HomeMy WebLinkAbout05-01-07
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IN THE COURT OF COMMON PLEAS
CUMBERLAND CO., PENNSYLVANIA
IN RE: ESTATE OF KENNETH E.
WALLACE, DECEASED
ORPHANS' COURT DIVISION
NO.: dl- {)5~()885
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PETITION FOR APPROVAL OF COMPROMISE SETTLEMENT
AND DISTRIBUTION OF PROCEEDS PURSUANT TO PA. R.C.P. 2206
Petitioners, Paul E. Stone and Barbara J. Myers, as Co-Administrators of the Estate of
Kenneth E. Wallace, deceased, by and through their attorneys, Navitsky, Olson & Wisneski LLP,
hereby avers as follows:
1. Petitioners, Paul E. Stone and Barbara J. Myers, are the Co-Administrators of the
Estate of Kenneth E. Wallace by virtue of Letters of Administration duly granted by the Register
of Wills of Cumberland County, Pennsylvania on or about October 6,2005. A copy of the
Certificate of Grant of Letters of Administration is attached hereto as Exhibit "A".
2. Petitioners, Paul E. Stone and Barbara J. Myers, are the nephew and sister of the
decedent, Kenneth E. Wallace.
3. On or about, July 28,2005, Kenneth E. Wallace was involved in a motor vehicle
accident that took place on Route 581 in Camp Hill, Cumberland County, Pennsylvania. A copy
of the police accident report is attached hereto as Exhibit "B".
4. Kenneth E. Wallace died as a result of the injuries that he sustained in the
accident. A copy of the Death Certificate for Kenneth E. Wallace is attached hereto as Exhibit
"C" .
5.
COO)
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The person alleged to be responsible for the accident, Joyce G. Cise,,"Wied
following the accident but prior to the initiation of suit.
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6. On or about April 19, 2006, Petitioners, in their capacity as the Co-Administrators
of the Estate of Kenneth E. Wallace, filed suit against the Estate of Joyce G. Case in the Court of
Common Pleas of Cumberland County. The suit was docketed to No. 2006-2166.
7. Petitioners, Paul E. Stone and Barbara J. Myers, in their capacity as Co-
Administrators of the Estate of Kenneth E. Wallace, asserted Wrongful Death and Survival
Claims against the Estate of Joyce G. Case for the injuries arising out of the aforesaid accident.
8. As of the date of the accident, Joyce G. Case was insured under a policy of
automobile insurance issued by Donegal Mutual Insurance Company that provided for combined
liability and property damage limits of One Hundred Thousand ($100,000.00) Dollars. A copy
of the Donegal Mutual Insurance Company policy is attached hereto as Exhibit "D".
9. Donegal Mutual Insurance Company has agreed to tender its One Hundred
Thousand ($100,000.00) Dollar policy limits in settlement of the claims asserted against the
Estate of Joyce E. Case. See, September 5, 2006 correspondence from Donegal's attorney,
attached hereto as Exhibit "E".
1 O. As of the date of the July 28, 2005 accident, Joyce G. Case was not insured by
any other policy of insurance that would afford coverage for the claims arising out of the
accident. See, Affidavit of No Additional Insurance executed by Joyce G. Case, attached hereto
as Exhibit "F".
11. As of the time of the July 28, 2005 accident, the decedent, Kenneth E. Wallace,
was insured by an Allstate Insurance auto policy that provided for underinsured motorist's
benefits in the maximum amount of Fifty Thousand ($50,000.00) Dollars per-person per
occurrence. See, copy of Kenneth E. Wallace's Allstate Insurance policy attached hereto as
Exhibit "G".
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12. Allstate Insurance Company has agreed to tender its Fifty Thousand ($50,000.00)
Dollar policy limits in satisfaction of the Estate's underinsured motorist's claim arising out of the
July 28,2005 accident. See, letter from Allstate dated July 21,2006 confirming the tender of the
Fifty Thousand ($50,000.00) Dollar underinsurance policy limits attached hereto as Exhibit "H".
13. There are no underinsured motorists' benefits available under the auto policy
insuring the commercial vehicle that Mr. Wallace was operating at the time of the accident. See,
October 10, 2005 correspondence from counsel for Giant Good Stores, LLC, George B. Faller,
Jr., attached hereto as Exhibit "I".
14. The Estate of Joyce G. Case has net assets of approximately Thirty-Seven
Thousand Eight Hundred Ninety-Four Dollars and Thirty-Seven ($37,894.37) Cents. See,
informal accounts of the Estate provided by the Estate's attorney, Douglas C. Yohe, attached
hereto as Exhibit "J".
15. In addition to the aforesaid insurance proceeds, the Estate of Joyce G. Case has
agreed to pay Twenty Thousand ($20,000.00) Dollars out of the Estate's assets in order to
resolve three claims against the Case Estate that arose out of the aforesaid accident: the claim of
the Estate of Kenneth Wallace, the property damage claim of Giant Food Stores, LLC, and the
property damage claim of Snyder's of Hanover.
16. Neither Giant Food Stores, LLC nor Snyder's of Hanover Foods has a claim
against Mr. Wallace's underinsured motorist limits.
17. Giant Food Stores, LLC's property damage claim against the Estate totaled
Ninety-Five Thousand Seven Hundred Forty-Two Dollars and Thirty-Nine ($95,742.39) Cents.
See, correspondence and property damage estimate from Giant Foods' attorney, George Faller,
attached hereto as Exhibit "K".
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18. Snyder's of Hanover's property damage claim against the Estate totaled Five
Thousand Six Hundred Eight-Four Dollars and Sixty ($5,684.60) Cents. See, damage estimate
provided by Hanover Foods attached hereto as Exhibit "L".
19. Giant Food Stores, LLC has agreed to compromise its Ninety-Five Thousand
Seven Hundred Forty-Two Dollars and Thirty-Nine ($95,742.39) Cents claim against the Estate
of Joyce G. Case for the amount of Thirteen Thousand Five Hundred ($13,500.00) Dollars.
20. Snyder's of Hanover has agreed to compromise its Five Thousand Six Hundred
Eight-Four Dollars and Sixty ($5,684.60) Cents claim against the Estate of Joyce G. Case for the
amount of One Thousand Five Hundred ($1,500.00) Dollars.
21. Of the Twenty Thousand ($20,000.00) Dollars to be paid out of the net assets of
the Estate of Joyce G. Case, Five Thousand ($5,000.00) Dollars will be allocated to the
settlement of the Estate of Kenneth Wallace's claim, and that the remaining Fifteen Thousand
($15,000.00) Dollars will be allocated to the settlement of Giant Food Store, LLC's and Snyder's
of Hanover's property damage claims.
22. Giant Food Stores, LLC through its counsel, George B. Faller, Jr., Esquire, agrees
that such a course of action would be in the best interest of all parties involved and concurs in
this Motion. A Certificate of Concurrence is attached hereto as Exhibit "M".
23. Corporate Claims Management, as subrogee for Snyder's Of Hanover, through its
representative Rick Bruno, agrees that such a course of action would be in the best interest of all
parties involved and concurs in this Motion. A Certificate of Concurrence is attached hereto as
Exhibit "N".
24. The total amount (insurance proceeds and Estate assets) that will be paid to the
Estate of Kenneth G. Wallace in order to settle the Wrongful Death and Survival Action claims
4
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Thousand Two Hundred Thirty-One Dollars and Fifteen ($3,231.15) Cents. An itemization of
the expenses is attached hereto as Exhibit "P".
32. No liens have been asserted in this matter.
33. By reason of the death of the decedent, Kenneth E. Wallace, two causes of action
arose against The Estate of Joyce G. Case: one under the Wrongful Death Act for the benefit of
those relatives of the decedent entitled by law to recover damages for his wrongful death, and
one under the Survival Act for the benefit of his Estate to recover damages for his death.
34. By letter dated January 29,2007, a copy of which is attached hereto as Exhibit
"Q", the Commonwealth of Pennsylvania Department of Revenue has agreed to allocate eighty
(80%) percent of the settlement proceeds to the Wrongful Death action and twenty (20%) percent
of the settlement proceeds to the survival action.
35. Your Petitioner believes that, in accordance with the terms of the Power of
Attorney and Fee Agreement, a fair, just and equitable distribution of all settlement proceeds
would be as follows:
a)
The Estate of Kenneth E. Wallace
Wrongful Death allocation (80% of settlement
proceeds)
$84,215.08
Survival Action allocation (20%) of settlement
proceeds)
$21,053.77
b)
Navitsky, Olson & Wisneski LLP legal fees
(30% of settlement proceeds)
$46,500.00
c)
Navitsky, Olson & Wisneski LLP
reimbursement of expenses
$ 3.231.15
TOTAL
$155,000.00
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36. Pursuant to Pennsylvania's Intestacy Law, the One Hundred Five Thousand Two
Hundred Sixty-Eight Dollars and Eighty-Five ($105,268.85) Cents in Wrongful Death and
Survival Action proceeds shall be equally divided between the decedent's parents, Ralph W.
Wallace and Betty S. Wallace.
37. Ralph W. Wallace and Betty S. Wallace join in this Petition and request that the
proposed settlement be approved. Affidavits of concurrence are attached hereto as Exhibit "R".
38. The remaining Fifteen Thousand ($15,000.00) Dollars to be paid out of the net
assets of the Estate of Joyce G. Case shall be paid One Thousand Five Hundred ($1,500.00)
Dollars to Snyder's of Hanover and Thirteen Thousand Five Hundred ($13,500.00) Dollars to
Giant Food Stores, LLC in resolution of their property damage claims.
WHEREFORE, Your Petitioners pray that your Honorable Court approve the settlement
of the claims set forth above pursuant to agreement of the parties.
Respectfully submitted,
"
RE~
David isneski, EsqUIre
Navitsky, Olson & Wisneski LLP
2040 Linglestown Road, Suite 303
Harrisburg, P A 171110
Counsel for Petitioners
Paul E. Stone, Petitioner
GJ (JAIL ~-~
Barbara J. Myer PetIt ner
Date:
'-(-2-07
7
BXHIBIT ^
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STATE OF PENNSYLVANIA
COUNTY OF CUMBERLAND
SHORT CERTIFICATE
I,
GLENDA FARNER STRASBAUGH
Register for the Probate of Wills and Granting
Letters of Administration in and for
CUMBERLAND County, do hereby certify that on
the 6th day of October, Two Thousand and Five,
Letters of ADMINISTRATION
in common form were granted by the Register of
said County, on the
estate of KENNETH E WALLACE , late of WEST PENNSBORO TOWNSHIP
(FIISt, Middle, Last)
in said county, deceased, to BARBARA J MYERS
(First, Middle, Last)
and
PAUL E STONE
(First, Middle, Last)
and that same has not since been revoked.
IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the
seal of said office at CARLISLE, PENNSYLVANIA, this 6th day of October
Two Thousand and Five.
File No.
PA File No.
Date of Death
S.S. #
2005-00885
21- 05- 0885
7/28/2005
207-58-2926
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Road AliQnment
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FORM It AA-500 (12102)
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Carao Bodv Tvne
o Not Applicable
00 VanlEndosed Box
o Cargo Tantt
Hazardous Material
o Yes 00 P\!o
ReJe.ase Jndicator
cl
0'
.';::
"
E
i
-!I
13 il
>
III
1;
..
1.1
E
E
8
CaI'QO Bodv TYDe
o Not Applicable
o VanlEndosed Box
o cargo Tank
Hazardofls Material
o yes 0 No
Release Indicator
FO.~ 0 ~(12JIIZ)
Number of Axles
~() _ (Code Number of Axles
~ or '99' for unknown)
o Rat Bed
o Dump
o c~ncrete Mixer
o Auto Transport
o Garbage/Refuse
o Bus
o Other/Unknown
r:.A 1"
III11 mIl I II I II 11111 III ~I
Crash Number
I
Enter 1-digit hazardous material class
" "'V" '7 '7
DODD
DODD
~ ~ ~ ~
, = No Release 2 = Release Occurred 9 - Unknown
Number of Axles
IT] (Code Numb..- of Axles
or .," for unknown)
o Flat 8f:d
o Dump
o Concrete Mixer
o Auto Transport
o Garbage/Refuse
o Bus
o Other/Unknown
Page;
CEEJ
QD New
Enter 1-digit hazardous material class
-.;;;:7" ""7 "'9'" ""V
DODD
DODD
~ ~..6.~
1 == No Release 2 = Release Occurred 9 = Unknown
./ . Change!
'--" Continuation
Carrier Phone
([illI]])~-~
GVWR
~
Oversize Load
o Yes @ ~
State Zip 0 Unmown
~~ITIJJ
PUC #
Vehicle Confiauration
o Not Applicable
o Passenger Car. Only Record if
HuMat Placard Displayed
o Light Truck (Van. Mini-Van. Panel.
Pickup or SUV with HazMat Placard)
o Single Unit Truck (2 Axles. 6
Tires)
o Single Unit Truck (3 or More Axles)
o Single Unit Truck (Unknown
Number of Axles)
o TrucklTrailer(s)
o Trude Tractor (I1obtd)
<Xl Tractor/5emi-Traller(s)
O Medium/Hea"Y Trum. Ci1tmot
Classify .
O Small Bus (SeatS ~15 ~
Including Driver)
o Bus (Seats Mote Thzn 15
People. Indu~9 th2 DriverJ
o Other
o Unknown
Carrier Phone
(ITIJ) ITIJ - CIIIJ
GVWR
CIIIIIJ
Oversize Load
o Yes 0 reo
o Unlmown
State Zip
CD ITIITI ITIJJ
puc,
Vehicle Confjouration
o Not Applicable
o Passenger Car - Only Record if
HazMat Placard Displayed
o light Truck (Van. Mini-Van. Panel.
PiCkup or SUV with HazMat Placard)
o Single Unit Truck (2 Axles. 6
Tires)
o Single Unit Truck (3 or More Axles)
o Single Unit Truck (Unknown
Number of Axles)
o TrucklTrailer(s)
o Trude Trartor (Bobtail)
o Tractor/Semi- Trailer(s)
o Medium/Heavy Truth - Cannot
dassify
o SmaU Ius (Seats l).15 ~
Including Driver)
o Bus (Seats l\Q0ft! Than 15
People. Induding the Driver)
o Other
o Unknown
PE(\!i\!OOT COpy
r---
0 I.m!!
...
10 !i Unit
...
'i:
::J
c:
o
;:
AI
E
..
o
....
.5
c:
III
'i:
l' 1;;
Ii
I~
I,~
,0
;~I
ii
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,
-------~----,
--.J
~('
III ~~nmllllmlllllg
Crash Number
-,
COMMONWlEALTH Of PENNSYLVANBA
POLICE CRASM REPORTING fORM
AA 500 2 I Police Use O~I~
,.,.6\ - '4 0.. ~ \ C- l...
@ New
Page;
I~
~ Changel (.)
