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Home My WebLink About08-0065 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN RE: BRIANNA J. SEXTON, a Minor, by and through her Parents and Natural Guardians, CHARLES P. SEXTON and JOSELYN M. SEXTON and STATE FARM FIRE & CASUALTY COMPANY Cl u l tr QRnTTAA?1TT71T " T p"- .- No.: 0 MINOR'S CLAIM PETITION REQUESTING COURT APPROVAL OF SETTLEMENT OF A Filed on Behalf of State Farm Fire & Casualty Company Counsel of Record for This Party: Christopher P. Deegan, Esquire PA I.D. #85635 WEBER GALLAGHER SIMPSON STAPLETON FIRES & NEWBY LLP Firm #594 Two Gateway Center, suite 1450 603 Stanwix Street Pittsburgh, PA 15222 Phone: (412) 281-4541 Fax: (412) 281-4547 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA (I, .0" 1 IN RE: BRIANNA J. SEXTON, a Minor, ) O?RT by and through her Parents and Natural ) Guardians, CHARLES P. SEXTON and ) NO.: d F- C : u Tz r «? JOSELYN M. SEXTON and STATE ) FARM FIRE & CASUALTY COMPANY ) PETITION REQUESTING COURT APPROVAL OF SETTLEMENT OF A MINOR'S CLAIM AND NOW, come Brianna J. Sexton, a Minor, by and through her Parents and Natural Guardians, Charles P. Sexton and Joselyn M. Sexton, and State Farm Fire & Casualty Company (hereinafter referred to as "State Farm"), by and through their attorneys, Christopher P. Deegan, Esquire and the law firm of Weber Gallagher Simpson Stapleton Fires & Newby LLP, and petition this Honorable Court to approve the settlement of a minor's claim and to seek distribution pursuant to the proposed Order of Court: 1. Charles P. Sexton and Joselyn M. Sexton, the Parents and Natural Guardians of Brianna J. Sexton (hereinafter referred to as "the Sextons"), reside with the Minor at 601 Sandpiper Lane, New Cumberland, Cumberland County, Pennsylvania 17070. 2. The Minor, Brianna J. Sexton, was born on September 7, 1990. 3. The Minor was 16 years old at the time of her injury and is presently 17 years old. 4. Maurice and Patricia Lefevre (hereinafter referred to as "the Lefevres") are individuals residing at 8207 Fenwick Farm Place, Louisville, Kentucky 40220. 5. At all times relevant hereto, the Lefevres were the holders of a policy of boat owners insurance issued by State Farm bearing Policy Number 17-58-8080-8. 6. On or about June 23, 2007, the Minor and her aforementioned parents were vacationing at Lake Cumberland in Kentucky. -2- 7. While operating a jet ski, the Minor was struck from behind by a boat owned by the Lefevres which was being operated by their son. 8. Following the collision, the Minor was taken to the emergency room at Lake Cumberland Regional Hospital in Somerset, Kentucky. 9. As a result of the incident, the Minor sustained a concussion and laceration to the area under the chin. 10. To alleviate the laceration, the Minor had five sutures. 11. After returning home from vacation, the Minor had the sutures removed on June 28, 2007 at the Cumberland Medical Center. 12. The Minor is no longer affected by the injuries sustained as a result of the collision and said injuries have healed. 