to and subscribed before, me this ~--J~ay of ,,.Jt.,C F/E ,2003. VERIFICATION I, Angela Nickle, hereby verify that the facts contained in the foregoing Petition for Leave of Court to Settle and Compromise Minor's Claim is true and correct to the best of my knowledge, information and belief. I have read the foregoing Petition, consent to the settlement proposed therein, and understand the restrictions to be placed upon the disbursement of the settlement monies, should this Petition be approved. I further understand that false statements herein are subject to the penalties of 18 Pa. C.S.A. 4904 relating to unsworn falsification to authorities. Date: EXHIBIT E CERTIFICATE OF SERVICE I do hereby certify that I have served a true and correct copy of the foregoing Petition for Approval of Minor's Settlement, by placing the same in the United States Mail, first class, postage prepaid, at Harrisburg, Pennsylvania, addressed as follows: Angela Nickle 7 Pine Road Apartment 506 Mt. Holly Springs, PA 17065 Parent/Natural Guardian By: Brigid q{. Alford, Esq~e Date: IN THE CUMBERLAND COUNTY COURT OF COMMON PLEAS In Re: Jason Nickle, a minor ~d ~RDER NOW, this ay of ,2003, upon consideration of the foregoing Petition Settle and Compromise Minor's Claim, same is hereby for Leave of Court to the GRANTED. Bdgid Q. Al ford, Esquire Supreme Court I.D. #38590 BOSWELL, TINTNER, PICCOLA & WlC KERSHAM IN THE CUMBERLAND COUNTY COURT OF COMMON PLEAS In Re: Jason Nickle, a minor CIVIL DIVISION No. 03-2822 CIVIL TERM VERIHCATION OF DEPOSIT OF MINOR'S FUNDS 1. I, the undersigned, am counsel for State Farm Insurance Company, the insurance company that insures John R. Shaffer, who was involved in an automobile accident on July 23, 2003, in which the minor child, Jason Nickle, was injured. 2. Attached as Exhibit "A" is a copy of a settlement check in the amount of $5,000.00, which represents the gross settlement proceeds. 3. hi accordance with Order of Court of June 20, 2003, of Judge George E. Hoffer, I hereby certify the following: (a) The sum of $5,000.00 was deposited with Waypoint Bank, located at 1160 Walnut Bottom Road, Carlisle, Pennsylvania on July 8, 2003. A Certificate of Deposit was opened in the name of Jason S. Nickle, minor, Angela M. Nickle, Custodian. A copy of the Certificate of Deposit is attached hereto as Exhibit "B." Co) The bank also received a copy of Judge Hoffer's Order of June 20, 2003 and acknowledged on its data entry system that the funds cannot be disbursed until Jason S. Nickle attains the age of majority. A copy of the printout reflecting the account information is attached hereto as Exhibit "C". 4. The facts and documents contained herein are tree and correct to the best of my knowledge, information and belief. Respectfully submitted, By: Boswell, Tintner, Piccola & Wickersham 315 North Front Street Post Office Box 741 Harrisburg, PA 17108-0741 Attorneys for State Farm Insurance Company DATE: July 9, 2003 CLAIM NO ~-J~b-//4 POLICY NO ~4Z-72Z-38M-OOZ LOSS DATE 7/23/2002 PAYMENT NO 1 q 3 897935 J Coverage Descrfptfon Amount COL Pa¥Cd--~ DATE 6/25/2003 BODILY INJURY $5,000.00 1~0 l-Il AMOUNT ~S,O00.O0 r j TIN AUTHORIZED BY ALVIANI, NADINE PHONE (717) 774-9052 REMARKS STATE FARM 'MUTUAL AUTOMOBILE INSURANCE COMPANY [] ~ ] PENNSYLVANIA OFFICE EIRST UNION ~A"K OF,'~E~A~ARE INSURED SHAFFER, JOHN CLAIM NO 38-J~BB-77~ LOSS DATE 7/2~/2002 Pay ~o the OrEero~' ANGELA NICKLE, AS PARENT AND NATURAL GUARDIAN OF JASON NICKLE, A MINOR 7 PINE RD APT 506 MT HOLLY SPRING PA 17065 Certificate of Deposit Receipt This receipt is issued to: JASON S NICKLE MINOR ANGELA M NICKLE CUSTODIAN 7 PINE RD # 506 MOUNT HOLLY SPRINGS, PA 17065 Account Number: 9600014467 IRA Number: Amount $ 5,000.00 Date Opened 7/8/2003 Term 34 Months Maturity