A Continuation ,
(g Motor Vehicle in 0 Hit & Run Vehide 0 Illegally Parked 0 Legally Parked 0 Non - Motorized
Transport
O . 0 Pedestrian on Skates, 0 Disabled From 0 0
Pedestrian in Wheelchair, etc Previous Crash Train Phantom Vehicle
(If "Pedestrian" or .Pedestrian on Skates, in Wheelchair, etc", Complete Form M, Section 28)
First Name Date of Birth (MM-DD-YYYY)
~ ~ lli[ill
Telephone Number
I 'I/O - B~() - 2:2/2,. I
Z'
~
Commercial Vehicle
Q?J Yes 0 No
(If Yes, Complete Form C)
Unit No
~
AkohoVDruos SusPected
00 No 0 Illegal Drugs
o Alcohol 0 Akohol and Drugs
Driver or Pedestrian Physical Condition
~ Apparently 0 1IIegal Drug
Normal Use
o H~d ~een 0 Sick
Drlnk'n
o Medication
o Unknown
o Medication
o Unknown
o fatigue
o Asleep
Alcohol Test Tvpe
~ Test Not Given
o Blood
Primary Vehicle Code Violation
I
Charged?
o Yes 0 No
o Other
o Unknown if
Test GIven
O Unknown
Results
o Breath
o Urine
;Vcf#'c
Driver Presena
Alcohol Test Results 0 Test Refused
rcf1 [JJ 0 Test Given,
~" Contaminated Results
I!, ,II I:~~_~~~~~~~~~:_ _ ::~~~~~ :::~r
1 =Driver Operated
Vehicle
2=No Driver
3=Driver Fled Scene I
4=Hit and Run --L..
9...Unlmown
OJ
04=State Police Vehicle
05=PENNDOT Vehicle
06=Other State Gov Veh
07=Munidpal Police Veh
08=Other Municipal
Government Vehicle
09=Federal GOII Veh
98=Other
99=Unknown
I
Ie
':8
'iii
.~
12.02
,.5
e
"0
.:E
CIJ
! >,
I
f
Vehicle Make *Matte Code
HAHOVe-Y( PA n3'$1 II Wo....kh~t I~
Model Year Vehicle Model (see overlay)
~ I 1"K I
Est. Speed Vehicle Towed Towed By
1010101 a Yes CB" No I tJ/A I
Insurance Insurance Company Poli<y No
00 Yes Otllo o ~~~wnl wdl,~ ~r~ A W'c.-J'L"...., ~~.II "OlS-~L-lS04 I
l=Towing Pass. Veh 4=MobilelModular Home 7;;Semi-Trailer
D 2=Towing Truck 5=Camper 8=Other
3=Towing :. Trailer 6=Full Trailer 9=Unknown
Trailino f
Unit No. of r;::lO ~
- Tra,iling ~ Unit
Units:
Tag No
I
Tag Year
II
Tag 5t
tD
Direction of ~ "Vehicle Position "Movement ~ · See Speaal Usaoe
Travel Overlay [ill
Vehicle Color Vehicle Tvpe 05=Large Truck 20=Unicyde, Bicycle, 12=Commercial
[E]}] 06=Ye!low ~ 01=Automobile 06=SUV Tricycle OO=Not Applicable Passenger
07=$ilver o ~ 02=Motorcycle 07=Van 21 =Other Pedalcycle Carrier
08;,::Gold 03=Bus lO=Snowmobile 22=Horse & Buggy 01 =Fire Veh 13=Taxi
01 =Blue 09=Brown 04=Small TrUCK 11 =Farm Equip B=Horse & Rider 02=Ambulance 21=Tractor Trailer
02=Red lO=Orange (If "or, Complete Form 12=Construdion Equip 24:Train 03=Police 22=Twin Trailer
03=White 1 1 =Purple M. Section 26) 13=A TV 25=Trolley O8=Other Emergency 23"",Trip!e Trailer 'I
04=Green 12=Other (If "20" or "21", Complete 18=Other Type Spec Veh 98=Other Vehide 3bModified Vet! 'I
05=Black 99=Unknown Form M, Section 27) 19=Unk. Type Spec Veh 99=Unknown 1 bPupil Transport 99=Unknown
. Initial Impact Point
I ~ OO=Non.Collision
~ 11l..Q...CLj 01-12=C1ock Points
~ 13-=Top
FQR:': 0 AA-~U (12.02')
Damaqe Indicator
ril, O=None 2=Functional
L:.J 1 =Minor 3=Disabling
9=Unknown
Gradient 3=Downhill
r;--1, =level 4=Bottom of Hill
~ Z...Uphill 5=Top of Hill
9=Unknown
Road AIiQnment
f/I 1 ",Straight
~ 2=Curved
9=Unknown
14=Undercarriage
15= Towed Unit
99=Unkr'lown
I
I
-~
?~l\!i\!DOT CO:>V
Page
EEJ
IIIIIIIII~ 1111111111 ~III~
P0923958
Crash Number
I
.-J.
COMMONWEALTH OF PENNSYLVANIA
POLICE CRASH REPORTING FORM
AA 500 3 l:::fi6 I '""
(-l49Ci\oc,",
~A"\
I
I
I
L
A Person T VDe: Seat Position: Safety Eauioment One. G firojQn.:
1 = Driver D OO=NOl A Passenger/Occupant E OO=None Used / Not Applicable O=Not Applicable
2= Passenger 01=Oriver - AU Vehicles 01=Shoulder Belt Used 1 -Not Ejected
7=Pedestrian 02=Front Seat Middle Position 02=Lap Belt Used 2=Totally Ejected
8=Other 03=Front Seat Right Side 03=Lap And Shoulder Belt Used 3=Partially Ejected
9=Unknown 04-Second Row - Left Side Or O4=C hild Safety Seat Used 9=Unknown
Motorcycle Passenger 05=Motorcycle Helmet Used H
05=Second Row - Middle position 06:Bi;lecle Helmet Used ~ection Path:
~. 06=Second Row - Right Side 10=5a ety Belt Used Improperly O-Not Ejected I Not Applicable
B F =Female 07=Third Row Or Greater- 11 =Child Safety Seat Used Improperiy 1 = Through Side Door Opening
-= Left Side 12=Helmet Used Improperly
0 M =Male 2= Through Side Window
i U =Unknown 08= Third Row Or Greater - 90=Restraint Used, Type Unknown 3:;; Through Windshield
Middle Position 99=Unknown
! 09= Third Row Or Greater - 4= Through Back Door
Right Side Safety Equiomenr Two: 5= Through Back Door Tail~ate Opening
6= Through Roof openin~ Sunroofl
Iniurv Severity: 10=S\eeper Section of Truckcab F OO=None Used I Not Applicable Convertible Top Down
41 C O=Not Injured 11 =In Other Enclosed 01 =Front Air Bag Deployed (For This Seat) 7= Through Roof Opening (Convertible
A. l=Killed Passenger Or Cargo Area 02=5ide Air Bag Deployed (For This Seat) Top Up}
0 2-Major Injury 12=ln Open Area 03=Other Type Air Bag Deployed 9=Unknown ~
ell 3=Moderate (Back Of Pickup, Ete.) 04=Multiple Air Bags Deployed
A
Injury 13:::;. Trailing Unit 05=Motorcycle Eye Protection
4=Minor Injury 14=Riding On Vehicle Exterior 06=Bicyclist Wearing Elbow/KneelPads I Extrication:
8=lnjury, Unk 15=Bus Passenger 'O=Air Bag Not Deployed, Switch On O=Not Applicable
Severity 98=Other 11 =Air Bag Not Deployed, Switch Off 1 -Not Extricated
9..Unknown if 99=Unknown 12=Air 8ag Not Deployed, 2=Extricated By Mechanical Means
Injury Unk Switch Settln~ 3=Freed By Non - Mechanical Means
13=Air Bag Removed Prior To Crash) 8..0ther
19-Unknown If Air Bag Deployed 9=Unknown
99=Unknown
I
3; EMS Agency: I c,t'tJP 11,/1 i::"ft1 ~ I Medical Facility: I N/A I
Unit No Person No Delete? Date of Birth (MM-DD-YYYY) A B C 0 E F G H I
ru0U 0 [iliJ - [!]I] - CLEIiliJ [JJ [f] @] [iliJ [ili] 0QJ [!] ~ @]
4
Name I Address J Phone EMS Transport
~same as ~ I DYes ~No
Operator
--
Unit No Person No Delete? Date of Birth (MM-DD-YYYV) A B C D E F G H I
[ili] [ili] 0 @liJ-~ -[ili]ili] [Q~W [ili]~ @EJ ITJ~~
Name I Address I Phone EMS Transport
I}(l Same as I I DYes IIl) No
Operator
Unit No Person No Delete? Date of Birth (MM-OD- YYYY) ABC 0 E F G H I
0IJ~ 0 rn-0i] -[Uillli][D0@]~~~ 0~0
NarJ1e I Address / Phone EMS Transport
~ Same as I I aYes ~No
Operator
Unit No Person No Delete? Date of Birth (MM-DD-YYYY) A B C D E F G H I
rnrn a OJ-m-ITIIJDDDmITJOJDDD
Name / Add ress I Phone . EMS Transport
o Same as I I DVes DNa
Operator
Unit No Person No Delete? Date of Birth (MM-DD-YYYY) A B C D E F G H I
rnrn 0 m-[I]-ITIIJDDD[I]rnITJDDD
Name I Address I Phone EMS Transport
o Same as I I DVes Ot-;o
Operator
Unit No Person No Delete? Date of Birth (MM-DD-YYYY) A B C D E F G H I
rnrn 0 [J]-[l]-ITIIJDDDOJITJITJDDD
Name I Address I Phone EMS Transport
o Same as I I Dves ONe
Operator
fORM. AA-SOO(12/02)
PENNDOT COpy
- -r---
~
COMMONWlEAo..l1HI Of IPIE~NSVLVANIA
POUCE CRASIHI ~E~DliING fORM
AA 500 4 I Police U1e cno \ -, L( q q \ 10 '2..
~T
Page
[ili]
1.2
611;
E
2i
-
.E
f4l O=Non-Collision
l2..J 1 =Rear End
f/l 1=00 Travel lanes 3=Medlan
L.:.J 2--Shoulder 4=Roadside
(J]
OJ
~ ~~t
Harm Event LlR Most? Utility Pole Number
Unit No 1 ~ D 0 o=IIIIJJ
0IJ2 [ili] D 0 o=IIIIJJ
Pi~:~~j~t 3 [ill] D (g) o=IIIIJJ
Sequential
Order 4 rn D 0 o=IIIIJJ
Crash Oesaipuon
2=Head On
3=Rear to Rear
(Backing)
c:~
o c:
_ 0
- ..
e-i
- 8
.g u
.=-t
5 .;; .~
IV ::
~ :l
U N
_ c:
la ..
- ...:
QI -
c= ~
QI 0
~~
Relation to Roadwav
3=Dark - Street
Lights
4-Dusk
Illumination
1=Daylight
2=Dark . No
Street LiiJhts
1-No Adverse
Conditions
2-Rain
Weather Conditions
3=51oot (Hail)
4-Snow
2=5aod, Mud. Dirt,
Oil
3=Snow Covered
Road Surface Conditions
Harm Event L1R Most? Utility Pole Number
~ Unit No 1 [TII] D 0 o=IIIIJJ
>
; ~2[ili] Do
"c
;:) Please ~t 3 I ~ I LI I D ~
I Events In ~ 7 'OJ
I Sequential
I Order 4rn D 0
o=IIIIJJ
o=IIIIJJ
o=IIIIJJ
First Unit No Hann Event Most Unit No Harm Event
~~~~ rarJl I 0 I '2..1 ~~':tf~~ ~ ~
iIiiOiSh L:::J...:J iTii"Uash ~ ~
Do not ~ this irItormition on rnul~ pages
Environmental I Roadwav
Potential Factors (ElRJ 1
OO=Non~
OhWindy Conditions
Ol=Sudden Weather Conditions
03=Other Weather Conditions
04=Deer In Roadway
05=Obsta<le On Roadway
06--other Animal On Roadway
07=Glare
O~Worlc Zone Related
~ 2IT] 3IT]
l1=Slippery Road Conditions (kelSnow)
12=Substance On Roadway
13::Polholes
l~Broken Or Cracked Pavement
15~ TCD Obstructed
16=Soft Shoulder Or Shoulder Drop Off
28--other Roadway Factor
29=Other Environmental Factor
99;:unknown
c
-8
." Possible Vehide Fai/uf@S IV)
~ OO=None 06=Exhaust
_ 01=Tires 07=HeadJights
.5 02~BraKe System 08=Signallights
g' 03=Steering System 09=0ther Ughts
~ 04=Suspension l0=H0m
i 05===Power Train 11=Mirrors
"ii
8 ~~it [9JI] 1 ~ 2 OJ
~~~~1@E]2rn
12=Wipers
1 3=Driver Seatin~Control
14=Body, Doors, Hood, He
15= Trailer Hitch
16=Wheels
17=Airbags
18", Trailer Overloaded
19=Unsecure/Shifted
Trailer load
20=lmproper Towing
21 =Obstructed Windshield
99=Unknown
19
Indicated Prime Factor
Do not repeat this information on
roolti~ pa4JI!S.
EIR V D P
00000
Unit No factor Code
EEJ 0I]
If fIR is the Prime Factor
Type, leave Unit No blank
FOR=' II AA-5CIX~
18 New
IIIIII~IUIIIIIIIIIII
Crzsh ~
I
_ Changel
......J Continuation
4=AngJe
5=Sideswi~9
(Same Direction)
5=Outside Trafficway
6=ln Parking Lane
6=Sideswipe
(Opposite DirecOon)
7=Hit F"axed Obied
8=tB PeIfesbian
~
7=Gore (Ramp InIe.sectiw.)
9=UnknOWn
5=Dawn
6~Dark - .~~known
Roadw..y Uahting
5=Fog 7=Sleet & Fog
6=Rain & Fog 8--<>1her
4=Slush 6=lce Patches
5~lce 7=~~ S&ardng
Harmful Events (Harm EventJ 3O--Hit Fence Or Wa!I
01=Hit Unit 1 31=Hit Building
02=Hit Unit 2 32=Hit Culvert
03=Hit Unit 3 33=Hil Bridge Pier Or Abutrnmt
04=Hit Unit 4 J4;Hit Parapet End
05=Hit Unit 5 3S--Hit Bridge Rail
06=Hit Other Traffic Unit 36::Hit Boulder Or Obstadr
07~Hit Deer On Roadway
08=Hit Other Animal 37=Hit Impact AttI!nua1DJ
09=Collision With Other Non 38=Hit fiR! Hydrcmt.
Fixed Object 39=Hlt Roadway Equ:p:rs
11 =Struck By Unit 1 40=Hit Mail Box
12=Struck By Unit 2 ' 41=Hit Traffic: Island
B===Struck By Unit 3 42=Hit Snow Bim
14=Struck By Unit 4 43=Hit T~ Constn:affm
1 5::;Struck By Unit 5 Barrier
16=Struck By Other Traffic Unit 48=Hit Other Fixec! ~
21=Hit lree Or Shrubbery 49=Hit Unknown t1Jl!O 0h:s1
22~Hit Embankment 50:::0vertum1R0l CM!r ·
23=Hit Utili~ PoSe 51=Strud By ThR:J:rJII Or FOg
24=Hit TraffiC Sign Object
2S:;Hit Guard Rail 52=Pot Holes Or Other
26=Hit Guard Rail End Pavement Irr~
27=Hit Curb 53=Jacknife
28=Hit Concrete Or 54==fire In Veh:cre
Longitudinal Barrier 58--other Hon-{~on
29=Hit Ditch 99=Unknown ~ Etatt
8=OIher
~
8=O:hsf
Driver Action (OJ
OO=No contributing Action
01=Dr;ver Was Distracted
02=Driving Using Hand Held Phone
03=Driving Using Hands Free Phone
04=Mating Illegal U-Turn
05=lmproper/Careless Turning
06=Turning From Wrong lane
07=Proceeaing W/O
Clearance After Stop
08=Running Stop Sign
09=Running Red Light
10=Failure To Respond To
Other Traffic Control Device
11 = Tailgating
12=Suddel1 SlowinglStopping
13;lIIegally Stopped On Road
14=Careless Passing Or Lane
Change
15=Passing In No Passing Zone
16~Drjving The Wrong Way On
l-Way Street
~:it lEE]
l1:Car~ Or ~~a1
Badcing On Road.";.'iS)f
18--Driving On The Wr
Side Of Road ong
19=Malcing ~
Entrance To Hight'~
20=Making Improper Em
From H~
21 =Careless PaOOngllJnpamng -i
22=OverJUnder
Compensation At CW\'e
23=Speeding
24=Oriving Too Fa5t
For COnditions
2S=Failure To Ma:nta:n Props' SJlmI
26=Ori'M Aeeing Pdn (Po! (him!)