13. The Minor's medical bills that resulted from the aforementioned incident totaled $3,367.00. 14. The MPC policy limits of $1,000.00 have been paid pursuant to the Lefevres' policy of insurance. 15. The parents and natural guardians of the Minor have also paid $200.00 to Lake Cumberland Regional Hospital. 16. Therefore, a balance of $2,167.00 is currently owed to the health care providers and $200.00 is currently owed to the parents and guardians of the Minor to reimburse them for their $200.00 payment made to Lake Cumberland Regional Hospital. 17. State Farm has made an offer to the parents and natural guardians of the Minor for the settlement of this claim in the amount of $13,181.00. -3- 18. Of this amount, $2,167.00 will be paid directly to the following health care providers in the amounts listed below (please see medical bills attached hereto as Exhibit A): (1) Lake Cumberland Regional Hospital $1,410.00 (2) Southeastern Emergency Physicians, Inc. $565.00 (3) Emergency Coverage Corp. $192.00 19. The balance of the settlement funds ($10,814.00) will be placed in a federally insured bank account, certificate of deposit, or US Savings Bond in the name of Brianna J. Sexton only, marked not to be withdrawn until Brianna J. Sexton reaches the age of majority or by further order of Court. 20. State Farm, its counsel, and Charles P. Sexton and Joselyn M. Sexton, Parents and Natural Guardians of Brianna J. Sexton, the Minor, all believe that this is a fair and reasonable compromise of any claim which may exist on behalf of Brianna J. Sexton, the Minor, Charles P. Sexton and/or Joselyn M. Sexton in relation to the Minor's accident which occurred on or about June 23, 2007 at Lake Cumberland, Kentucky, and request this Honorable Court to approve the settlement. WHEREFORE, all parties respectfully request that this Honorable Court grant the within Petition and approve the settlement according to the terms set forth herein. Respectfully submitted, WEBER GALLAGHER SIMPSON STAPLETON FIRES & NEWBY LLP By: C\ Christopher Deegan Attorneys for State Farm Fire & Casualty Company -4- PATIENT NO: MED REC NO: (GUARANTOR NO: PATIENT: `SEXTON BRIANNA 1000948764 LAKE CUMBERLAND REG HOSP BILLING DATE 288050 PO BOX 620 08/25/07 SOMERSET, KY 42502-0620 ADMITTED 06/23/07 h Eok?-038 BILL TO: SEXTON CHARLES 601 SANDPIPER LANE NEW CUMBERLAND PA 17070 DATE OF BATCH F NDC/CPT-4/ SERVICE REF DEPT S PROC HCPCS 250-PHARMACY - - 062307 23B161 0712 029952 64124154 259-DRGS/OTHER 062307 23B174 0712 055055 907420 062307 23B174 0712 051476 5107906052 062307 23B174 0712 015680 16800120 271-NON-STERI SUPPLY 062307 23B161 0712 006457 67618015004 351-CT SCAN/HEAD 062307 238163 0726 403358 70450 450-EMERG ROOM 1062307 27B560 0780 800427 062307 23B173 0780 800387 9928425 EMERGENCY ADMIT THRU DISCHARGE REPRINT QTY SERVICE DESCRIPTION YOUR COMPLETE SATISFACTION IS VERY IMPORTANT TO US, THANK YOU FOR CHOOSING LAKE CUMBERLAND REG HOSPITAL EXHIBIT A PAGE` 1 DISCH RGED 06/23/07 FC=99 