Date 5/8/2006 [merest Rate 2.370 % The account evidenced by this receipt is subject to and further explained in the terms and conditions contained in the account agreement and account disclosures. The account is Not Negotiable and Not Transferable. Oaly the items checked apply. [] Fixed Interest Rate [] Additions Permitted [] Automatically Renewable [] Variable Interest Rate [] Single Maturity (not automatically renewable) [] Callable [] Notice Account Interest will be: [] mailed to the owner(s). [] added to principal (compounded), [] paid to account No. 1994 Bankers Systems, Inc,, St, Cl~d, MN 11-80~-397-2341] Form CDREC-BK-LAZ 3/1/95 (psge ! of II 0?-08-2003 11:Zlpm From-WAYPOINT BANK +717 24E Z679 yI wayp i.n. LOOK FOR US. WE'LL GET YOU THERE.. T-684 P.OOZ/OOZ F'45Z Boswell, Tintner, Piccola & Wickersham Attn: Denise L Foster 315 N Front Street PO Box 741 Han'isburg, Pa 17108-0741 RE: Jason S Nickle Trust Account 9600014467 July 9, 2003 Dear Denise, This letter is to confirm the receipt and deposit into the above referenced account on July 7, 2003 as follows: Jason S Nickle Trust ~600014467 - $5000.00 Should you have any questions, please feel free to contact me at (717) 245- 2114, Sincerely, ~ Customer Sales Rep ~ 1160 Walnut Bottom Rd Carlisle, Pa 17013 RO, Box 171 I, I'IARRISBURG, PENN~-YLVANIA 17105-171] Toll Free 1-865-WAYPOINT (I-866-~29-7646) ' www. wa!Jpolntbanl(.com O?-Oa-ZOO] ~ccoun~ number: 9600014467 000 M Short name: NICKLE JASON S Type: CERTIF OF DEPOSIT * ............ Balance Data ........... * Current balance: 5,000.00 Hold amount: Available Balance: 5,000.00 Interest due: .32 * ........ Basic Interest Data ........ * From-WAYPOINT BANK +'Fl;' Z4.~ 267g T-88S P.OOZ/OO4 F-453 *-i .......... Customer Data ...... -. .... ~-* JASON S NICKLE 7 PINE RD APT 506 MOUNT HOLLY SPRINGS PA 17065 Interest rate: 2.370 Average rate: 2.370 Daily factor: .324657 Interest paid ITU: .00 Interest W/H YTD: .00 Interest method: SIMPLE INT * ........... Account Dates ........... * Issue/Open da~e: 7-08-03 Last renewed: Maturity date: 5-08-06 Automatically renewable: YES Available interest: .00 F3~Exit Home phone: 717-486-3347 NON SPEC Business phone: Officer: 027 TIN/Crt: 181-76-4824 C * ............ Payment Data .............. * Next paymen~ date: 8-31-03 Payment amount: 17.53 Disposition: (CAPITALIZE) Last pa}anent date: 7-08-03 Last payment amount: .00 Last payment APY earned: .00 * ............... Co~en~s ............... * F13=Inquiry window F15=Rsstart 07~08-2003 ll:31pm From-WAYPO[NT BANK +717 Z4B Z6?g T-;8~ P.OO;/OD4 F-45; ,Time Subsystem 009600014469 N~CKLE JASON S TI;De options, then press E~ter. 2=Change 4=Delete $=Displa¥ 8=Action Opt Item ID Memo MEMO Description CUSTOMER OR ACCOUNT MEMO Closeout Conditions Date ?/o /o3 7/09/03 Bottom F3=Exit FS=Refresh F6-Create F12=Cance1 Fl?=Subset 0~-~8-2003 11:31pm From-WAYPOINT BANK Time Subsystem Item class .... : Item ID ..... : Item type ...... : Short description Primary officer . Secondary officer Required view ..... Private item Message ........ Expiration date 009600014467' MEMO +717 Z45 Z6?g NICKLE JASON S T-fiB5 P.004/004 F-453 MEMO i 1-Memo, 2-Required view memo, 4~Required view tickler Closeout Conditions 635 3-Tickler 0=NO, 1-Yes Court Order: Jason must be 18 0/00/00 to closeout Press Enter to continue. F3-Exlt Fll~Additional data F12=Cance1 CERTIFICATE OF SERVICE I do hereby certify that I have served a true and correct copy of the foregoing Verification of Deposit of Minor's Funds, by placing the same in the United States Mail, first class, postage prepaid, at Harrisburg, Pennsylvania, addressed as follows: Angela Nickle 7 Pine Road Apartment 506 Mt. Holly Springs, PA 17065 Parent/Natural Guardian Denise L. Foster, Paralegal DATE: July 10, 2003