27..DriYer Inexper iencm
28=Failure To Use Specia52ed fqliJJ
92=Affected By Phy5iGd Conrl:-flm
98--other Improp8' Dmr.ng Attcms
9~Unknown
~:it~
1 [Zill 2 CD ] IT] 4[IJ
1 [ili] 2 rn ] OJ 4IT]
Pedestrian Action (PJ
OO=None
01 =Entering Or Crossing At
Specified Location
Q2=Walki09. Running, Jogging,
Or PlaYing
Unit No CD
03=Worting
04=Pushing Vehide
05=ApprOOching Or I..eiMng v~
06=WorIcing On Vetide
07=S1anmng
98=Other
99==Unknown
[I] unk~oCD CD
PEKNDOT CO~V
,,-1
COMWJONWIEAo..lr~ O~ 'lbuNSYLVANIA
IPODJCE OMSDf IlIIELl>>ODlVING FORM
AA 500 4 I Pdice Use ftht _ 1'-( C\ cl\ (P 2..
,::'A -r
Page
lol~1
D O=Non-Collision
1 =Rear End
D 1=On Travel Lanes
2=Shoulder
o
o
D O:Dry
1 ==Wet
Mann Event LlR 1\IOst7 Utility Pole Number
unit~ 1 ITEJ D ~ ITIIIIIJ
[ill]2 CD D 0 ITIIIIIJ
o 0 ITIIIIIJ
DO
Oash~
2:;Head On
3:::Rear to Rear
(Backing)
c~
.,g ~
1;j
~ r
.1?3
lI::~
'IS ~ 5
... ;!I
~ '"
O~
Relation to Roadwav
3==Median
4==Roadside
3~Oar\( . Street
lights
4=Dusk
Cumination
1 _Daylight
2=Dark - No
Street Uijhts
1 =No Adverse
Conditions
2=Rain
3=Sleet (Hail)
4-Snow
2::Sand, Mud. Dirt,
Oil
3=Snow Covered
_ c
o .
~ ii
~ ~
.g!
~ Conditions
Road Surface Conditions
~MCD
&mIs in 3
St!qIrential
Otder 4 [[]
c:
o
";:;
~ Q
~
J! Harm Event UR Most?
i I Unit~o 1[[] D 0
~,1[[]2rn D 0
15) P:easePut rn D 0
. . Elfl:fIts in 3
SftJuential
Order 4 rn D 0
Utility Pole Number
ITIIIIIJ
ITIIIIIJ
17
First
HaiinfuJ
Event m
iIiiCiiSh
unit ~o Harm Event Most Unit No Harm Event
OJ OJ 11arinful OJ OJ
Event In
~h
00 not repe;n this information on multiple pages
Ul
Emfimnm2lltall Roadwar
Fo:entiaI FactOIS (EJR) 1
00=H0ne
01=WuvJy ConOtions
ol:;SUdden weather Conditions
O3=Other Weather Conditions
04=Deer In ROCJ(t.vay
05=0bstade OIl Roadway
()&;()ther Animal On Roadway
07:::G~
08--wort Zone Retated
OJ 20J 30J
11=Slippery Road Conditions (lcelSnow)
12=Substance On Roadway
13=Potholes
14=Broken Or Cracked Pavement
15= TeD Obstructed
16=:50ft Shoulder Or Shoulder Drop Off
28--otheT Roadway factor
29=Other Environmental Factor
99=Unknown
c
o
1; hssib!e Vehicle Failures (VJ
~ 00=f\.'one ~Exhaust
_ O1::TIR5 07=Headlights
.E 02=6rake System 08=Signal lights
~ 03=Steering System 09==0ther lights
~ 04=Suspension 10:=H0m
~ 05=P0wer Train 11=Mirrors
1i
c
.3
12=Wipers
13=Driver SeatinglC ontrol
14:::Bodv. Doors, Hood, Etc
15=Traifer Hitch
16=Wheels
17:::;Airoags
1S=Trailer Overloaded
19=Unsecure/Shifted
Trailer load
20=lmproper Towing
21 =Obstructed Windshield
99==Unknown
:it @ill 1 ~ 2 IT]
~nit rn 1 CO 2 IT]
,gl
I
tml!Glted I'rime Factor
Do not repeiIl1his infonna1ion 00
~~
Ellf V 0 P
0000
Unit No Factor Code
IT] CO
If fiR is the Prime Factor
Type, leave Unit No blank
FC;:::j 0 ~(12lDZI
~New
CJ Changel
Continuation
4=Angle
5=SideswiDe
(Same Direction)
5==Outside "( rafficway
6=ln Parking Lane
5-0awn
6=Dark . Unknown
. Roadwav lighting
5=Fog
6==Rain & Fog
4=Slush
5=lce
Harmful Evenn (Harm Event)
01=Hit Unit 1
02=Hit Unit Z
03=Hit Unit 3
04=Hit Unit 4
OS=Hit Unit 5
06=Hit Other Traffic Unit
07=Hit Deer
08==Hit Other Animal
09=Collision With Other Non
FiJted Object
11 =Struck By Unit 1
U=$trucl< By Unit 2
13=Struck By Unit 3
14=Struck By Unit 4
15=Struck By Unit 5
16=Struo:: By Other Traffic Unit
21=Hit Tree Or Shrubbery
22=Hit Embankment
23=Hit Utility Pole
24=Hit TraffIC Sign
2S=Hit Guard Rail
26=Hit Guard Rail End
27=Hit Curb
28=Hit Concrete Or
Longitudinal Barrier
29=Hit Ditch
--..-- -
,
~(t lll\~ U' lllllllll
Crash Number
--,
Unit rn
No
Pedestrian Action (PJ
OO=None
01=Entering Or Crossing At
Specified Location
02=Walkin9. Running, Jogging,
Or PlaYing
Unit No IT]
P~''::~:JOL CO::v
L
8=Hit Pedestrian
6=Sideswipe
(Opposite Direction)
7=Hit Fixed Object 9=:OtherlUnknown
7=Gore (Ramp Intersection)
9=Unknown
8=Other
7=S1eel & Fog
8=Other
6=lce Patches
7=Water : Standing
or MOVIng
9==Unknown
8::Other
30:=Hit Fence Or Wall
31 =Hit Building
32=Hit Culvert
33=Hit Bridge Pier Or Abutment
34=Hit Parapet End
3S=Hit Bridge Rail
36=Hit Boulder Or Obstade
On Roadway
37=Hit Impact Attenuator
38=Hit Fire Hydrant
39=Hit Roadway Equipment
40:::Hit Mail Box
41=Hit TfaffK Island
42=Hit Snow Bank
43=Hit Temporary Construction
Barrier
48=Hit Other fixed Object
49=Hit Unknown Fixed Object
50~erturnIRoll Over
51 =Struck By Thrown Or Falling
Object
S2=Pot Hates Or Other
Pavement Irregularities
53-Jacknife
54=Fire In Vehide
58=Other Non..col1ision
99=Unknown Harmful Event
Driver Action (D)
OO=No Contributing Action
01 =DTNer Was Di~tTacted
02=Driving Using Hand Held Phone
03=Driving Using Hands Free Phone
04=Making Illegal U. Turn
05=lmproper/Careless Turning
06", Turning From Wrong Lane
07=Proceeding WIO
Clearance After Stop
08=Running Stop Sign
Q9:;;Rur.ning Red light
1 O=Failure To Respond To
Other Traffic Control Device
11 = Tailgating
12=Sudden Slowing/Stopping
13==lIIegally Stopped On Road
14=Careless Passing Or Lane
Change
15=Passing In No Passing Zone
16=Dri\ling The Wrong W~ On
1-Way Street
~~it [ill]
17=Careless Or Illegal
8acking On Roadway
18=OrNing On The Wrong
Side Of Road
19=Makinglmpro~r
Entrance To Highway
20:=Making Improper EXIt
From Highway
21=Careless PartinglUnparking -1
22=OverlUnder
Compensation At Curve
B-Speeding
2~Drivin9 f 00 Fast
For Conditions
25=Failure To Maintain Proper Speed
26=Driver Fleeing Police (Pol Chase)
27=Oriver Inexperienced
28=Failure To Use Specialized Equip
92=Affected By Physical Condition
98=Other Improper Driving Actions
99".Unknown
1~ 2[03[0 4[IJ
10J 2m 3 IT] 4IT]
03=Working
04==Pushing Vehide
05=Approaching Or Leaving Vehicle
Q6;Working On Vehicle
07=Standing
98=Other
99:::Unknown
IT] Un~ No [I] CD
.~
~.+r
COMMONWll:ALTIli OIF 'IEMNSVlVANIA
POlICIE CRASH RlEPO~iING \FORM
M 500 F I Police u~ ~Jy
"'0\ - \ t..\ q C1 \ ~ 2
Road Surface Type
o Dirt Soecial Jurisdiction 0 Military 0 Other Federal Sites
O Other 00 No Special 0 Indian Reservation 0 other
Jurisdiction
o Unknown 0 National Park 0 ~~~~:,niversity 0 Unknown
Please complete Unit Information for each unit involved in a fatal crash. Do not repeat the information in the fields above on multiple pages.
Unit No
[ili]
o Restrictions
Complied With
o Restrictions Not
Complied With
O Compliance
Unknown
@ Required. 0 Not a Pennsylvania
Complied With Driver
o Required - Non 0 Unknown
Compliance Compliance
o Required -
Compliance Unknown
24
~. Concrete
o Blacktop
o Brick or Block
o Slag, Gravel or
Stone
Driver Restrictions
Compliance
tg) No Restrictionsl
Not Applicable
<<;
o
i Driver Endot's<<nent
~ Compliance
o
...
.s
o None Required
25 ;t: .
c:
~
Driver License
Comoliance
o Not Required for
Vehicle Class
o No Valid. License
for Class
~ Valid License for
Class
o Not licensed
Droq Test Type
~ None
o Blood
o Urine
Drug Test Results . (Up to Four Results)
0= No Test Given 5 = Amphetamines
1 = No Drug Reported 6 = PCP
2 = Marijuana 8 = Other
3 = Cocaine 9 = Unknown Test
4 = Opiates Results
Unit No
CD
Driver Restrictions
Compliance
o No Restrictionsl
Not Applicable
c:
o
:.-.
~
loa
o
-
5 =
1:
::)
Driver Endorsement
ComplIance
o None Required
Driver License
ComplIance
o Not licensed
DruqTestType
o None
o Blood
o Urine
If -
DfIMI Test Results. (Up to Four Results)
o == No Test Given 5 = Amphetamines
1 :: No Drug Reported 6 = pcp
2 -:: Mariiuana 8 = Other
3;;;;; Cocaine 9 = Unknown Test
4 == Opiates Results
fQ::OO~~
o Not a Pennsylvania
Dri\J~r
o Unknown
Compliance
DUnk if COL or
CDl Required
o Not a Pennsylvania
Driver
o Unknown
o other
o Unknown jf Test
Given
~[Q] 0
DD
o Not a Pennsylvania
Driver
o Unknown
Compliance
o Other
o Unknown if Test
Given
~D D
DO
Page
~
~ New
C) Changel
Continuation
Principle Impact Point
o Non-Collision
DTop
o Undercarriage
o Towed Unit
o Unknown
A voidance Maneuver
o No Avoidance
Maneuver
o Braking - Skid
Marks Evident
Braking - No Skid
o Marks, Driver
Stated
Under Ride Indicator
~ No Underride or
\,,01 Override
Underride,
o Compartment
Intrusion
I
--, II
I
III 111111111 II lll~lllll ~l
Crash Number
.,
.\
11
000
01~1l lZ 01 02~
009 030
o 08 040
07 06 05
o 0 0
:1
I
I
:1
I
o Braking - Other
Evidence
o Steering. Evidence
or Driver Stated
o Other Avoidance
Maneuver
o Inconclusive
~ Steering and Braking 0 Unknown
Evidence or Stated
Underride. No
o Compartment
Intrusion
o Override, Other
Vehicle
Underride, Unknown if
o Compartment 0 Underride or
Intrusion Unknown Override
Emerqencv Use
('0\ Not in Emergency
'AI Use 0 Siren Sounding
o Ughts Flashing
o Both lights and
Siren
o Unknown
Principle Impact Point
o Non-Collision
aTop
o Undercarriage
o Towed Unit
o Unknown
Avoidance Maneuver
o No Avoidance
Manewer
O Braking - Skid
Marks Evident
Braking - No Skid
o Marks, Driver
Stated
Under Ride Ifldicator
o No Underride or
Override
Underride,
o Compartment
Intrusion
Emergencv Use
o Not in Emergency
Use
PENNDOT CO?Y
000
Dl~l1 12 010Z0_
009 030
008 040
07 06 050
o 0
~
o Restrictions
Complied With
O Restrictions Not
Complied With
O Compliance
Unknown
o Required - 0 Not a Pennsylvania
Complied With Driver
o Requir~d - Non 0 Unknown
Comphance Compliance
o Required -
Compliance Unknown
o ~~~i~l~ci~~~ for 0 Unk if CDL or
COl Required
o No Valid license 0 Not a Pennsylvania
for Oass Oriver
o ~~~ License for 0 Unknown
o Braking - Other
Evidence
o Steer~ng - Evidence
or Dnver Stated
o Other Avoidan<e
Maneuver
o Inconclusive
o Steering and Braking 0 Unknown
Evidence or Stated
Underride, No
o Companment
Intrusion
o Override, Other
Vehicle
Underride, Unknown if
o Companment C) Underride or
Intrusion Unknown Override
o lights Flashing
o Siren Sounding
o Both Lights and
Siren
o Unknown
"---
-.J . COMMONWEALTH OF PENNSYLVANIA
... . POLICE CRASH REPORTING FORM
AA 500 5 I Po/ic~ U5e On~
\+0\ - \<<-\ ~ ~ \ ~ 2...
m 111111 U I1I1II1II M
P0923958
Crash Number
I
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Page
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. . . .
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~~~~~~~~
21
Witness Name Address
1 Sere- AlfIt,tt,c:! NA"I'AT/ V~-
2
I...
Phone
Narrative and additional witnesses:
Accident Investigation Notification Issued? (BJ Property Damage 0
-Phone Use.
Unit # 3 Cell Phone Not In Use at Time of Crash
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nftbi., ('ol1j5ion SR "81 WP'r::.t ROlmri i~ ~ two lnnf" ro~dVtlHY witJ
seed limit of 55 MPH. The crash location is a ramp from SR 11115 North Bound to SR
58l \Vest Bound in Camp Hill Boro, Cumberland County. The ramp is short and ends at
ncre e arrier 1 is appr x Jig .
collision the weather was sunn
possible obstructions.
FORM. AA-500 (12102)
PENNDOT COpy
~\ --.J .