CHARGES 1 1 LIDOCN 1 EPI 1 1ML SUBTOTAL: 5 1 MOTRIN 600 MG TAB (GEN 0 1 KEFLEX 500/MG CAP (GEN 9 3 NED BAC POLY OT .031 SUBTOTAL: 1 BETADINE 120ML SUBTOTAL: 1 CT HEAD/BRAIN W/O CONT SUBTOTAL: 1 ER PROCEDURE LEVEL 11 1 ER VISIT LEVEL IV SUBTOTAL: TOTAL ANCILLARY CHARGES TOTAL CHARGES. PAYMENTS ADJUSTMENTS BALANCE 40.00 40.00 8.00 15.00 3.00 26.00 .00 .00 i 1227.00 1227.00 165.00 471.00 636.00 1929.00 1929.00 .00 .00 1929.00 Rug 28 07 12:56p Chuck Sexton 717-938-0451 p.1 00002SR LAKE CUMBERLANDREGHOSP SEXTON CHARL 00100094876405412009001929001 P.O. BOX 99400 LDUISVILLE, KY 40260 S T 0%TE.V.F_- T OA . E IPA(-.F i Op 1 08110107 _ ........ _l, EMERGENCY _a . 1000948764 SEXTON BRIANNA 06/23/07 TO 06/23107 $1,929.00 SEXTON CHARLES MAIL PAYMI.1,T FO 0 601 SANDPIM LANE LAKE CUMBERLAND REG HOSP v°1 NEW CUMBERLAND PA 17070 PO BOX 620 SOMERSET, KY 42502 BUSINESS OFFICE lr..IIL.,IIL..ir..IIL....Irltl.l..ll?.l???li111,??1111„III Ill??lllillli?llll???lll?lilll??lll???l?lll???lll?lll?l?l??.tl 70 ::!' G:,V: :':iC)''_" C ::' ?'?, :? ,?:':: : V::ti ):; :+f);:'aiC7:\ W!TH YOUR PAYMENT NOTE: SHOULD YOU WISH TO PAY BY CREDIT CARD, SEE AUTHORIZATION NOTICE ON THE BACK. LAKE CUMBERLAND REG HOSP ;',;:L EMEXT SATE 08/10/07 P.O. BOX 99400 LOUISVILLE, KY 40289 A :;. ?. tiF AC:000N)' 06/23/07 TO 06/23/07 SEXTON BRIAN NA 1000948764 CLA;MC. Ot=-ANDING RCI`:IL!:L..MI :: OU;, ( r,,'IIMATE N:.;tJ(:A1f.:-:.'Ari!;TY :'•A::1 U ON UUit IIItil )NI-r:)fCMA:tt/N ' ,..::AI fXIA' X c1 ; A:1ti0UNT DUE •bg29.00, 0.00. 0.00. 00 $1,929 :00._ UNITS AMOUNT *06/23/07 EME.RMNCY SLRV I GLS '06123107 BEflu) I NE 12(ML 1 0 00 *06/23/07 NEO BAC POLY 01' .031 3 3.00 *06/23/07 LIDOCN 1 F.PI 1 imL , 1 40 00 *06/23/07 KEFLEX 500/MG CAP (GFNF,R 1 15.00 *06/23/07 MOTRIN 600 MG TAB (CENE1t . 1 A 00 *06/23/07 CT HEAD/BRAIN W10 CONT 1 1,227,00 *06/23/07 ER VISIT LEVEL IV . 1 b71 0o *06/23/07 CR PROCEDURE LEVEL 11 1 165100 TOTAL CHARGES . 1,/2.)29,(H) ACCOUNT BALANCE 119?9.(H) DUE FROM PATIENT 1,9?.9,00 BRIANNA SEXTON .JJI :"11' uu I.,y, pyw Cumb.rknd, PA r707n i/1/1.71 mil RX # 0312099-07664 DATE: 06/24/07 HYDROCODONWAPAP 5MG/600MG TAM QTY: 10 NO REFILLS - DR. AUTH REQUIRED Now NDC:00591-0349-05 r--? $' 3.00 U. WFLI I M[1 PLAN: T HI?5 MhIis i:WA'rW. 'Tf?N Gr30uP# TRRX LIMHAMA/ /nAW CLAIM HJ:F# U07175K5513001 BRIANNA SEXTON W l .6,wP4p,L YM, "-- r-"'l--d, PA 1)070 RX # 0312100-07664 DATE: 06/24107 CEPHALEXIN 500MGI CAPSULES QTY: 15 NO REFILLS - DR. AUTH REQUIRED New NDC.*OOW3.3147-05 .,.-..l L 03.00 + R. WILLIAMS, MD PLAN: TRj25 -' MFC:TEVA GROUP# TkHX WR/DAW/ /DAW CLAIM RCF# U07175K5662101 ?•^n/??"..[•,C?[r` auas nomr-r n:mwwuT, rr .twn (,rJ?Ii.?E?? rmz wp,,,..r er sowensn,.r .annl PH: (605)677-0596 PH: (606)67?-0596 IF YOU HAVE QUESTIONS REGARDING YOUR ACCOUNT, PLEASE CALL: 800-223-9899 HOURS OF OPERATION MON-FRI SAM-9PM SAT 9AM-IPM ET THANK YOU FOR THE OPPORTUNITY TO SERVE YOU. PLEASE PAY THE AMOUNT NOW DUE INDICATED ABOVE. WE ACCEPT ALL MAJOR CREDIT CARDS. Jul 31 07 08:55a ALCUA BIL.I,ING C r-..NTISR ;429 REGAL DR ALCUA, TN 37701-3265 Chuck Sexton PATIENTBRIANNA SEXTON - AMTDUC: NAM F: $883 PHYSICIAN SERVICES RENDERED AT: LAKE CUMBERLAND REGIONAL MED CNT .10I87627-4(X)-&'58I SM. I r i IsT V1 ° C .ARLES SEXTON M)1 SANIWIP)iR LN NEW CUMBERLAND PA 17070-2967 1111111111111111111111111,loll 111111.1111111111111111111111111 717-938-0451 P.2 DETACH AND RETURN THIS COUPON WITH THE REVERSE SIDE COMPLETED TO PAY BY CREDIT CARD, TO PROVIDE INSURANCE INFORMATION OR FOR CHANGE OF ADDRESS Credit card chargos will appo,u as'Tmm Health' 4W SOUTHEA,STGRN RMERC, PIIYS,IN(' own A ? B ? C. ? (rhWk 11TIC - kC revers0) .429 REGAL DR ALCUA, TN 37701-320.5 IIII II1111111IIII Ia11 as LIT 11111111111111111111111111II111111 07x800030],876272034400633100658140008830091 06/23/07 06/23107 67892352 07892352 EMERGENCY DEPT VISIT REPAIR SUPERFICIAL WOUND(S) THIS IS YOUR PHYSICIAN SERVICES BILL MAMAUAG MD,GILBERT MAMAUAG MD,GILBERT ND IS SEPARATE FROM THE HOSPITAL BILL $492,00 $391,00 t ACCOUNT NUMBER: 30187627-40"581 STATEMENT DATE: W=7 TOTAL NOW DUE: $883.00 PI.FA.SE REMIT BALANCL DUE. IF YOU HAVE INSURANCE C:OVLHAGE OR WANT TO PAY BY CREDIT CARD. VISIT OUR WEBSITE AT WWW.TEAMHLALTH.COM OR COMPLETE THE BACK 01= THIS STATEMFNT OR SEND A COPY (FRONT AND BACK) OF YOUR INS CARD For Billing Inquiries, call 1-888-952-6772 on Monday through Friday, from Sam to 8pm and Saturday from 10am to 3pm Eastern Time. SEND US YOUR INFORMATION OVER THE WEB! You may now provide insurance information and make credit card payments at www.teamhealth.com y Detach Here i PAYMENT COUPON - RETURN WHEN PAYING BY CHECK OR MONEY ORDER PATIENT NAME. BRIANNA SEXTON ACCT #: 30187627-400-6581 PHYSICIAN SERVICES RENDERED AT: LAKE CUMBERLAND REGIONAL MED CNT ? CHECK HERE. FOR CHANGE or ADDnESS 301 X7627-400-6571 l CIIARI.T:S SIiX'IC)N 601 SANDPIPER LN NEW CUMBERLAND PA 17070-2907 CHECK #: AMT PAID: DO NOT STAPLE OR TAPE YOUR CHECK OR MONEY ORDER TO THIS COUPON MAKE CHECKS PAYABLE TO: 400 SOUTHEASTERN RVIERG PIIYS,INC. PO BOX 740023 CTNC'.INNA'1'l UIi 45274-0023 III IIIIII11111IIl IIIIIIIIIITaaIlaaYlY11IIIIIl IIIIIIIII1111II 018000301876272034400633100658140008830091 Jul 31 07 08:55a Chuck Sexton 717-938-0451 P.1 ALC OA BILLING CENTER :3429 RP.GAL DR ALCOA, TN :37701-3265 PATIENTBRIANNA SEXTON AMT DUE: $19200 PHYSICIAN SERVICES RENDERED AT: CUMBERLAND MEDICAL CENTER 30187627-401-4503 +Hxn?r,:v r, (:HARLK% SEXTON 601 SANDPIPER LN N6W CUMBEKLND PA 17070-W)7 r111III111rII11III IIIII11111IIrrII 111111111111111111181111 till DETACH AND RETURN THIS COUPON WITH THE REVERSE SIDE COMPLETED TO PAY 8YCREDIT CARD, TO PROVIDE INSURANCE INFORMA77ON OR FOR CHANGE OF ADDRESS. Credit card charges will appear as 'Team Health' 401 EMURGINCY C OVP.RAGE CORP DEFT' A? REl ('? (ChWk ont: sta! rcwcrs4) 3429 REGAL DR ALC.OA,'I'N 37701-3201 I IIIIIIIIIII IIIIIIII III IIII IIII III IIIIII III III I IIII I III i IIII 018000301876272034401512050450340001920053 T i)atach Hwre T (W.8107 68007319 EMERGENCY DEPT VISII THIS IS YOUR PHYSICIAN SERVICES BILL LYM.D..HAOA./HARRISONPA.ROBERT LD IS SEPARATE FROM