COMMONWlEALTH OF PENNSYLVANIA
POLICE CRASH REPORTING fORM
AA 500 N I Police Use Oil!)'
hOI~lyqot\(,2
Page
I [ill] 0
(8) New
1111111111111111111111111
Crash Number
R
Changel
Continuation
22
Trailer began to jack knife. After initial impact Unit # I was then knocked into Unit # 3,
still stopped and waiting to safely merge onto SR 581. Unit # 2 was now out of control
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Operator # I had to be removed from her vehicle with the assistance of passing motorists
and Fire Dept Personnel. Unit # 3 final rest position was on the on ran1p to SR 58\ rom
H/IS, <1llht: :,aTTn:~-puiIll ur ilIlpi:1d wiLli Unil #- 1.
For further details relative to the examination of the hvsical evidence refer to the
supplemental report attached to this report completed by State Police Crash
econs fue lOntS rooper JNZER.
U on this otlicer's arrival at the scene this officer observed the followin
evidence:
. er-ofUnit # 2 "lId conCH:
Unit # I had severe damage to both drivers side and passenger side
Operator # 1 was standing out of her vehicle and had a minor cut on her leg
er side front of Unit # 2 from im act with concrete
Damage to concrete Barrier from impact with Front Passenger Side of Unit #2
Damage to Top of Bridge Pillar from impact with Trailer of Unit # 2
L
FOOO 0 ~ (t.2JM)
~E~~I:OT COPY
--1,
-----1__ --
.
<Xl
III ~ 11II11111' 1I111111111~
Crash Number
I
COMMO~WEALiH OF PENNSYLVANIA
POLICE CRASH RIEPOIRTING IFORM
AA 500 N I Police Use 1t 0 l - \ '-\ q 0, 1 ~ 2.
22
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Continuation
Narrative and additional witnesses:
Interviews:
Operator # 2 NO STATEMENT POSSIBLE
from SR 11115 north to SR 581 West. STEIRER was waitin for a break in traffic and
for the vehicle in front of him to merge onto 581. While stopped on the ramp, STEIRER
wa C e as a W I e UIC passe 0 1m an e ue Ie p rue In ron o. nTI,
Rd-theR-entered-tRte-tr-affie--witheut-step~EIR-ER-stated-that-the-white.car-erosse .
directl 'into the ath of a Tractor Trailer that was already traveling on SR 581 We~t
Bound. The car then struck the Tractor Trailer. After initial impact with the Tractor
ral er t e tme pus e t e car mto t e nvers SI e rear 0 s ve Ie e.
S~EHtE-R-watehed-as-tlle T 1 a GtorTnriJer-then-stid-on
alTieLaLthe_ha5-e.-nLthe.hridge_SIEIRER..stated th~t the Trllck imme .
He stated that the Truck separated from the trailer and the truck slid along the concrete
barrier before coming to rest. STEIRER then saw the white car that initially passed him
.. .. .. ..
Itness # 1
.?
YUNKER was Interviewed on Scene 07/28/05 at 0815 hrs. YUNKER was driving the
Blue Pick Up Truck that was stopped in front of Unit # 3 on the ramp waiting to merge
a i \
, l:mit-#Jj~-behind him. YUNKER di
FOR~j It AA-6OON (1~
PE"\':~DOT COPV
._~ .
-..--
I
QO New
III ~ 1111111111II~11I11111
Crash l'tIumber
I
COC\fJMOOOWEAlLiH (W /lI'E""NSVLVANIA
lJ>>OUa mAS~ RlE~LnDNG IFORM
AA 500 N I PdXrU5e~O' -I~ ~ cr, ~ 2
22
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Continuation
~rrative and additional witnesses:
Tractor Trailer trik
began to slicPout of control. He stated the truck struck the concrete barrier along the base
o ten ge an a most immediately caught fire. The trailer from Unit #2 then pinned
Witness #2
Terrie Lee FETROW
Witness #3
Denise ROBETIEFRY
door but were also unable to open the door.
Fmt:J 0 AA<<C..l (1~
pa.:.\!;)OT CO?V
..--1 .
. -
~ New
11111111~11 U 1lIIIIUIIlI
Crash Number
I
CO~MONWEAlTH OF PEh'lNSYLVAMIA
POLICE CRASH RIEPORTDNG FORM
M 500 N I Police USe On~
\-\ 0\ - '4 C\ q, ~ (.2..
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Continuation
Narrative and additional witnesses:
Operator # 2 was pronounced dead on scene 07/28/05 by Cumberland County Chief
Deputy Coroner Todd ECKENRODE. See attached Coroners Report for case 0 death.
Troo er Mark DEAN Troo H Harrisbur Forensic Services Unit res onded to and
Photographed the Scene. See attached Supplemental.
f
this incident. Supplemental to follow.
Res
EMS and Fire De artments:
FIRE DEPT
ree iCe Ire
Ca.mp Ilill fire
West Shore Fire
Hampden Twp Fire
Upper Al en Twp FIre
thp. st:;ttlon r.opy ofthi" r
FORa I AA60CJ ~
P~~NDOT COpy
- --. - j. -- - -
.
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COMMONWEALTH OF Pl: '.SYlVANIA
POLICE CRASH REPORTING FORM
Case Closed Reportable Crash
DYes 0 No 0 Yes 0 No
~
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o Change'
ContinuatJon
11111111 Itll lllll 11111111
Crash Number
,
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Police Agency Patrol Zone
~~
Investigation Date (MM-DO-Y'NY)
Illil-[g]81-~
Badge Number
/.J~-4J I ~
Badge Number Approval Date (MM-DO-YYYY)
I ITIITI ITJ-OJ-DID
Municipality Municipality Name Day of Week
I ITD I OSun OThu
o Mon 0 Fri
~ NOJO 01 Units 0 I cr I ITJKilled* ~~~pf:ie 0 Tu~ 0 Sat
L-!.-L..l.-J Form F) 0 Wed 0 Un~
Workzone(1f Yes, Comp{ete 0 Yes 0 No School Bus 0 Yes 0 No School Zone 0 Yes 0 No ~ PENNDOT 0 Yes 0 No
Form M. SectIon 29) Related Related Maintenance
&iI1n..". ection Type 04 Way Intersection 0 .Y. Intersection 0 Multi-Le9 0 Off Ramp 0 Railroad Crossing ~ OJ..
3 ~. . . ,Intersection ~
~ I 0 Mldblock 0 .r Intersection 0 TraffIC (Irclef 0 On Ramp 0 Crossover 0 Other
_ ~ : Round About LQ Se<2 ~~ill(,
, I R()Ute Number Segment (Optional) Tr~vel Lanes Speed Limit a North House Number (if applicable)
\11 [Ill] DID OJ rn .g 0 South ITIIIIJ
~! Street Name Street Ending ~ 0 East For Mid-blOCK crashes only. Use
4 ~l rn 1:0. 0 West postal HOu~ Number and make sure
.1 u , 0 Unknown Principal Roadway Street Name is
.E : filled in If using this option
.., Bmde
r~Jl Sjgning 0 ~~~[Si~~~pike) a JE:~:st) 0 ;~~Pike 0 ~~~~wa.Y 0 ~g~dty 0 ~~s~lr:~ad 0 ~~~dte 0 ~~;~wn _
[111] ~ Segment (Optlonall Travel Lanes Speed lim;' ~ g ~:~~
I'" c L.L.L....LJ DID CD CD J! 0 East
5 ~ ,~! 't Street Name Street Ending ,~ 0 West
~l ~ OJ 0 0 Unknown
\1:' .2 ~ 0 Interstate 01urnpike 01urnpike 0 State 0 County 0 Local Road 0 Private 0 Otherl
II :11 ~ S.i9111D9. (Not Turnpike) (EastIWest) Spur Highway Road or Street Road Unknown
r' -I. '. Intersecting Rt Hum Or Mile Post
ill i i DID DIJ.D
-! e .a Or Intersecting Street Name
c: u Please c:
j ~ Enter !J
o Information
6 E CD for BOTH
e ~ landmarks
~ I ~ if Using
~ '[ of This Option
~ ;
S:
j
~ Degrees Minutes Seconds Degrees Minutes Second~
1 ~I Latitude: OJ o]:OJ.LD longitude: - OJ rn:[]]. m
M5001
tI (J
Agency Name
I lit- Smrc
Dispatch Time (mil)
~
Reviewer
r
/bL I C?
AlTival Time (mil)
101810 101
Precinct
II fi1~S&~JS
Investigator
I /111<. /J7A/!~
County County Name
! ITJI
2 0 Crash Date (MM-DD-YYVY)
~ -OJ-DID
l-
.... Intersecting Rt Num Or Mi'e Post
~ DID DIJ.D
~ Or Intersecting Street Name
II:
III
.J
~I 0 North feet
~ 0 South QI=cTI
St Ending ~
IT] 0 East Or Mites
~ o West m.D
~I 0 North Distance From Crash
GI 0 So th Scene to Landmark 1
St Ending ~ 0 u (For Crash between
IT] East Landmark 1 and
i 0 West Landmark 2)
a::
0/
:1
~'i
...\
9 ~l
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Traffic Control Device
o Not Applicable 0 Traffic Signal
o F~ashing Traffic 0 StOP Sign
Signal
o Yield Sign
o Active RR Crossing
Controls
o Passive RR
Crossing Controls
o Police Officer or
Flagman
o Other Type reD
o Unknown
rm Functionirtg
o No Controls 0 Device Functioning
Improperly
o Device Not 0 Devi,e Funcfloning
Functioning Properly
Emergency
o Preemptive
Signal
o Unknown
Une..SJ..flBfII-(1f . Not Applicable', skip rest of the Lane Oosure section)
o Not Applicable 0 Partially 0 Fully 0 Unknown
~ 0 North
Dm1im 0 South
o East
o West
o North and South 0 All
o East and West (N,S,E,W>
Icidfk. Yes 0 No 0
Detoured Unknown 0
~ 0 < 30 Min. 0 30-60 Min. 0 1-3 hrs 0 3-6 hrs 0 6.9 hrs 0 > 9 hours 0 UnknOwn
FOh:.'lll AA.e;:L. ~
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22
Page ~ ~w llllllnlllllllmllll ~I
I ~ 0 ~~~~~ation
Crash Number
-,
--1 COMMON\ftf~LTH Of PEi\lNSVLVANDA
~" .. 'allele CHASM REPORTING FORM
AA 500 N I Police Use Only
HO' - IL/qq, ~'Z-
I PHOTOGRAPHED THE ABOVE MENTIONED SCENE ON 07/28/05 AT APPROX. 0820 HRS.
FORENSIC SERVICES UNIT.
2005-0448.
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BXll1B11 C
Il05805 REV 1/05 I ,
This is to certify that the information here given is correctly copied from an original certificate of death duly filed with me \lS
Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
No.
R:-~.~~..~~
Local Registrar
Fee for this certificate, $6.00
p
11851883
OCT
5 2005
Date
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COMMONWEALTH OF PENNSYlYANIA. DEPAIl11IENT OF HEALTH · VITAL RECORDS
CERTIFICATE OF DEATH
(COroner)
~~:;:7 N AI....
..
PERIWlENT
IIl.ACK INK
S1JIII'E FU NUNllEIl
sex SOC1AL SECURITY NUloIIIER
2. Male 3. 207-58-2926'
8IRTHPl.ACE ten and PLACE OF DERH (QlICk any one' _ ir1IlrUclions onolier!lide)
SlIMe '" forlign Counlry) HOSPI1l\L:
July 24.1962 Carlisle PA ~O
7. .. . ., ...
I'ACIUTY NAME (1Ino1 irlMiIuIicn. give ~ end runbell
PA Rt. 581 W/B, M/p 5.5
DATE OF DERH (MonIh,!'ley. ~
July 28, 2005'
~~
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prx. DATE PRONOUNCED DEAD (Marllh.!'ley.-)
24. A. M. 25. July 28; 2005 ..
%7.1W1T I: :::-':-~QIMe=~~_"-"''''''Do 11lll........_olclylng.__Cllrd8correopR/aly-. _",_IaIln. !::=....
:---
Blunt Force and Thermal Trauma i
DUE 10 (OR I<S A.CONSEQUENCE OF):
Motor Vehicle Crash with Fire
DUE 10 (OR I<S A CONSEauENcE OF):
NoD
IWIT.: 0Iher""""" CIlIlIIiIcn~Io-' bul
11lll--.o In"'~ _s;v.nln PMTI.
DUE 10 ((lR I<S A CONSEOUfNCE OF):
... ~ NoD
-.. 0
-.. }If..
SuIcide D
PencIng 1..-IgIIion
CcUdl1lllbe_
Hill, PA
'MEDICAL EXAIIIINER/CORO
On the bMla of eumin8Uon Mdlor InVMllgallon. In mr opinion. CIAIIIOCCUl'Nd.the time. ~. IIIId ......1IIId due to the C8UW(IJIIIId
----......................... .........................................................................
31L
REGISTIWl'S SlGIUlI"URE AND NUIotIIER
~. ~~~
14, \ ~I \ I() I
Coroner
DATE llIGNED~. c-r.. ~
3111. October 3. 2005
AND ADllRESSOFPERSON WHO CXlMPlETED CAUSE OF DERH
(ltem27)TypeorPrtnl Michael L. Norris. Coroner
~6375 Basehore Road. Suite #1
~a Mechanicsburg. Pa. 17050
ORE FIlED (Monlh. Day. ~
,OO,~ ~Qo.s-
34.
'PRONOIiNaNG ~CERTlFY1NG PtIYSICIAH (Physic:ien _ pIonounc:ing_ endcortilyWlg to.,... ol._)
To.,.....oIMY~.duIIl__........_. ondplilcle....._k1.,........Jond_._..........................
B~1l1131ry. D
J
~GAL e~SUREDS COPY
MARIETTA, PENNSYLVANIA 17547-0302 RENEWAL OF POLICY PAE 0578208
CASE JOYCE G
118 HOLLY DRIVE
MECHANICSBURG PA
17055
3- 4
INSURANCE , SURETY INC
3045 MARKET STREET
POBOX 698
CAMP HILL PA
05
17011
VEHICLES COVERED
UNIT ST TER YR MAKE
002 PA 027 04 BUICK
MODEL SERIAL NUMBER SYM CLASS MAX LT CHG DATE
CENTURY C 2G4WS52JX41218962 08 882310 04/12/05
INSURANCE IS PROVIDED WHERE A PREMIUM IS SHOWN FOR THE COVERAGE
COVERAGE
LIMITS OF LIABILITY
PREMIUMS
UNIT 2
YES
FULL TORT OPTION APPLIES TO THIS POLICY
LIABILITY $100,000 EACH ACCIDENT
UNINSURED MOTORIST $50,000 EACH ACCIDENT
(NO STACKING OF COVERAGE)
UNDERINSURED MOTORIST $50,000 EACH ACCIDENT
(NO STACKING OF COVERAGE)
MEDICAL EXPENSE COVERAGE $10,000
OTHER THAN COLLISION LOSS LESS $100 DEDUCTIBLE
COLLISION LOSS LESS $500 DEDUCTIBLE
INCREASED TRANSPORTATION EXPENSE COVERAGE
$30 PER DAY/MAX $900
TOWING , LABOR $75 ~IMIT
04/20/05
A~~ President
CONTINUED ON REVERSE SIDE
PL-2 (9188)
REFER TO FINAL PAGE FOR BILLING NOTICE
. ,-;;. ;:~'~!l"i" ~61'
." ""':' ._ ,.-.... ........,1.
't:' \,,) ....; 'w"
r "..
, .