THE HOSPITAL BILL ?i1ylA0 _ ACCOUNT NUMBER: 30187627.401-4503 STATEMENT DATE: 07/23107 TOTAL NOW DUE: $792 pp? r PI.FASF REMIT RALANCF D(JF. IF YOU HAVE INSURANCE COVERAGE OR WANT TO PAY BY CREDIT CARD, VISIT OUR WEBSITE AT WWW.TEAMHEALTH.COM OR COMPLETE THE BACK OF THIS STATEMENT OR SEND A COPY (FRONT AND BACK) OF YOUR INS CARD For Billing Inquiries, call 1-888-952-6772 on Monday through Friday, from 8am to 8pm and Saturday from loam to 3pm Eastern Time. SEND US YOUR INFORMATION OVER THE WEB! You may now provide insurance information and make credit card payments at www.teamhealth.com I n-#- h r.I-.,e i 0<11 PAYMENT COUPON - RETURN WHEN PAYING BY CHECK OR MONEY ORDER x (PATIENT NAME; BRIAN NA SEXTON ACCT #: $01$7627-401-4503 CHECK #; AMT PAID: 1 PHYSICIAN SERVICES RENDERED AT: CUMBERLAND MEDICAL CENTER DO NOT STAPLE OR TAPE YOUR CHECK J OR MONEY ORDER TO THIS COUPON ? CHICK HERE FOR CHANGE OF ADDRESS MAKE CHECKS PAYABLE TO: 401 30187627-401-4503 EMERGENCY COVERAGE CORP C:IIARLE-1; SHX1X)N K) BOX 740023 601 SANDPIPER LN CIN('INNATI 01145274-(x)2:3 NEW C-UMI ERI-ND PA 17070-2867 111111111 11111111111 Ills IIIIIIIIII 1111111111 111 018000301876a72034401512050450340D01920053 Jul 31 07 08:55a Chuok Sexton , 1 F1 1 tMtN 717-838-0451 P,3 ...-.•.. A NL.L 11 FIDW.•-- Biuegrass Radiology Assoc p p vas r3 PO Box 3176 CARn NVMUL•'R AMOUNT Somcrtiet ICY 42564-3176 I / NAM( ON fAwl(iidyyyN pRVfn !\P.DA Yr.' NKMU•rZrr(rL . 6TATIlMF:NY M•rrt Af.MUMr' Ir ?AY THIN An U ffr 07/23/2007 01000948764 $171.00 Office How- 8.00 a.01. to 4:30 p.m. Monday - Friday Paticnt: SEXTON BRIANNA - Phone: 888/273-2009 IRS# 61-1121623 Primary Ins,: SELF PAY r AI!RN7'PAID 6111216230000000000100094876400171001 MAKE C1I: Cot PAYAUL.L t. 1rCMST TO- 5716 1 MB 0.360 •25 05716 1 111111111111111111111111111111plot] 1111111111111111IIIBill IslIIl1111111111111111111IN Ills?lsllllstill 11111loll Civules Sexton 01000948764 (Bluegrass Radiology Assoc 601 Sandpiper I,?ane PO Box 3176 Ncw Cumberland PA 17070-2867 Somem et KY 42564-3176 CUMBERL1-01400211.00051 G-peazo+6-0ot -0oooot -aoo59 r;.., nN>w AI)10(1!,f;I^r1N.r.l I 19 -N IAQIIII:;1 AN:)U ;WIN :11:!; Y.`:'r)I;:!<>11 NAYN IANTIIMr I-:n n 1'.I WA1:rv;ArR rli::iY1JGii ?:X: r r r --.- .._.. ... .. _....._ uwc: x131 ':.r4111Ir't.1wt._ ATL •110S DESC:RlrriON OF SFRVICES DIAGN051s AMOUNT j 00/23/07 I; 70450 CT [IF AT) W/O CUN'rR 959,01 $171,00 PAYMENT DUE ON.- 0$/07/2007 1 1 I BALANCE DIJk,: $171.00 Patient: SEXTON BRIANNA _ Account Number: 01000948764 Statement pate: 07/23/2007 I ocation of Service -" _.__ .-.. ,.. Rctcrrin,g Phy4ician Pcrl'orming Phylsician LAKE CUM13I'sRLANO REGIONAL 1IOSPT GILBERT MAMAUAG - LAURA A SIMONS MD ? IF YOU HAVE INSURANCE, PLEASE CONTACT OUR Bluegrass Radiology Assoc j OFFICE IMMFDIA T'CLY. 1.1115 Is'rFiL•' ONLY STATEMENT PO Box 3176 YOU WIr.I. RFC13IV8. PLEASE PAY IN FULL BY DUE DATE. Somcr.qct KY 42564-3176 5l OWN ABOVE. CUMOCRL1.014002A.0005710-I!12W.00i.000001a100W NO Phone: 888/273-2009 1RS#F 61-1121623 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN RE: BRIANNA J. SEXTON, a Minor, ) ORPHAN'S COURT by and through her Parents and Natural ) Guardians, CHARLES P. SEXTON and ) NO.: JOSELYN M. SEXTON and STATE ) FARM FIRE & CASUALTY COMPANY 1 AFFIDAVIT BEFORE ME, the undersigned authority, a Notary Public in and for said County and Commonwealth, personally appeared Charles P. Sexton, Parent and Natural Guardian of Brianna J. Sexton, a Minor, who being duly sworn according to law, deposes and says that the averments of fact contained in the foregoing Petition Requesting Court Approval of Settlement of a Minor's Claim are true and correct to the best of his knowledge, information and belief. Date: /,2-)3-200"7 Sworn to and subscribed before me thisy day of 2007. otary Public My Commission Expires J (!4 Charles P. Sexton COMMONWEALTH OF PENNSYLVANIA NOTARIAL SEAL SHARON R. FEISTER, Notary Public New Cumberland Boro., Cumberland Co. My Commission Expires April 15, 2011 t IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN RE: BRIANNA J. SEXTON, a Minor, ) ORPHAN'S COURT by and through her Parents and Natural ) Guardians, CHARLES P. SEXTON and ) NO.: JOSELYN M. SEXTON and STATE ) FARM FIRE & CASUALTY COMPANY 1 AFFIDAVIT BEFORE ME, the undersigned authority, a Notary Public in and for said County and Commonwealth, personally appeared Joselyn M. Sexton, Parent and Natural Guardian of Brianna J. Sexton, a Minor, who being duly sworn according to law, deposes and says that the averments of fact contained in the foregoing Petition Requesting Court Approval of Settlement of a Minor's Claim are true and correct to the best of her knowledge, information and belief. Date: I°Z -/ 3 26 6 7 Sworn to and subscribed before me this`day of 2007. n Notary Public My Commission Expires: COMMONWEALTH OF PENNSYLVANIA NOTARIAL SEAL SHARON R. FEISTER, Notary Public NewCumberland Boro., Cumberland Co. MY Commiaafon Expires April 15, 2011 00 +It J J 3 C"t rv Cr - (T7 i -rll f7i j IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNS YJ _.VANIA Gnat. IN RE: BRIANNA J. SEXTON a Minor, ) by and through her Parents and Natural ) Guardians, CHARLES P. SEXTON and ) NO.: evil - erVA JOSELYN M. SEXTON and STATE ) FARM FIRE & CASUALTY COMPANY ) ORDER tl? AND NOW, to-wit, this 7 day of _S*,vW P 4 , 2007, upon presentation of the attached Petition, it is hereby ORDERED and DECREED that Charles P. Sexton and Joselyn M. Sexton, the Parents and Natural Guardians of Brianna J. Sexton, a Minor, are permitted to settle the claim of the Minor, Brianna J. Sexton, for the total sum of $13,181.00. Of this amount, the following health care providers will be paid directly by State Farm Fire & Casualty Company: (1) Lake Cumberland Regional Hospital $1,410.00 (2) Southeastern Emergency Physicians, Inc. $565.00 (3) Emergency Coverage Corp. $192.00 The sum of Two Hundred Dollars ($200.00) will be paid directly to Charles R Sexton and Joselyn M. Sexton for reimbursement of their payment made to Lake Cumberland Regional Hospital. It is further ORDERED and DECREED