/~,<EGAL e~SUREDS COpy
.t1IETTA, PENNSYLVANIA 17547-0302 RENEWAL OF POLICY PAE 0578208
PERSONAL AUTO POLICY - PREFERRED RATING PROGRAM
AMENDED DECLARATION EFFECTIVE 04/12/05
SUPERSEDES ANY PREVIOUS DECLARATION BEARING THE
SAME POLICY NUMBER FOR THIS POLICY PERIOD
.
: A.M
10/01/05
CASE JOYCE G
118 HOLLY DRIVE
MECHANICSBURG PA
17055
INSURANCE & SURETY INC
3045 MARKET STREET
POBOX 698
CAMP HILL PA
05
17011
TOTAL BY UNIT 370.00
TOTAL TERM PREMIUM
A $37.00 ACCOUNT CREDIT HAS BEEN DEDUCTED
IN DETERMINING YOUR TOTAL PREMIUM
15% ANTI-THEFT DISCOUNT APPLIED TO UNIT 2
30% PASSIVE RESTRAINT DISCOUNT APPLIED TO UNIT 2
ANTI-LOCK BRAKING DISCOUNT APPLIED UNIT 2
DRIVER ID DRIVER NAME
01 JOYCE G
LICENSE NUMBER
17966007
BIRTH DATE
07/18/31
APPLICABLE FORMS
FORM # DATE UNIT FORM # DATE UNIT FORM # DATE UNIT FORM # DATE UNIT
PPOO01 06/94 ALL PPD0151 01/97 ALL IL0910 01/81 ALL PAEOOl 12/89 ALL
PP1301 12/99 ALL PPD0421 06/02 002 PPD0417 06/02 002 PPD0302'10/96 002
PP0303 04/86 002 PP0551 06/94 002 DAACP 02/92 002 PP0305 08/86 002
LOSS PAYEE FOR UNIT 1002
MEMBERS 1ST FCU
PO BOX 24046
FT WORTH TX 76124
04/20/05 VEHICLE DELETED
----- STATEMENT OF ACCOUNT -----
od~~ President
------- PAYMENT PLAN ------- PAE0578208 07 05
PL-2 (9188)
TRANSACTION PREMIUM
TOTAL PREMIUM
TOTAL AMOUNT DUE 05/06/05......
TOTAL AMOUNT RECEIVED
ACCOUNT BALANCE
THANK YOU FOR LETTING US SERVE YOU
'. ~1" ~.,.,. 2
J?,~J '" '... .' '. "; .l!.l-J
O' '-' ....s -.; -
EXHIBIT E
~,
DONALD H. NIKOLAUS
JOHN P. HOHENADEL
MATTtEW J. CFEME. JR.
JOHN F. MARKEL
PAULA D. MUNSON
RICHARD G. GREINER
JEFFREY A. MILLS
MDiAEL S. GRAB
MICHAEL A. VANASSE
JOSEPH G. MUZIC. JR.
USA J. McCOY
BERNADETTE M. HDtENADEL
ANTHONY MARC HOPKINS
JOHN C. HCJH:NADEL
WANDA S. WHAFE
NADIN: C. BELL *
GLORIA A. SHATTO
NIKOLAUS & HOHENADEL. LLP
ATTORNEYS AT LAW
212 NORTH QUEEN STREET
LANCASTER, PA. 17603
717/299-3726
FAX 717/299-1911
September 5, 2006
David Wisneski, Esquire
Navitsky, Olson & Wisneski, LLP
2040 Linglestown Road, Suite 303
Harrisburg, P A 17110
Re: Paul E. Stone and Barbara J. Myers, as Co-Administrators of the Estate
of Kenneth E. Wallace, Deceased, v. Lisa J. Case, as Administratrix of
the Estate of Joyce G. Case, Deceased
Cumberland County CCP No. 2006-2166
Dear David:
COUNSEL
JOSEPH J. LOMBARDO
327 LOCUST STREET
COLUMBIA, PA. 171512
(717) 6944422
FAX 717/684-6099
* ALSO ADMITTED TO
NEW YORK STATE 9AR
Donegal Mutual Insurance Company wanted me to make it clear that they are
tendering the $100,000 combined single liability limit of the policy covering Joyce G. Case in
this matter with a date of loss of July 28,2005. A copy of the applicable declaration sheet is
attached. Again, this offer to settle is to resolve all claims within the $100,000 combined
single liability limit.
If you have any questions, please do not hesitate to call.
JGM/des
enclosure
cc: Douglas Y ohe, Esquire
Keith Eisenhart, DMIC
(CHum No. P AE0578208(5A))
BXlllBll f
AFFIDAVIT OF NO ADDITIONAL INSURANCE
I, Lisa J. Case, as Administratrix of the Estate of Joyce G. Case, hereby depose and
affirm that Joyce G. Case had no liability insurance policies, including any excess coverage
policies or umbrella policies, that would provide liability coverage to her or her Estate for the
injuries and damages arising out of the motor vehicle that occurred on July 28, 2005, other than
the Donegal Mutual Insurance Company Automobile Insurance Policy #P AE 0578208, effective
from April 1, 2005 through October 1, 2005, which had combined bodily injury and property
damage liability limits of $1 00,000.00 per accident.
I verify that the statements made above are true and correct to the best of my knowledge,
information and belief:
Date:-1 \ ').0 \. 0\
Sworn to and subscribed before me this
~daYOf-4rJ. J ,2007.
N~{$/J.L p. ~A )
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Allstate Insurance Company
Policy Nllmblr : 0 D1 037225 01/13
Policy Enlme Date: Jan. 13, 2005
Your Agent: Singleton Ins Ay In (717) 43&-3428
COVERAGE FOR VEHICLE # 1
1994 Chevy Irk C1 Series
COVERAGE LIMITS DEDUCTIBLE
Automobile Uability Insurance -- full Tort
· Bodily Injury $100,000 each person Not Applicable
$300,000 each occurrence
· Property Damage $100,000 each occurrence - Not Applicable
Medical Expenses $5,000 each person Not Applicable
Income Loss
Each person up to $5,000 maximum benefit Not Applicable
Subject to $1,000 monthly maximum
Uninsured Motorists Insurance $25,000 each person Not Applicable
Full Tort I Stacked Umits $50,000 each accident
Underinsured Motorists Insurance $25,000 each person Not Applicable
Full Tort I Stacked Umits $50,000 each accident
Auto Collision Insurance Actual Cash Value $500
Auto Comprehensive Insurance Actual Cash Value $50
Total Premium lor 94 Chevy Trk C1 Series
PREMIUM
$72.34
$64.63
$26.71
$4.36
$24.13
$21.18
$78.54
$34.84
$326.73
DISCOUNTS
Multiple Car
Utility Car
Your premium for this vehicle renects the following discounts:
$64.40 Multiple Policy
$36.55 Premier Plus
RATING INFORMATION
This vehicle is driven over 7,500 miles per year, 3-9 miles to work/school, unmarried age 42
$17.96
$70.36
lntoI1ndun as 01
...., 6. 2lIOS
Page 2
PAIl1UMO
Policy Nlmblr : 0 01 031225 01/13
Policy Effective Dale: Jan. 13. 2005
Your Agenl: Slnglelon Ins Ay In (711) 438-3428
~Ailstate.
'lbu"re In good hands.
,lIstate Insurance Company
COVERAGE FOR VEHICLE # 2
1976 Pontiac Grand Prix
COVERAGE
UMITS
DEDUCTIBLE
each person Not Applicable
each occurrence
each occurrence Not Applicable
each person Not Applicable
maximum benefit Not Applicable
monthly maximum
each person Not Applicable
each accident
each person Not Applicable
each accident
PREMIUM
Automobile liability Insurance -~ Full Tort
· Bodily Injury $100,000
$300.000
· Property Damage $100,000
Medical Expenses $5,000
$57.88
$51.70
$24.57
Income Loss
Each person up to $5,000
Subject to $1,000
Uninsured Motorists Insurance $25,000
Full TortI Stacked Umits $50,000
Underinsured Motorists Insurance $25,000
Full Tort I Stacked limits $50.000
T etal Premium for 76 P,aac Grand PriI
$3.54
$24.07
$21.20
$182.96
DISCOUNTS
Multiple Car
Premier Plus
Your premium for this vehicle reflects the following discounts:
$46.21 MUltiple Policy
$34.42
$8.79
RATING INFORMATION
This vehicle is driven over 7,500 miles per year, for pleasure, adult age 42. with no unmarried driver under 25
iiiiiiiiiillllllllllllllllllllllllllllllll
InIonrIIIIIn as ..
....., 5. 2IID5
Page 3
PMtMMO
E~111Bl't 11
MAR. 29. 2007 12: 12PM
I . .
ALLSTATE INS. Hbg, Pa, 17112
~ BA~lUS.UIlG
~Jf5 I'LAN~ DRlVB, SCl17'r 4QOO
~llstate.R4~RlSaVRG PA l1.112-2'~5
VIun! ., gOld hWIlII.
111.11I.. .1,"11",11I1...1 .1",1.1..11. .1..1.1.1111.1," 1..11
NAVITSKY OLSON , WISNESKI
2040 LINGLBSTOWN RO
8m 303
HARRISBURG PA 17110-9568
July 21, 2006
INSURED; KENNETH EUGENE WAlLACE
DATE OF LOSS: July 28, 2005
CLAIM NUMBER: lSS'2347OS B27
Reference: Estate ofKcoaeth WaJlac;c
NO. 5707 P. 2
PHONB NUMBER: 800-726-8890
FAX NUMBER.: 717.S40.7S40
OmCE HOURS: MOIl - Pri 8:00Im . ':3Opm
Dear Mr. WimewskJ:
This letter is to confilm 1hII we ... otTeriDt our UIM policy limits of SSO.OOO. F.admr.d p1ase ftDd alae JII'OPC)SeCI VIM
reJeue. AI you bow. siDcc Ihis maua- mwlYes a faII1it;y the daim will need to be court apwa-ovecl Once _ receive the
WUi1's approval we will p-omprJy release the $dlemeet draft.
As ah~.ys, thank yoa far your cooperation with this matta-.
Sincerely,
Tim SbaffPJ
Tim Shaffer
717~S40-7S'S
AIlNte msuraucc Compuy
GfNIOOI
IS5523470S B27
EXIlIBlrr 1
MARTSON DEARDORFF WILLIAMS & OTTO
MDW&:O
INFORMATION.AD~CE.ADvOCACY
ATTORNEYS & COUNSELLORS AT LAW
TELEPHONE
FACSIMILE
INTERNET
(717) 243-3341
(717) 243-1850
www.mdwo.com
WILLIAM F. MARTS ON
JOHN B. FOWLER III
DANIEL K. DEARDORFF
THOMAS 1. WILLIAMS*
Ivo V. OTTO III
GEORGE B. FALLER JR.*
CARL C. RISCH
DAVID A. FITZSIMONS
DAVID R. GALLOWAY
CHRISTOPHER E. RICE
JENNIFER L. SPEARS
HILLARY A. DEAN
10 EAST HIGH STREET
CARLISLE, PENNSYLVANIA 17013
"BOARD CERTIfIED OVlI. TRIAL SPECIALIST
October 10, 2005
David S. Wisneski, Esquire
Navitsk-j, Olson & \Vis:leski, LLP
2040 LinglestonRoad
Suite 303'
Harrisburg, PAl'll 00
RE: Your client: Estate of Kenneth E. Wallace
Date of Loss: 07/28/05
Our File No.: 9500.359
Dear Dave:
Our office represents Giant Food Stores, LLC. Libby Christman, the Director of Risk
Management~ has referred your letter of October 6, 2005 to my attention. Pursuant to your request,
I am forwarding you a copy of the Certificate of Insurance which I believe' was issued on
December 8, 2004. As you can see, there is no coverage for uninsured or underinsured motorist
coverage. I am also enclosing a copy of the Pennsylvania Rejection of Uninsured and Underinsured
Coverage. These are dated December 1, 2004.
It is my understanding that the vehicle which caused this accident was operated by Joyce G.
Ca~e. It is further my understanding that she was insured by a oolicv of insurance issued by Donegal
with a $100,000.00 in cOlnbined single limit. Steve Spotts is the Donegal adjuster. Their claim
number is P AE 057820840. In the meantime, if you have any questions, do not hesitate to contact
me.
Very truly yours,
GBF/mam
Enclosures
~ON DEARDORFF WILLIAMS & OTTO
~aller, Jr.
CC: Mr. Kevin McCoy (via e-mail)
Ms. Lizabeth Christman (via e-mail)
F:\FILES\DA T AFILE\MAC9500\Current\359Idw I
I N FOR MAT ION · A D V ICE · A D V 0 CAe y SM
08/12i2005 15:~O FAX
JUL. L~. LOU~ 1 U: 11 AM
NO. 6 21
IgJ002 ·
P. 3
~ .
ACOR{l CERTIFICATE OF INSOR)(NCE ISSUE DATE
1~
PAODIJCl;R ". tlJrtHlade 13 lllUC!d.. Q maUer gf InMmatlDrl ~ and cgderv no ~
upon theCeftiioD Helder. This CertiIadB does. nd amend.. .\'er1d or the
MQGRIpt:. SElSSLS & WIl.LlAMS, aNC. CO\I.21J91 ldbrdlld by~t. paIdea b8kw.
P.O. Box1026S
BirmIngham, AL $620~ OOIlPANIm AFFORDING COVSAME
205-252-9671
COmpany IlInciB Union ImlUruceCoqmhY
A
INSUR!D . Company At>> Amctilgan IdIWl'llnclO CDmpnn)'
U.S. FOODSERVICE. INO. B
AND ALl. WHOlLY OWNS) SUBSIDIARIES Oomrny
8755 PATUXENT WOODS ORNE
OOLUMB1A, MO 21048 Company
D
Company
E
",.Is '\0 ~ 1h1Il th.~.. of Inw1'al1l;:e describfId hDtdn hiM bftn 1ssued 110" Inand named herel" for ttw P*r I*focIln~ Ngln~~
my I\MPJfllment.1r:Irm or condtlon of ~ or ctherdocum.ntVi4th respect =whk:h iNs OIdfieate may be -- of m:ay peltllin, th&s inecnnw ~ by
h pet_ ~ ..... ie suJ::;Ic:t>> 8I1ht 1ef'mI. cordIIon.lIhd ~ d such ~ Urnita shcMn mar t1BVIlI tiwn Nducad ~ patd dah....
~ ,..". OJ: lum IIIAU"!III' POUO\' NUISER I!FFEOTMi UIIITB OF LlABLITV
IIUN
A GENERAL UABIL.IlY HOO G1 99CH-72S 121011B104 EACH OCCURRENCe $ 2,.OOo.OQC
IJI am"... ...... LiiII:IIII:r 1M)1J20OS FIfE DMWSiS $ aiO,ooc
COt..u..:t.III~ MEtlIOAL exPeNII I S.QOC
Dawr-'.. ~ PratMllan
C I'!M. N<<J ADVEFITI81NO lNolJIW $ 2.OQO.aOt
[J G~.at AGGREGATE $ 2.QOOJ)O(
a..r.t ~Limi\""_ per. PAODUC"nI AND COMP. OPEI\ AGG. $ ~oooyOOC
II PalbJ 1:1 Ptq~l:I~
S j,UT'OUC)BILS LJABIUTY ISAH07l4e~21 1a'0112OO4 OOfl@lNiD stNGLK LIMIT I s.ooomc
I!IPnr ~obIo 1~1/2O';S BODILY I NJURV .P......)
CAlI 0IIIhId AtIIan1aOl 1!tF-IfSURED 1fO~ eoDlL V I NJUAY flY ). ...
CsncuBdMomabIM pI'I't8CA\.DMlAGe PROPERlY DAMAGE ~er 8CdcIetIl
II....~
iii *~_...d JulElnebll8. OOVEAAGE COM.-.........-......SIVE
[J COWSION
[WORKERS' OOMPENSAT1CJ!t_ we Umft: I I ot.... I I
AND EIlPLOYER8' LlABlLrTY EL IiACS-I A :X~Derr
a OlBEAS ~, tesdl.mdcnel
1m. Pdlev Urit'I
exCESS UA811.11Y EACH OCC LB 'RENeE
[J 0xuIwD8 cCWm. Mlde ALlBRSClATE
III E: '111e CerliIic:Ut Holder i. indudeG CD AddifoMllnlLlmd _ r.quited by wrHtvn contra:WbJect to pollq 'lenn2s. GOl1c1t1c:m & 8xdu....
uGt d SLbIidlllft. end CuDm1er NumN'llI
US FaodseMce 1m.. euatt S61073,Me01~,M661~S
AmBrU:M SeIeI 09~ lna. - CUDtIGOSOB6
Giant Food Ston.IhG. . Oual fi19582
Joceph Webb FoodII- CLmt.12B46B
US FoocfHMat of Butrllo Inc. . 0Lm #ee5778
ttI:JnDrued n~ t'lI!!Iti.t\
~ICATE HOLDIaI ~OULD AN'{ OF THE ABOVE DESCfnBED POLICIES BECANCEW!D SeFOFtE
lliE EXPIRATION DATE 'THEREOF, THE INBUFIEA WILL !NDEAVO'ATO MAIL ao
CAYS WAJTTe:N I'OTICETO THe C~TE HOLDeR NAMEO TO THE I.EfT,
BUT A t:AlWRE TO MAIL 8lJCH N011CE SHALL IMPC€F! NO OBLIGA'TIC>N OR
UAan.1T'f OF Atl'f KIND tJfON Tl-Ie ISSUI!R, COMPANY, ITS AQENTS OR
REP'AUENT'AT\ves..
PENSK6 TRUCK LEASING 00 LP Authorized Represel'ltBive
AnN: MIKE WATERS/CAROl- PARKERlPAULA ~)... IU~ 'A ..' ..
Q~WN
'...... ,;'
08/12/2005 03:53PM
m
ACE USA
Pennsylvania
Rejection of Uninsured
Motorists Coverage
ApplicanU
Named Insured Ahold Americas Holdings, Inc.
Policy No. ISA 907942321
PLEASE READ CARE FULL Y BEFORE MAKING YOUR DECISION
Pennsylvania law does not require that you purchase uninsured motorists coverage. We are, however, required to include it in
your policy unless you sign and date this waiver below under paragraph A. Paragraph A gives you a brief description of
uninsured motorists coverage.
REJECTION OF UNINSURED MOTORISTS PROTECTION
By signing this waiver I am rejecting uninsured motorist coverage under this policy, for myself and all relatives residing in my
household. Uninsured coverage protects me and relatives living in my household for losses and damages suffered if injury is
caused by the negligence of a driver who does not have enough insurance to pay for losses and damages. I knowingly and
voluntarily reject this coverage.
Jjy~~~~~
Signature of First Named Insured
DEe 0 1 200~
Date
Instructions to Agent: The First Named Insured shown (or to be shown) on Item 1 of the Declarations must sign this form in order
for the rejection(s) to be valid.
OA-4P62d (09/03) Ptd. in U.S.A.
m
ACE USA
Pennsylvania - Rejection of
Underinsured Motorists Coverage
Applicant!
Namedlnsured Ahold Americas Holdings, Inc.
Policy No. lSA H07942321
PLEASE READ CAREFULLY BEFORE MAKING YOUR DECISION
Pennsylvania law does not require that you purchase underinsured motorists coverage. We are. however, required to include it in
your policy unless you sign and date this waiver below under paragraph A. Paragraph A gives you a brief description of
underinsured motorists coverage.
REJECnON OF UNDERiNSURED MOTORiSTS PROTECTION
By signing this waiver I am rejecting underinsured motorist coverage under this policy, for myself and all relatives residing in my
household. Underinsured coverage protects me and relatives living in my household for losses and damages suffered if injury is
caused by the negligence of a driver who does not have enough. insurance to pay for losses and damages. I knowingly and
voluntarily reject this coverage.
:?J~4d/wd ~
Signature of First Named Insured
DEe 0 1 200"
Date
Instructions to Agent: The First Named Insured shown (or to be shown) on Item 1 of the Declarations must sign this form in order
for the rejection(s) to be valid.
DA-4P61d (09/03) Ptd. in U.S.A.
EXlllBlrr J
ESTIMATE OF INFORMAL ACCOUNTING OF THE
ESTATE OF JOYCE G. CASE
ASSETS:
Real Estate located at 118 Holly Drive,
Mechanicsburg, P A (see attached HUD-1)..........................$ 64,743.79
Vanguard Mutual Fund............................. ........ ......................... ...$ 3,024.91
Car Insurance Claim........... .............. ... ... .......... .......... ........ ..... .... ...$ 2,000.00
Donegal Insurance Reimbursement .............................................$ 1,100.00
Personal Property sold at auction....................................................$ 500.00
Union Account.. ...... ........... ..... ........... ....... ...... ........ ........................ ......$ 26.20
Total................... ................. .......... .......... .... ....... ...... ......... ..... ...$ 71,394.90
DEBTS AND DEDUCTIONS:
Administrative Expenses ... .... ........ ....... .......... ........ ......................... $ 328.00
Attorney Fees
. Jeff Y offee ... ..... ......... ....... ........................ .... ............ .......... $ 485.00
. Latsha Davis Yohe & McKenna, p.e.......................... $ 7,000.00
Baron Enterprises Gunk removal)................................................... $ 435.00
Black's Detachable (dumpster) ..... .......................... ........................ $ 427.15
Chase - rental car fee ........................................................................ $ 800.00
Prepayment of Partial Inheritance Tax ....................................... $ 3,750.00
Executrix Fee...... ....... ..... .... .... ... ........ ....... ....... ....... ........ ........ .... ..... $ 6,000.00
Funeral Expenses .......... ............. ....... .... ................ ........ ................. $ 9,452.80
House Related Expenses ............................................................... $ 4,747.58
Utilities (electric, water, sewer, telephone) ..........$1,953.86
Insurance ... ........... ......... ................... .... ...... ..... ......... ....$ 469.00
Mortgage................... ............. ...................................$ 1,863.72
Yard Maintenance ........ ............. ....................................$ 90.00
Final House Oeaning .................................................$ 371.00
Real Estate Appraisal............... ....... .............. .......... .................. ......... ..$ 75.00
Total............................ .................... ....................................... ...$ 33,500.53
RECONCILLATION:
Total Assets:
Total Debs/Deductions
Net Estate Estimate
$ 71,394.90
($ 33.500.53)
$ 37,894.37
112008
" OMS NO 2502..0265 .,-...
A. .. B. I yt"e U~ LOAN:
.. 1.[ ]FHA 2.0FmHA . 3. [ ]CONV. UNINS. 4.DVA 5. DCONV; INS.
U.s. DEPARTMENT OF HOUSING & URB~. DEVELOPMENT 6. ~~~~~re~~,VF; 17... LOAN-NUMBER: :
. SETTLEMENT STATEMENT
8. MORTGAGE INS CASE NUMBER:
C. NOTE: This form is fu1f8Cd'to give Y9U a statement of setusJ settiemem costs. Amounts paid to and by the settiSment agent a1'8 shown.
Items roamed · :r wel8 paid outside the. clcising,' they are $hown here for Informational PUfPOSflS and are not included In the totals.
. .1.0 3IQ8 r118 HOLLY DRIVE.PFDJ118HOU.Y DRlVEI18)
O. NAME AND ADDRESS OF BUYER: E. NAME'AND ADDRESS OF SELLER: F. NAME AND ADDRESS OF LENDER:
Charles R. Fleltls Estate of Joyce G. Case, by. Lisa J. Case,
118 Holly Drive P~naIRep~entative
Mechanlcsburg, PA 17055
G. PROPERTY LOCATION: H. sEm.EMENT AGENT; . 23-1284840 . I. . SETTLEMENT DATE;
118 Holly Drive Wian, Zulli & Seibert
Mechanlcsburg, PA 17055 May 17, 2006
Cumberland Cou!"ty, Penns)1vanJa PLACE OF SE1TLEMENT'
109 LocustS1reet
HarrIsburg, PA 17101
~OF . '1rv.N~AC1l0N K &m:OFSELLER'STR}.~ION
11nn r.u..nl'l:~ FROM RIJVI:::R! ~_ ng,. , Tn ~CI Ice. .
101. eomract Sales Price' . 131,000.00 401. Contract Sales Price. '. 131,000.00 .
102. Personal Pl'Qperty 402. Personal ProDertv
103. SetUernent Charges to Buyer (Line 1400) 2.365.88 403.
104. 404.
105. 405.
'. ~" anvanca
106. Countynwp Taxes 05118/06 to 01/01/07 332.22 406. CountyflWP Taxes 05118106 to 01101107 332.22
. 107, Schoo Taxes 05118106 to 07101/06 221.83 407. School Taxes 05118106 to 07101106 221.83
108. Assessments to 408. Assessments- . to
109. . 409.
110. 410. .
111. 411.
. 112- 412.
120. GROSS AMOUNT DUE FROM BUYER 133,919.93 420. GROSS AMOUNT DUE TO SELLER '131,554.05
. 200. AMOUNTS PAID BY OR IN BEHALF OF BUYER: 500. REDUCTIONS IN AMOUNT DUE TO'SELLER:
201. DeDOSIt or earnest money 10.000.00 501. Excess.DeDoslt (See Instructions)
202. PrIncipal Amount of New Loan(s) . 502. Settlement ChargeS to Seller (Une 1400) 3.638.84
203. existing Joan(s) taken sublect to 503. ExIsting loanes) taken subJect to
.204.. 504, Paygff of first Mortgage to M&T Bank 54,262.28
205. 505. Pavoff of second Mortaaae to M& T Bank 8.857.49
206. 506; .
207. 507.. (Deoosltdl$b. as Droceeds)
208. 508.
209. 509.
.II.,.,jucoM'lantt: F'Or If9ms Unoalc1 BY seller . Aalustments For Items Un eller
210. Counly/TWP Taxes . to 510. CounlyITWPTBX8S to
211. SchoolTaxes to 511. School Taxes to
212. Assessrrents to 512. Assessments to
213. Sewer Charges 04101106 to '05118106 51.65 513. Sewer Charges 04/01106 to 05118106 51.65
214. 514.
215. 515,
216. . 516.
217. 517.
218. 518.
219. 519.
220. TOTAL PAID Byn=OR-BUYER 10,~1.65 520. TOTAL REDUCTION AMOUNT DUE SELLER 66,810.26
300. CASH AT SETTLEMENT FROMITO BUYER: . 600. CASH AT SETTLEMENT TO/FROM SELLER:
301. Gross Amount Due From Buver (Une 120) 133,919.93 601. Gross Amount Due To Seller (Una 420) 131,554.05
302. Less Amount Paid BylFor Buyer (Une 220) ( 10,-051.65) 602. Less Reductions Due Seller (Une 520) ( 66,810.26)
303. CASH ( X FROM J ( T01 B~ /. ) 123.868.28 603. CASH.( X TO) ( FROM) SELLER 64,743.79
The undersigned ~r"'/ L V~ ~~~y of pages 1&2 of this statement & ~Z\Ty r;: to herein.
8U)<lf · -? 7J c ~ ~ 'r>
. ~arles R. F elds' ./'.F . '. /EState of Joyce G. : fe,
'. . Personal Re resentative. .
~
p
HUIM (3-811) RESPA, 1-184305.2
, ...........
L. SETl'LEMENT CHARGES
.700. mT~ COMMISSION Based on Price S dJ1 0.0000 % PAID FROM PAID FROM
Division of CommissJoii (line 700) as Follows: BUYER'S SEU.ER'S
701.$ to . FUNDS AT FUNDS AT
702.$ to s&1TLEMENT SE1TLEMENT
703. Commission Paid at Settl8ment
704. . to
BOO. In;MS PAYABLE IN IIUN WI I n LOAN . .
801. loan OriQlnation Fee 0.0000 % to
802. Loan Discount % to
803. Appraisal Fee to
804. Credit Report to
805. LeAder's Inspection Fee to
806. Mortgage Ins. ADD. Fee to
807. Assumption Fee to
808.
809.
810.
811.
. 900. ~MS REQUIRED BY' t:"nI:D 1M
- 901. Interest From to @ $. ./day ( days %) .
902. MIP T ot/ns. for UfeOfLoan for months to .
903. Hazard Insurance Premium for 1.0 wars to
904.
905.
1000. RESERVES DEPOSITED WITH .
1001.~rdlnsunance mon1hs I $ - per month
1002.~ortgagelnsunance months I $ per month
1003. Countynwp Taxes .months ( $ . per month
1004. School T~ months I $ oer month
1005. Assessments . months @ -.$ p&r month
1006. months ~ $ per month
1007. . months @ $ . per month
1008. months @ $ per month
.1100. TITLE CHARGES
1101. SetUementorCloslna Fee to
1102. Abstract Dr TItle Search to
1103. TiUe Examlnatlon to
1104. 11l1e Insurance Binder to .
1105. Docu~ntPmparation to
1106. Notarv Fees . . to Wlon .Zulll & Seibert. .5.00
1107. Attorneys Fees to.
(includes above Item numbers: J
1108. Title Insurance to Commonwealth Land TItle Insurance Corroanv 912.38
(incluctes above Item nui11bers: )
1109. Lender's Coverage $
1110. owner's Coverage $ 131,000.00
1111. .
1112.
1113.
1200 MENT RECQRnINr.l .AND I
1201. RecordIng Fees: Deed $ 38.50; Mortgage $. ; Releases $ 57.00 38.50 57.00
1202. City/CountyTaxlstamps: Deed 1.310;00' Mortaaae 1,310.00
1203. State Tax/Stamos: Revenue Starnes 1.310.00: Mor1aaae 1,310.00
1204.
1205.
1300. ADDITIONAL SETTLEMENT CHARGe;
1301. Survey to
1302. Pest InspecUon to
1303. Overnight Man Fee to Wlon ZUlU & Seibert 25.00
1304. Auction Broker Fee to Chuck Bricker Auctioneer 1,715.00
1305. See addifl dlsb. exhibit to 100.00 531.84
1400. TOTAL SETTLEMENT CHARGES (Enter on Lines 103, Section J and 502, Section K) -. i A,365.88 3.638.84
By signing ~ 1 of this stalemon~ the slgnalol1es acl<nowledge receipt of a Ct1lffPn,.r~ ~W-
. ~~A~.
. . . ~4~- /
Certified to be a true copy. rJm&~~ ()
e nf Agent
( 118 HOU. Y DRIVE /1111 HOlJ. Y DRIVE /10 )
, I AD-[>>ITIONAL DISBURSEMENTS EXHIBIT . ".