that Weber Gallagher Simpson Stapleton Fires & Newby LLP is appointed Temporary Limited Guardian of Brianna J. Sexton, a Minor, for the sole purpose of receiving the balance of the settlement funds ($10,814.00) from State Farm Fire & Casualty Company and depositing said funds into a federally insured savings account or certificate of deposit in the name of Brianna J. Sexton only and marked "NOT 'TO BE WITHDRAWN UNTIL MINOR REACHES MAJORITY OR WITHOUT AN ORDER OF COURT OF COMPETENT JURISDICTION". It is further ORDERED and DECREED that Weber Gallagher Simpson Stapleton Fires & Newby LLP shall file with the Court proof of said deposit within thirty (30) days of the distribution of said funds at which time its Temporary Limited Guardianship shall cease. BY THE COURT: /5 ,f $Cp_ $ 1_/ ,:1 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN RE: BRIANNA J. SEXTON, a Minor, ) CIVIL DIVISION by and through her Parents and Natural ) Guardians, CHARLES P. SEXTON and ) NO.: 08-65 Civil Term JOSELYN M. SEXTON and STATE ) FARM FIRE & CASUALTY COMPANY ) AFFIDAVIT OF DEPOSIT This Honorable Court issued an Order amending the approval of settlement of a minor's claim on or about January 17, 2008. 2. Pursuant to said Order, the proceeds of said minor's settlement in the amount of $10,814.00 were to be deposited into a federally insured savings account or Certificate of Deposit in the name of the Minor, Brianna J. Sexton, only. 3. On or about February 21, 2008, said funds were deposited at Members 1st Federal Credit Union, New Cumberland Giant, 130 Old York Road, New Cumberland, Pennsylvania see Exhibit A attached hereto). WHEREFORE, the undersigned counsel respectfully believes that all duties laid upon him by the Order of Court have been satisfied as of the date of this pleading. Date: cf a 1° b`? Sworn to and subscribed before me thisQ1,Nay of 1 o ,la,'i .r i rLh . ?, - . 2008. Christopher . Deegan, Esquire Notarial Seri Denise M. Williams, Notary Public City Of Pidtsburgh, Allegheny County My Corrtrnission Expires Jan. 17, 2009 Member, Pennsylvania Association of Notaries St r r r -a CT3 .L] f-JEWAAAlLi-P WIT 00A ON New Cumberland Giant 130 Old York Road New Cumberland PA 0 Inquiries Call: 717-774-6231 Acct XXXXXXX568 SEXTON,BRIANNA J ru r Eff: 02/21/08 pate: 02/21108 Ul Tlr: 0441 Time: 11:06am .d ru Deposit to 9 MONTH NO PENALTY CERT .. 40 r Prev Bal. 0.00 U1 Maturity date: 11/17/08 ru Amount: 10,814.00 a- new Bal: 10,814.00 0 Seq: #587747 0 O r Check Received 10,814.00 O Z w Authorized by I ID Source: ? Drv Lic ? SigCard ? Known ? Other Bile your taxes with TurboTax through our Web site and rece ive TurboTax for free or at a 10% disc ount! www.memberslst.org BRIANNA J SEXTON o? O mom `2-D U) Z ED L 'a A mZ z 0Z> Q (A D X V O O Z •4 D O Z O M ?r * a i :. Wo ` rn `. OO<' oar Co. z _ZX fTl C ?. .. '. m " . -i r C m' , rn t -n D s„ C , - *.. i.?r?L D Q 'o 0 0 Q O r i ". ?s. ? 3;Os o c , , .1Z 00 ' T K o"... ... ^ Z _ x;00::• . •?? o C"- .. .. deW4R Al ?-?? ?? '» „s ?? ' ,,,. `? °? ??'.