Settlement Date:
Properly Location:
Charles R. 'Fields
Estate of Joyce G. .Case. by Lisa J. Case, Personal Representative
Wion. Zulli & Seibert
(717)232-1488
109 Locust Street
Harrisburg, PA 17101
May 17,2006
118 Holly Drive
Mechanicsburg. PA 17055
Cumberland County, P&nnsylvania
NOTE/REF NO
BUYER
SELLER
Buyer:
S&lIer:
Settlement Agent:
Place of Settlement:
PAYEE/DESCRIPTION
. Upper Allen TownShip Authority
Sewer Charges (2nd Quarter) ,
Marlin A. Yohn. Sr., Treasurer
2006 CountylTWP Taxes
100.00
531.84'
Total Additional Disbursements shown on Line 1305' $'
100.00
$
531.84
(118 HalLY DRIVE.PFD/118 HOLLY DRlVE/16)
EXlllB1rr R
MARTSON DEARDORFF WILLIAMS & OTTO
MJ2W&:O
ATfORNEYS & COUNSELLORS AT LAW
TELEPHONE
FACSIMILE
INTERNET
(717) 243-3341
(717) 243-1850
www.mdwo.com
WILLIAM F. MARTSON
JOHN B. FOWLER III
DANIEL K. DEAROORFF
THOMAS 1. WILLIAMS.
Ivo V. OTTo III
GEORGE B. FALLER JR. ·
*BOARD CERTIFIED CIVIL TRIAL SPECIALIST
CARL C. RISCH
DAVID A. FITZSIMONS
CHRISTOPHER E. RICE
JENNIFER L. SPEARS
HILLARY A. DEAN
10 EAST HIGH STREET
CARLISLE, PENNSYLVANIA 17013
November 11,2005
David S. Wisneski, Esquire
Navitsky, Olson & Wisneski, LLP
2040 Lingleston Road
Suite 303
Harrisburg, P A 17100
RE: Your client: Estate of Kenneth E. Wallace
Date of Loss: 07/28/05
Our File No.: 9500.359
Dear Dave:
As you know, I represent Giant Food Stores in the above-referenced matter. I am enclosing
a copy of a summary of the expenses associated with Ken Wallace's accident of July 28, 2005. As
far as we know, this is all of the expenses associated with the accident. As you can see, they total
$95,742.39. I am also supplYing the supporting documentation. If you have any questions, please
give me a call.
Very truly yours,
U~~N DEARDORFF WILLIAMS & OTTO
~a11er, Jr. .
GBF/mas
Enclosures
cc: Mr. Kevin McCoy (via e-mail)
Ms. Lizabeth Christman (via e-mail)
Ms. Pam Graeff (via e-mail)
F:\FILES\DA T AFILE\MAC9S00ICurrent\3S9\dw3
INFORMATION · ADVICE · ADVOCACY SM
EXPENSE SUMMARY
Kenneth Wallace's Accident
July 28, 2005
GE Equipment Services (trailer)
Penske Truck Leasing (tractor)
Penske Truck Leasing (tractor)
John's Mobile Repair Services
John's Mobile Repair Services
Hollinger Funeral Home (funeral)
$35,395.52
$42,226.64
$ 330.79
$10,477.84
$ 1,740.00
$ 5.571.60
Total
$95,742.39
ffl. I ,
Ii '>
v. 'I.. '
\: .
Trailer Fleet Services
Dlna Guenther
530 E Swedesford Road
Wayne, PA 19087
USA
T 484 254 0195
F 484 254 0686
dlna.guenther@ge.com
Per the Stipulated loss Schedule Annex D on the below listed units and Schedules, please pay the following amount
Serial Number
lJJVS32W72L782039
Owner
Fifth Third
Schedule #
1
Casualty Value
$3$,395.52
Total Due: $35,395.52
Please wire funds promptly to TIP and notify Dina Guenther at the above email
General Electric Company
~-~4-U~;~0:01AM;GIANI
II-'lANSPOH I A I ION
; /1/ 240 O~~O
#'
2/
.
::.:l
8-1g-05: 6: 1IPM;PENSKE TRUCK LEASING
;717 5644512
#0
3
MAKE CHECKS PAYABLE TO;
PENSKE TRUCK LEASING CO., L.P.
P.o. BOX 301
READING PA 19603-0301
SPECIAL
INVOICE
'PENSKEJ
Truck Leasing
r c',' NVOIar'_'" ':;: I
. '.' . I ,,_ ,,".' ..,
$42,226.64
WE'RE
CUSTOMER
DRIVEN 1M
GrANT FOOD STORES :me
WELDON THOMAS
1604 nmUSTRiAL DRIVE
CARLISLE, PA 17013
savxes LOCATION
Car1is1e, PA
(711) 766-1546
.. REFERENCE INVOICE NUMBER ON REMITTANCE"
CUSTOMER NUMBER
619582-4517
PERIOD ENDING
08119105
INVOICE DATE
INVOICE NUMBER
PAYMENT DUE BY
08/26/05
PAGE
1 OF1
08/19/05
51005510507
::~~;:i~HH~:,~~:\ ~~.'~~f:~:,,:~':?\.~'<;;~~~~~~f*,:..;T:.'Y:\;,~:r .": i:~} ;E~:j:: :':~:,t.:;,.::~~::,":..,~ ',:
5510507 8/1912005
Schedule A Purchase for unit 5510507
VIN .. 2HSCNAER01 C004725
Dale of Accident 7/2812005
42.226.64
$
42.226.64
INVOICE TOTAL
$
4~..$4 ~
}5-IO -7m -85'OO-o,-s2.-6~
TAX CODE
TAX RATE
TAX CHARGE
.-. '
LId')
MAKE atECKS PAYABLE TO:
PEHSKE TRUCK LEASING CO., L. P.
P.O. BOX 827380
PHILADELPHIA PA 19182-7380
LEASE
INVOICE
( PEIIISKE I
Truck J"/lsi,,,
39.1.7618 1 AS 0.301 70295D11.ps2 1 of 1
111111I1111111111111111111111111111111111111111111111111111I11
GIANT FOOD STaRBS IRe
ATTR: TIll ROHRBAUGH
1604. IRDUS'ft\:IAL D1UVB
CARLISLB PA 17013-9614.
E)~~!~t{UtYm$Jl\~1!...Jfff\j
$330.79
SERVICE LOCATION
(71W~1~~f546
CUSTOMEI' NUMBER
61958250-4517
PE1tIOD BNDING
8/25/05
INVOICE'DATE
08/30/05
INVOIcE NUMBBR.
L12338861
PAYMENT DtJR BY
09/09/05
PLEASE DETACH AND RETURN WITH PAYMENT
*REFERENCE INVOICE NUMBER ON REMITTANCE*
CUSTOloO!.t NUMBBR.
61958250-4517
pmuO)) BNDING
8/25/05
INVOIcE DATI!
08/30/05
INVOIcE NUMBER
L12338861
PAYMENT DuE BY P AGB
09/09/05 1 or 2
EXTENDED RENTAL VEHICLES
INVOICE TOTAL
-to -7o(;J, ~._(Y;S"2-~Cf j
293918 P R 1 186000 194805 B805 880S .05sa
VEHICLE OUT OF SERVICE 08/31/05
NEW VEHICLE IN SERVICE FROM 08/01/05 TO 08/31/05
5510507* P L 1 1 566324 566324
VEHICLE OUT OF SERVICE 07/28/05
o
o
.0558
1541.82-
92.51- 1634.3
aJSTOMER TOTALS
TAX CODE TAX RATE TAX OIARGE
PA-37 01 .0600 92.51-
8805 MI
481.32
330.7
68.02-
92.51-
VT-VEHlCLB TYPB
P-PO~ R-REEPBR
T-TRAILER. S-STANDDY
X-MISC. M-MAINT. AUOC.
C-LICENSB p- FLEET TO
VU..VBHICLR USE
L-Ll!ASE S-SUBSTlmn
1- INTERIM E-BXTRA
.R-EXTENDBD' .RENTAL
/JOHN'S MOBILE REPAIR SERVICE, INC.
./ 1511 EAST COMMERCE AVE. CARLISLE, PA 17013
www.johnsmobileservice.com
(717) 245-0076 · FAX: (717) 245-0648
Invoice Number: 127764
Invoice Date: 7/28/05
Cust. PI 0 #
Page 1 of 2
Bill To: 489
PENSKE LEASING - GIANT
c/o GIANT FOODS
1604 INDUSTRIAL DRIVE
CARLISLE PA 17013
Vehicle No. 626
Make:
Model:
Mechanic:
Serial #:
Phone: 717-240-0421
License:
Year: 0
Mileage: 0
WORK PERFORMED/COMMENTS
7/28/05
- RESPOND TO ACCIDENT SCENE RT 581 AT RT 15
- TRUCK BURNT AND TRAILER WAS TORN IN HALF BEHIND 5TH WHEEL PLATE
- REFER WAS TORN OFF NOSE OF TRAILER AND LAYING IN ROADWAY
- REMOVED REMAINING FUEL FROM MELTED TANKS
- SECURED DAMAGED AXLES AND MISC PARTS TO FRAME TO TRANSPRORT TRUCK
- LIFTED TRUCK AND LOADED ON LOWBOY TRAILER
- T ARPED TO SECURE DEBRIS
- CUT DAMAGED FLOOR AND SIDE WALLS OFF TRAILER TO TRANSPORT
- RELOAD SPILLED CARGO AND ALL LOOSE DEBRIS ONTO TRAILER
- REMOVED 5TH WHEEL PLATE AND DEBRIS FROM TRUCK FRAME
- LOAD FIFTH WHEEL PLATE AND REFER UNIT ONTO LOWBOY AND ROLL BACK
- TRANSPORT ALL EQUIPMENT TO JMRS
7/30/05
- ASSIST PSP IN ACCIDENT INVESTIGATION AND EQUIPMENT INSPECTION
- MOVED TRUCK OUTSIDE
-----------BREAKDOWN OF CHARGES-
1800.00
525.00
1800.00
675.00
675.00
3380.00
420.00
TRACTOR AND LOWBOY
1 ROLL BACK
1 HEAVY DUTY WRECKER
1 SERVICE TRUCK
1 TRACTOR
MAN HRS ON SCENE 52 @ $651HR
STORAGE OF TRUCK @ $301DAY
--STARTS 7/28/05 THRU 8/10/05
- STORAGE OF TRAILER @ $30/DA Y
- STARTS 7/28/05 THRU 8/10/05
TRAILER # 378
420.00
Part Number
FLOOR
11 M011
STORAGE
Part DescrlDtion
DRY
CAGE BOLT
STORAGE OF TRAILER ON LOT
Quantltv
10
4
14
Price
$10.80
$5.96
$30.00
Amount
$108.00
$23.84
$420.00
~~~o::~:~n:.~~~~~"'=~~ REPLACED PARTS WILL BE DISCARDED UNLESS CHECKED HER
FD4ANTAllUTYCRFmESSFClRAFWmC:ULARPUFFOSEMOnESELLEANEfTHERASSlM:SNOAJolJTHORlZESANYOTHER SAVE BY MY SIGNATURE I ACKNOWLEDGE RECEIPT OF THE VEHI
RSONTOASSWEFORrrANYlIABIlITYNCONNECTDNwrTHnESALEOFllolISITEMIn'EMS. AND AGREE THAT AFTER EXAMINING IT I FIND THE VEHICL:
~:=::=. ":=~~=': ~~-:::; :-=-....~-::..~r.:. ~~'= SATISFACTORY CONDITION AND I AM SATISFIED WITH THE aUAlIT'"
= ill pwIs 01 dMIys In pMa,,= by \lie ~lnnSpOIW. I herebr ggril ~ MdoW~ ~ peri'nIItlon 10 WORK AND MATERIAl.
~~ ~~ ~.o ~OIMlOUIlI of";':- ~ of IeSlIng 8IlO'or 1Mpdon. All..... rnec:lwIlc',
ro......... LI.-nl'"'
CUSTOMER'S
A""I::DTAr..'''1::
JOHN'S MOBilE REPAIR SERVICE, INC.
1511 EAST COMMERCE AVE. CARLISLE, PA 17013
www.johnsmobileservice.com
(717) 245-0076 · FAX: (717) 245-0648
Joice Number: 127764 Invoice Date: 7/28/05 Page 2 of 2
!art Number
TOWING AND
CONT AMINATED
FORKLIFT
STORAGE
CUT SAW
LABOR
Part DescriDtion
RECOVERY
FUEL (PER DRUM)
RENTAL \
STORAGE OF TRUCK ON LOT
BLADES
AlL WORK PERFORMED
Quantitv Price Amount
1 $8,855.00 $8,855.00
1 $225.00 $225.00
2 $75.00 $150.00
14 $30.00 $420.00
2 $18.00 $36.00
4 $60.00 $240.00
Taxable Parts: $0.00
Taxable Labor: $0.00
Non Taxable Parts: $10,087.84
Non Taxable Labor: $390.00
Sub Total: $10,477.84
Sales Tax: $0.00
Tire Tax: $0.00
Total Due: $10,477.84
~~~::~"=o~~~~~~~ REPLACED PARTS WILL BE DISCARDED UNLESS CHECKED HERE
"ABlJTYCAFmesFOAAPAAI'lClJLAAPlJNIOSEANDlHESEllEANEmERASSUMESNORAlJTHORIZESANYOTHER SAVE BY MY SIGNATURE I ACKNOWLEDGE RECEIPT OF THE VEHIC'
)ASSI.&fEFOAIUNYLlA8LlTYtfCONECTlONWfTHlHESALE0F1HIS1TEMIfTEMS. AND AGREE THAT AFTER EXAMINING IT I FIND THE VEHICLE
hartz....,..,.. herIMIler ...1011II10 be dorInlong" the ~ ...... IIlch"".. tMt you .. not responsllle SA TISFACTOAY CONDITION AND I AM SATISFIED WITH THE QUALITY {
~ to vehicle or.... .. In vWIicIe In caN of tn. ~c:::t. oIMr - beyoIId ywt C:onIrul or lor MY deIlIys ClIUMd WORK AND 'l..IA'TERIAL.
_ 01 J*\a or dcIIIp In pMI........ ~ lie IUIlIllIer or . IIIenIby gIMl you.-u 'fOI!I..,.yeee perinIIsIoI! 10 M , ,
~ Mr.rn cIMdIled 011 .... ~ or"""" lor IIie ~ of IeItIng i.nclfor Inspjdlan. M .... medllInIe'.
1 edcMwlMiClSd 0II1tlof. vehicle 10 ___ lie emount of ....liereto.
SIGN HERE
CUSTOMER'S
Af"f"r:nTA ..,.....
" I'
JOHN'S MOBILE REPAIR SERVICE, INC.
1511 EAST COMMERCE AVE. CARLISLE, PA 17013
www.johnsmobileservice.com .
(717) 245-0076 · FAX: (717) 245-0648
Invoice Number: 127779
Invoice Date: 8/11/05
Cust. P/ 0 #
Page 1 of 1
Bill To: 489
PENSKE LEASING - GIANT
clo GIANT FOODS
1604 INDUSTRIAL DRIVE
CARLISLE PA 17013
Vehicle No. 626
M,ke: TRAILER 378
Model:
Mechanic:
Serial #:
Phone: 717-240-0421
License:
Year: 0
Mileage: 0
WORK PERFORMED/COMMENTS
- STORAGE OF TRUCK 626 @ $30/DA Y
-- 8/11/05 THRU 9/9/05
- STORAGE OF TRAILER 378 @ $30/DA Y
-- 8/11/05 THRU 9/9/05
Part Number
STORAGE
STORAGE
Part DescriDtlon
STORAGE OF TRUCK ON LOT
STORAGE OF TRAILER ON LOT
Quantitv erg Amount
29 $30.00 $870.00
29 $30.00 $870.00
Taxable Parts: $0.00
Taxable Labor: $0.00
Non Taxable Parts: $1,740.00
Non Taxable Labor: $0.00
Sub Total: $1,740.00
Sales Tax: $0.00
Tire Tax: $0.00
Total Due: $1,740.00
':"') ~ t'. '. '"".-''''' ~';. ,..;. ~.. 'F' ~ '). ?I\Oh
C\ '1 L l e t.,..! .;) t '," ..... u .;
E FICfOR't WARMN1Y CClNS1lT\ITES ALL 01' 1HE WARfWrnES WI1H AESPECTTO 1HE SALE 01' THIS lTBMTBAS. THE SELLER
RElY EXPRESSlY CISClAIMS ALL WAAfWfTES, EITHER EXPAESSED OR IMPlED. N:UIDING NN IMPlED WAPIWlN OF
:RCHANrABILJ'I'Y OR FfTNESS FORA PAA1'ICUlM PUfIIOSE AH:) THE SB.LER NEITHEA ASSUMES NOR A&J1'HORIZES NN OllER
RSON TO ~ FOR If /iH'( LIA8UTY.. CClNNECT10H WITH THE SALE 01' THIS ITBWTEMS.
...., UhortD the =__ ......... ... kIr1IIlo be doM 8Iang will... -rr "......1IId -arM ... Y'N _ nol ,......
101I or cImMgIt lo y or MIIcIII ... 1ft veIlIde 1ft <<:Me Ill'" tiIII ~ aIw ~ beyond ycu c:onlnII or lor lIlY ..,. c.uMd
~J~'l:::=:="~~:':r~1or ~~::.o,-:or~~~
III heNby M:IlnowIIIdgId OIIl111love vehicle to ___ the __Ill ......1ieniIo.
'v
REPLACED PARTS WILL BE DISCARDED UNLESS CHECKED HER
SAVE BY MY SIGNATURE I ACKNOWLEDGE RECEIPT OF THE VEH
AND AGREE THAT AFTER EXAMINING .IT I FIND THE VEHICL
SATISFACTORY CONDITION AND I AM SATISFIED WITH THE OUALlT
WORK AND MATERIAL.
~~N "'~R~
CUSTOMER'S
ACCEPTANCE
",
....~~
. II - ,. ..".
,.
HoIIin~er Funeral Home & Crematory, Inc.
Eric L. HoIlinqer. Supervisor
August 8, 2005
Libby Christman
P.O. Box 249
Carlisle, PA 17013
The Funeral Services for Kenneth E. Wallace
The following is an itemized statement of the services, facilities, automotive equipment, and
merchandise that you selected when making the funeral arrangements.
1. Professional SerVices
Cremation Package D............ ......... ~...... ....................... ........................... .23 95 .00
Rent.al Casket.. :.............0...............0..... ~........................................ ......... ....500.00
Solid Oak with Cremation Insert
Urn......................................... ................................................................. ..405.00
Solid Oak "Jewel" Urn
Custom Engraving of Urn
Family Keepsake Urns:
I Solid Bronze (# 115) Jug Urn wI chain.............................................90.00
1 Large Silver Heart wI chain (#106 + #139).....................................220.00
3 Small Sliver Hearts wI chain (#130)...............................................360.D0
1 Pewter Cross wI chain (# 112)..........................................................90.00
2 Silver Turtles wI chain (#157)........................................................240.00
2 Silver Dolphins wI chain (#162).....................................................240.00
1 Sterling Silver Heart with Filigree Insert wI chain (#16Is)............120.00
2. Cash Advances
Clerg)' Honorarium.. ........... ................. ................ ........... ...... ...................100.00
Certified Copies of Death Certificate 15 copies at $6.00 per ...................90.00
Coroner's Fee (Cremation Authorization)......... ......... .... ....................... .....25 .00
Newspapers
Carlisle SentineL.................................................. ................................161.00
Patriot News.................. .0.................. ................................................ ..256 .50
501 NORTH BALTIMORE AVENUE. MOUNT HOLLY SPRINGS. PENNSYLVANIA 17065. (717) 486-3433. FAX (717) 486-3215
www.hoIIinqerfuneraIhome.com
".
.. ... ..... ~
...-
--
HoIIin~er Funeral Home & Crematoryt Inc.
Eric L. HoIlinqer. Supervisor
Flowers........... ...... ............................ ........ ............... ............................... ..249.10
Casket Spray "Autumn Theme" and 2 Matching Mache's wI Lillies
Poster Boards (2)....... .... ................. ............ .......... ..... .............................. ...30.00
T otal Cost...............................................................................................55571.60
Balance Due..........................................................................................._M,~:~,';.: I
Respectfully,
Eric L. Hollinger
Supervisor ~;f~
501 NORTH BALTIMORE AVENUE. MOUNT HOLLY SPRINGS. PENNSYLVANIA 17065 · (717) 486-3433 · FAX (717) 486-3215
www.holItnqerfuneraIhome.com
E~t\\a\" \...
Corporate Claims Management
Professional Accident Mana ement
Steve Spotts
Donegal Mutual
PO Box 212
Mohrsville, P A 19541
CCM Claim #:
G57682
CCM Client:
Snyders of Hanover
Driver: Johnathon Steirer
Claimant #: P AE0578208-40
Date of Loss:
July 28, 2005
May 1, 2001
Dear Steve Spotts,
This letter is to infonn you that Corporate Claims Management is subrogating the above claim md seeking reim-
bursement in the amoWlt of $5,684.60 for damages and related expenses. These charges include the
following:
Loss of Use:
16
days @ $79.99
+
6.()()O~
$3,253.16
$0.00
$0.00
Tax $1,356.63
$518.32
$30.89
$0.00
Repair:
Tow:
Rental:
Diminished Value:
Driver's Loss of Time:
1
hours @ $30.89
Company's Loss of Revenue:
hours @
Administra1ioo. Fee:
$300.00
Deca:
$225.00
Salvage:
$0.00
TOTAL: S5,684.60
All documentation to support this claim is eDdosed.
Please make your check payable to CORPORATE CLAIMS MANAGEMENT and fotWard to
P.O. BOX 2308, Ivyland, PA 18974. Be sure to indude tbe CCM Claim # on your cbeck.
SUBROGATION DEPARTMENT
Corporate Omces: 1 I'\')'brook Blvd, Suite 115, I'\')'land, P A 18954
Ph: 215-396-0581 Fx: 215-396-1997
E~t-\\B\l ""
64/e3/2667 e4:29 717-243-1856
. I
MDW&O
PAGE e2/62
INRE: ESTATEOFKENNETIlE.
WALLACE, DECEASED
IN THE COURT OF COMMON PLEAS
CUMBERLAND CO., PENNSYLVANIA
ORPHANS' COURT DIVISION
NO.:
CERTIFICATE OF CONCURRENCE
I, George Faller, Esquire, counsel for Giant Food Stores, LLC have read and do hereby,
on behalf of Giant Food Stores, LLC concur in Petition for Approval of Compromise Settlement
and Distribution of Proceeds Pursuant to Pa.R.C.P. 2206.
Date:
'-II 31 01
George Faller,
Martson, Deardorff, Williams & Otto
10 East High Street
Carlisle, PA 17013
Counsel for Giant Food Stores, LLC
E~\-\\B\1 N
.
~ Apr 26 07 01:08p
NOW LLP
7175419206
p.3
IN THE COURT OF COMMON PLEAS
CUMBERLAND CO., PENNSYLVANIA
IN RE: ESTATE OF KENNETH E.
VVALLACE,DECEASED
ORPHANS' COURT DIVISION
NO.:
AFFIDAVIT OF CONCURRENCE
I, Rick Bruno, on behalf of Corporate Claims Management as Subrogee for Snyder's of
Hanover, do hereby affirm that I have reviewed the terms of the Petition for Approval of
Compromise Settlement and Distribution of Proceeds, that I agree that the terms of the
settlement and distribution of proceeds as outlined in the petition are fair and appropriate, and
that Ijoin in Petitioners Paul E. Stone and Barbara J. Meyers and request that Vour Honorable
Court approve the terms of the settlement and distribution of proceeds.
Date: 1/J.v/IJ 7
Respectfully submitted,
~~
Rick Bruno
Representative of Corporate Claims Management as
Subrogee for Snyder's of Hanover
o
~
Sworn to and subscribed before me this
~~day of ~ \=>r-- : \ ~ 2007.
~&j-
Not ubhc
--
My Commission expires:
YL.VANlA
NOTARIAL SEAL
MELISSA D. TIEMANN, Notary PubHc
Ivytand Boro., Bucks County
Cornmfssion Ex ires Ju 16.2009
. E~\-\\B\l 0
. .
I .
POWER OF ATTORNEY AND FEE AGREEMENT
BY SIGNING TIllS AGREEMENT, I (WE) ACKNOWLEDGE THAT I (WE) HA VE ENGAGED THE LAW FIRM OF
NA VITSKY, OLSON & WISNESKI LLP (HEREINAFTER NOW LLP), TO REPRESENT ME (US) UNDER TIlE FOLLOWING
TERMS AND CONDmONS:
1. NOW LLP may on my (our) behalf secure medical, work and other similar records, conduct an investigation, negotiate, and if
necessary start suit against anyone responsible for my (our) injuries and losses with respect to11\€JUt..y Ole, ;ux6 V<\QE ~1'illJT
~ ~ SA/) CM.? ~ /..l.. i l1\ with full power and authority to appear on behalf of the undersigned in any Court of record or in any
administrative or other proceeding, to do and perform all and every act and thing whatsoever that may be requisite and necessary
to be done in connection with the above claim as fully as the undersigned might or could do if personally present; hereby ratifying
and confirming all that said attorney shall lawfully do or cause to be done therein by virtue of this power of attorney.
2. I (we) understand that so long as the case is handled by a NOW LLP attorney, I (we) will not be responsible for any fees and/or
expenses unless a recovery or benefit is obtained.
3. If my (our) case is handled to a successful completion by a NOW LLP attorney, I (we) agree to pay NOW LLP all reasonable out-
of-pocket expenses without the payment of interest, plus a fee for time expended as follows:
ME NOW LLP
a. SETILEMENT PRIOR TO STARTING SUIT AND 70% 30%
NO MEDIATION OR ARBITRATION
b. SETILEMENT FOLLOWING SUIT BUT PRIOR TO 65% 35%
MEDIATION, TRIAL OR ARBITRATION
c. SETILEMENT OR VERDICf AT MEDIATION,
TRIAL OR ARBITRATION, AFTER MEDIATION, 60% 40%
TRIAL, ARBITRATION, OR APPEALS OR
SHORTLY BEFORE MEDIATION, TRIAL OR
ARBITRATION IF THE CASE HAS BEEN
TOTALLY PREPARED
d. OTHER CASES
4. Iffor any reason I (we) take (our) case to another attorney or law firm or handle it myself (ourselves), I (we) recognize that NOW
LLP bas, in good faith, expended money and time for my (our) benefit and I (we) therefore agree to pay, or have my (our) new .
attorney pay, immediately, upon severing the NOW LLP attorney/client relationship, all the out-of-pocket expenses incurred on
my (our) case. In addition, when the case is successfully concluded, I (we) agree to payor to direct my (our) new attorney to pay
as a fee 20% of the gross recovery to NOW LLP.
5. In the event that any settlement is made on a structured or deferred payment basis, NOW LLP shall be entitled to receive their fee
based on the present value of the structured settlement, as if paid as a lump sum at the time of settlement. NOW LLP does not
structure or defer payment of their attorney fee or expenses.
BY SIGNING TIllS AGREEMENT. THIS b~AYOF (9e--+ ~/l) . 2~(WE)
ACKNOWLEDGE mAT I (WE) HA VB READ, UNDERSTOOD, AND RECEIVED A COPY OF SAME AND
AGREE WITH ITS TERMS AND CONDITIONS.
CLIENT(S):
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OFFICE OF CHIEF COUNSEL
P.O. BOX 1061
HARRISBURG, PA 17128-1061
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
January 29, 2007
Thomas J. Gohsler
Direct Dial: (717) 783-7539
tgohsler@state.pa.us
Fax: (717) 772-1459
David S. Wisneski, Esq.
Navitsky, Olson, & Wisneski LLP
2040 Linglestown Road, Suite 303
Harrisburg, PA 17110
Re: Estate of Kenneth Wallace, Deceased
Inheritance Tax
Wrongful Death/Survival Allocation Request
File Number 2105-0885
Dear Mr. Wisneski:
The Department of Revenue received your letter dated
December 21, 2005, concerning a petition to be filed on behalf
of the above-referenced Estate in regard to a wrongful death and
survival action. It was forwarded to this Office for the
Department's approval of the allocation of settlement proceeds.
Pursuant to your letter, the forty-three year old decedent
died on July 28, 2005 as a result of injuries sustained in an
automobile accident. Decedent died intestate and is survived by
a sister and a nephew. The Police Report attached to your
letter indicates that the decedent was trapped within a burning
vehicle and died as a result of burns sustained.
Please be advised that based upon these facts and for
inheritance tax purposes only, this Department has no objection
to the proposed. allocation of the gross proceeds of this action,
$124,000.00 to the wrongful death claim and $31,000.00 to the
survival claim.
Proceeds of a survival action are an asset included in the
decedent's estate and are subject to the imposition of
Pennsylvania inheritance tax. 42 Pa.C.S.A~ ~ 8302; 72 P.S.
~~ 9106, 9107. Costs and fees must be deducted in the same
percentages as the proceeds are allocated. In re Estate of
Merryman, 669 A.2d 1059 (Pa. Cmwlth. 1995).
~ .
I .
I .
David S. Wisneski, Esq.
January 29, 2007
Page Two
I trust that this letter is a sufficient representation of
the Department's position on this matter. As the Department has
no objections to the Petition, I will not be attending any
hearing regarding it. Please do not hesitate to contact me if
you or the Court has any questions or requires anything
additional from this Office.
TJG:sp
H:\OCC DOCS\WALLACEEST A TE(NO. 19837).DOC
---
il....
. .
, ,
AFFIDAVIT OF CONCURRENCE
I, Betty S. Wallace, do hereby certify and affirm that I have reviewed the terms of
Petition for Approval of Compromise Settlement and Distribution of Proceeds, that I agree that
the terms of the settlement and distribution of proceeds as outlined in the petition are fair and
appropriate, and that I join in Petitioners Paul E. Stone and Barbara J. Myers and request that
Your Honorable Court approve the terms of the settlement and distribution of proceeds.
WiQ! U~
&~ 51. 1J) tlrYt:kf2-
Bett Wallace
Date:
Sworn to and subscribed before me this
;ZJJP day of 1If!f(I- ,2007.
(h/Ii3fl/&~
Notary Public -
My Commission expires:
COMMONWEALTH OF PENNSYLVANIA
I Notarial Seal
Robert R. Black, Notary Public
Carlisle Boro, Cumberland County
My Commission Expires Sept. 28, 2009
rt,
4 .
AFFIDAVIT OF CONCURRENCE
I, Ralph W. Wallace, do hereby certify and affirm that I have reviewed the terms of
Petition for Approval of Compromise Settlement and Distribution of Proceeds, that I agree that
the terms of the settlement and distribution of proceeds as outlined in the petition are fair and
appropriate, and that I join in Petitioners Paul E. Stone and Barbara J. Myers and request that
Your Honorable Court approve the terms of the settlement and distribution of proceeds.
()#
Witness
"'-
~
~.Ptu ~ ~/~
Ralph W. Wallace
Date:
Sworn to and subscribed before me this
2tKJ day of ~(r..,. , 2007.
fZtW ~~
Notary Public
My Commission expires:
COMMONWEALTH OF PENNSYLVANIA
Notarial Seal
Robert R. Black, Notary Public
Carlisle Boro. Cumberland County
My Commission Expires Sept. 28, 2009